The Gluteus-Score-7 Predicts the Likelihood of Both Clinical Success and Failure Following Surgical Repair of the Hip Gluteus Medius and/or Minimus.

PURPOSE: To identify patient preoperative history, examination, and imaging characteristics that increase the risk of postoperative failure of gluteus medius/minimus repair, and to develop a decision-making aid predictive of clinical outcomes for patients undergoing gluteus medius/minimus repair. METHODS: Patients from 2012 to 2020 at a single institution undergoing gluteus medius/minimus repair with minimum 2-year follow-up were identified. MRIs were graded according to the "three-grade" classification system: grade 1: partial-thickness tear, grade 2: full-thickness tears with <2 cm of retraction, grade 3: full-thickness tears with ≥2 cm retraction. Failure was defined as undergoing revision within 2 years postoperatively or not achieving both a cohort-calculated minimal clinically important difference (MCID) and responding "no" to patient acceptable symptom state (PASS). Inversely, success was defined as reaching both an MCID and responding "yes" to PASS. Predictors of failure were verified on logistic regression and a predictive scoring model, the Gluteus-Score-7, was generated to guide treatment-decision making. RESULTS: In total, 30 of 142 patients (21.1%) were clinical failures at mean ± SD follow-up of 27.0 ± 5.2 months. Preoperative smoking (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.0-8.4; P = .041), lower back pain (OR, 2.8; 95% CI, 1.1-7.3; P = .038), presence of a limp or Trendelenburg gait (OR, 3.8; 95% CI, 1.5-10.2; P = .006), history of psychiatric diagnosis (OR, 3.7; 95% CI, 1.3-10.8; P = .014), and increased MRI classification grades (P ≤ .042) were independent predictors of failure. The Gluteus-Score-7 was generated with each history/examination predictor assigned 1 point and MRI classes assigned corresponding 1-3 points (min 1, max 7 score). A score of ≥4/7 points was associated with risk of failure and a score ≤2/7 points was associated with clinical success. CONCLUSIONS: Independent risk factors for revision or not achieving either MCID or PASS after gluteus medius and/or minimus tendon repair include smoking, preoperative lower back pain, psychiatric history, Trendelenburg gait, and full-thickness tears, especially tears with ≥2 cm retraction. The Gluteus-Score-7 tool incorporating these factors can identify patients at risk of both surgical treatment failure and success, which may be useful for clinical decision-making. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Meniscal Radial Tears Repaired With All-Inside and Inside-Out Techniques Result in Improved Clinical Outcome Scores, but Inside-Out Repairs May Be Associated With Higher Failure Rates Clinically and on Second-Look Arthroscopy: A Systematic Review.

PURPOSE: To compare patient-reported outcomes (PROs), failure, and healing rates after 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 after 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 criteria and the Modified Coleman Methodology Score. 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 with 86.9 to 94.2 and 6 to 7.5, respectively, in the IO repair group. All patients exceeded published values for minimal clinically important difference 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% to 2% within the AI group, whereas no complications were reported in the IO group. No implant-related complications were reported in any study group. CONCLUSIONS: 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. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Patients Aged 40 Years and Older Demonstrate Durable and Comparable Results to Patients Aged Less Than 40 Years After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity Matched Study at Minimum 10-Year Follow-Up.

PURPOSE: To compare clinical outcomes and rates of secondary surgery, including revision hip arthroscopy and conversion to total hip arthroplasty (THA), after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients ≥40 years of age at minimum 10-year follow-up compared with a propensity-matched control group of patients <40 years. METHODS: A retrospective cohort study was performed for patients who underwent primary hip arthroscopy for FAIS between January 2012 and February 2013. Patients ≥40 years old were propensity matched in a 1:1 ratio by sex and body mass index to patients <40 years old. Patient-reported outcomes (PROs) including Hip Outcome Score for Activities of Daily Living and Sports-Specific subscales, modified Harris Hip, International Hip Outcome Tool-12, and Visual Analog Scale for Pain and Satisfaction were collected. Rates of minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) achievement at 10 years were evaluated and compared between groups. Rates of secondary surgery including revision hip arthroscopy and conversion to THA were evaluated. Gross survivorship between cohorts was evaluated using a Kaplan-Meier curve. RESULTS: Fifty-three patients aged ≥40 (age 48.3 ± 5.8 years) were successfully matched to 53 patients aged <40 (age: 28.9 ± 7.2, <0.001). There were no other preoperative group differences regarding patient demographics, characteristics, or radiographic findings. Both groups demonstrated significant improvement regarding all PROs at a minimum of 10 years' follow-up (P < .001 for all). No significant difference was noted between cohorts regarding any delta (preoperative to 10-year postoperative) scores (P > .05 for all). High rates of MCID and PASS achievement were achieved in both cohorts, with no significant differences in any PRO measure (P > .05 for all). No significant differences in rates of complications (age ≥40: 2.0%, age <40: 7.7%, P = .363), rates of revision (age ≥40: 7.5%, age <40: 9.4%, P = .999), or conversion to THA (age ≥40: 13.2%, age <40: 3.8%, P = .161) were identified. On Kaplan-Meier analysis, no significant difference (P = .321) was demonstrated in overall gross survivorship between cohorts. CONCLUSIONS: Patients with age ≥40 with FAIS undergoing primary hip arthroscopy demonstrated durable and comparable 10-year PRO and rates of MCID and PASS achievement compared with a propensity-matched cohort of age <40 counterparts. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

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.

Partial Meniscectomy Yields Comparable Outcomes and Failure Rates to Meniscal Repair for Horizontal Cleavage Tears, with Fewer Complication Rates but Greater Progression of Degenerative Changes.

PURPOSE: To compare the clinical outcomes, failure rates, surgical complications, and postoperative radiographic changes following partial meniscectomy versus meniscal repair for horizontal cleavage tears (HCTs). 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. Clinical studies evaluating partial meniscectomy or meniscal repair for HCTs were included. Demographic characteristics, surgical techniques, clinical outcomes, failure rates, complications, and radiographic assessments were recorded. RESULTS: A total of 18 studies comprising of 833 patients with HCT were included, of which 562 patients (67.5%) were treated with partial meniscectomy and 271 (32.5%) with meniscal repair. Both types of treatments reported improved clinical outcomes, including IKDC, Lysholm, KOOS, and Tegner scores. Failure rates were reported to range between 0 to 15% following partial meniscectomy, and between 0 to 17.6% following repair; and complications were 7.5% after partial meniscectomy, and between 3.8 to 21.4% following meniscal repair. Patients undergoing meniscectomy demonstrated progression of degenerative changes on radiographic assessments. CONCLUSION: Repair of HCTs in the appropriately indicated patient can result in similar patient outcomes and failure rates compared to partial meniscectomy. However, especially in patients aged 42 years and younger, a greater complication rate can be expected with repair, while a greater degree of ipsilateral compartment degeneration is seen after partial meniscectomy.

Females and Males Achieve Similar Improvement, Outcomes, and Survivorship Following Hip Arthroscopy with Labral and Capsular Repair for Femoroacetabular Impingement Syndrome at Minimum 10-Year Follow-Up.

PURPOSE: To evaluate the effect of patient sex on 10-year patient-reported outcomes (PROs) and survivorship after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS). METHODS: Patients who underwent primary HA for FAIS with minimum 10-year follow-up from 1/2012-12/2013 were retrospectively reviewed. Female patients were propensity-matched to male patients in a 1:1 ratio by age and body mass index. PROs and rates of minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) achievement were compared between cohorts. Rate of reoperation-free survivorship was compared between sexes. RESULTS: One-hundred and twenty-one- females (age: 36.2 ± 12.3 years) were matched to 121 males (age: 35.7 ± 11.3 years, p = 0.594) at average follow-up of 10.4 ± 0.4 years. There were no differences in any preoperative demographic characteristics between the groups (p ≥ 0.187). Both groups demonstrated significant improvement in every PRO measure between the preoperative and 10-year postoperative time points (p < 0.001). The magnitude of improvement was similar between the groups for all PRO measures (p ≥ 0.139). At 10-years, female patients trended towards higher MCID achievement for the Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) than male patients (72.7% vs. 57.3%, p = 0.061), with otherwise similar MCID achievement rates. Females trended towards significantly lower HOS-Sports Subscale PASS achievement (65.4% vs. 77.1%, p = 0.121) with otherwise similar PASS achievement rates between the groups (p ≥ 0.170). CONCLUSION: Female and male patients experienced similar improvement in PROs at ten-year follow-up. MCID and PASS achievement rates were predominantly similar between sexes. Survivorship did not differ between groups. Long-term success can be expected for appropriately indicated patients undergoing HA for FAIS, regardless of sex. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Open and Endoscopic Gluteus Medius and/or Minimus Repair Achieves Clinical Success Regardless of Tear Grade: High-Grade Fatty Infiltration Portends Worse Outcomes.

PURPOSE: To evaluate minimum 2-year gluteus medius and/or minimus repair clinical success rates stratified by the 3-grade magnetic resonance imaging (MRI)-based classification (MRI grade) and to evaluate clinical success rates by the surgical approach used at each MRI grade and by the Goutallier-Fuchs (GF) classification. METHODS: A retrospective review identified patients who underwent primary endoscopic or open gluteus medius and/or minimus repair from 2012 to 2021 performed by a single surgeon. Preoperative MRI scans were classified using the MRI grade and GF classification. Patient-reported outcomes were collected preoperatively and at minimum 2-year follow-up. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was recorded. Rates of clinical success, defined as achievement of the 2-year minimal clinically important difference or patient acceptable symptom state with avoidance of revision surgery, were compared by MRI grade, by surgical approach at each MRI grade, and by GF classification. RESULTS: A total of 112 patients (71 with MRI grade 1, 19 with grade 2, and 22 with grade 3) were included. MRI grade 1 patients underwent endoscopic repair (P < .001) more often than the other groups. The overall clinical success rate was 90%. Clinical success rates by MRI grade were 93% for grade 1, 95% for grade 2, and 77% for grade 3 (P = .087). Clinical success rates by the endoscopic and open surgical approaches used at each MRI grade were 93% versus 90% for grade 1 (P = .543), 91% versus 100% for grade 2 (P > .999), and 60% versus 92% for grade 3 (P = .135). GF grade 1 tears achieved a higher rate of clinical success than GF grade 4 tears (100% vs 71%, P = .030). CONCLUSIONS: Primary repair of gluteus medius and/or minimus tears resulted in clinical success in most patients irrespective of MRI grade and irrespective of the surgical approach used at each MRI grade, yet GF grade 1 tears showed a significantly higher clinical success rate than GF grade 4 tears. LEVEL OF EVIDENCE: Level IV, prognostic retrospective case series.

Patients With Lateral and Anterolateral Cam Morphology Have Greater Deformities Versus Typical Anterolateral Deformity Alone but No Differences in Postoperative Outcomes: A Propensity-Matched Analysis at Minimum 5-Year Follow-Up.

PURPOSE: To compare pre- and postoperative findings between patients undergoing hip arthroscopy for femoroacetabular impingement syndrome with lateral impingement versus those without lateral impingement METHODS: Patients who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between 2012 and 2017 with minimum 5-year follow-up were included. Alpha angle (AA) was measured on preoperative anteroposterior (AP) and 90° Dunn radiographs. Patients with AA >60° on Dunn view but not AP view (no lateral impingement) were propensity matched by sex, age, and body mass index in a 1:3 ratio to patients with AA >60° on both views (lateral impingement). Demographic characteristics, radiographic and intraoperative findings, reoperation rates, and patient-reported outcomes (PROs) were compared between groups. Categorical variables were compared using the Fisher exact testing and continuous variable using 2-tailed Student t tests. RESULTS: Sixty patients with lateral impingement (65.0% female, age: 35.3 ± 13.0 years) were matched to 180 patients without lateral impingement (65.0% female, age: 34.7 ± 12.5 years, P ≥ .279). Patients with lateral impingement had larger preoperative AAs on both Dunn (71.0° ± 8.8° vs 67.6° ± 6.1°, P = .001) and AP radiographs (79.0° ± 12.1° vs 48.2° ± 6.5°, P < .001). However, there were no differences in postoperative AAs on either view (Dunn: 39.0° ± 6.1° vs 40.5° ± 5.3°, AP: 45.8° ± 9.0° vs 44.9° ± 7.0°, P ≥ .074). Labral tears began more superiorly in patients with lateral impingement (12:00 ± 0:49 vs 12:17 ± 0:41, P = .030), and they demonstrated greater rates of acetabular and femoral cartilage damage (P = .030 for both); however, there were no differences in PROs or reoperation rates between the groups at 5-year follow-up. CONCLUSIONS: Although cam deformities located laterally and anterolaterally are larger than those located anterolaterally alone, both can be resected adequately, resulting in similar postoperative radiographic measurements, PROs, and survivorship. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

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.

Failure and complication rates following meniscal all-inside and inside-out repairs: A systematic review and meta-analysis.

PURPOSE: This study examines failure rates, complication rates and patient-reported outcome measures (PROMs) for meniscal all-inside (AI) and inside-out (IO) repair techniques. METHODS: A systematic search was conducted on PubMed, Embase and Cochrane (inception to January 2024) assessing for Level I-III studies evaluating outcomes after meniscal repair. The primary outcome regarded differences in failure rates between AI and IO repair techniques. Secondary outcomes included a comparison of complication rates and PROMs. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation and Methodological Index for Non-Randomized Studies criteria. A meta-analysis was conducted for outcomes reported by more than three comparative studies. RESULTS: A total of 24 studies (13 studies and 912 menisci for AI vs. 17 studies and 1,117 menisci for IO) were included. The mean follow-up ranges were 22-192 months (AI) and 18.5-155 months (IO). The overall reported AI failure rate ranged from 5% to 35% compared to 0% to 25% within the IO group. When comparing meniscal repair failure rates in the setting of concomitant anterior cruciate ligament reconstruction, the AI group had a failure rate (AI: 5%-34%; IO: 0%-12.9%). The complication rate ranged from 0% to 40% for AI and 0% to 20.5% for IO. Post-operative PROM scores ranged from 81.2 to 93.8 (AI) versus 89.6 to 94 (IO) for IKDC and 4.0-7.02 (AI) versus 4.0-8.0 (IO) for Tegner. Upon pooling of six comparative studies, a significantly lower failure rate favouring the IO technique was observed (15.9% AI vs. 11.1% IO; p = 0.02), although this result was influenced by a study with a predominantly elite athlete population. Moreover, no significant differences were found regarding complication rates between cohorts (7.3% AI vs. 4.8% IO; p = 0.86). CONCLUSION: The present study underscores comparable clinical success between AI and IO meniscal repair techniques, with both techniques demonstrating similar complication rates. However, the AI repair technique was associated with 1.77 times higher odds of failure compared to the IO cohort. LEVEL OF EVIDENCE: Level III.

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.

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.

Editorial Commentary: Coracoclavicular Joint Reconstruction for Acromioclavicular Dislocation: Double-Bundle Techniques Are Anatomically and Biomechanically Favored.

For coracoclavicular (CC) joint reconstruction in the setting of acute acromioclavicular (AC) joint Rockwood type III or V dislocations, flexible fixation shows better clinical outcomes and complication rates than rigid fixation. Single-bundle CC reconstruction reconstructs the conoid ligament but poorly controls anteroposterior stability and is nonanatomic in nature. Thus, we favor double-bundle CC reconstruction incorporating a trapezoid bundle, replicating the broad insertion of the CC ligaments. Biomechanical data confirm improved stability with double-bundle, flexible fixation reconstruction, especially with the lateral clavicular tunnel in a more posterolateral location. An early clinical outcome study supports the double-bundle approach; meticulous surgical technique is required to avoid double-trouble complication rates.

Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review.

PURPOSE: To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes. METHODS: A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated. RESULTS: Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery. CONCLUSIONS: Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure. LEVEL OF EVIDENCE: IV; Systematic Review of Level III and IV studies.

Perioperative Outcomes of Open Anterior Vertebral Body Tethering and Instrumented Posterior Spinal Fusion for Skeletally Immature Patients With Idiopathic Scoliosis.

BACKGROUND: Correcting adolescent idiopathic scoliosis (AIS) without fusion can be achieved with anterior vertebral body tethering (AVBT). However, little is known about the perioperative outcomes, pain control, and clinical outcomes in patients undergoing AVBT compared with instrumented posterior spinal fusion (IPSF). METHODS: In this retrospective cohort study, we compared pediatric patients with AIS who underwent either AVBT or IPSF. Inclusion criteria were based on the AVBT group, which included primary thoracic idiopathic scoliosis, Risser ≤1, curve magnitude 40 to 70 degrees, age 9 to 15, no prior spine surgery, index surgery between 2014 and 2019, and minimum 2-year follow-up. Patient demographics, perioperative metrics, pain visual analog scale scores, opiate morphine equivalent usage, cost data, and radiographic outcomes were compared. RESULTS: We identified 23 patients who underwent AVBT and 24 matched patients in the IPSF group based on inclusion criteria. Patients undergoing AVBT and PSF were similar in age (12±1 y vs. 13±1 y, P =0.132) and average follow-up time (3.8±1.6 y vs. 3.3±1.4 y, P =0.210). There were 23 female patients (87%) in the AVBT group and 24 female (92%) patients in the IPSF group. Intraoperatively, estimated blood loss (498±290 vs. 120±47 mL, P <0.001) and procedure duration (419±95 vs. 331±83 min, P =0.001) was significantly greater in the IPSF group compared with AVBT. Length of stay was lower in the AVBT group compared with PSF (4±1 vs. 5±2 d, P =0.04). PSF patients had significantly greater total postoperative opiate morphine equivalent use compared with AVBT (2.2±1.9 vs. 5.6±3.4 mg/kg, P <0.001). Overall direct costs following PSF and AVBT were similar ($47,655+$12,028 vs. $50,891±$24,531, P =0.58). Preoperative radiographic parameters were similar between both the groups, with a major thoracic curve at 51±10 degrees for AVBT and 54±9 degrees for IPSF ( P =0.214). At the most recent follow-up, IPSF patients had greater curve reduction to a mean major thoracic curve of 11±7 degrees (79%) compared with 19±10 degrees (63%) in AVBT patients ( P =0.002). Nine patients (39%) required revision surgery following AVBT compared with 4 patients(17%) following IPSF ( P =0.09). CONCLUSIONS: In a select cohort of patients, AVBT offers decreased surgical time, blood loss, length of stay, and postoperative opiate usage compared with IPSF. Although IPSF resulted in greater deformity correction at 2-year follow-up, the majority of patients who underwent AVBT had ≤35 major curves and avoided fusion. There is optimism for AVBT as a treatment option for select AIS patients, but long-term complications are still being understood, and the risk for revision surgeries remains high. LEVEL OF EVIDENCE: Level III.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends.

BACKGROUND: Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time. MATERIALS AND METHODS: This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication. RESULTS: A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) ( P =0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered ( P >0.05). CONCLUSIONS: Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy. LEVEL OF EVIDENCE: Level III-retrospective.

Suture button placed beneath plate fixation for complex distal clavicle fractures and acromioclavicular joint injuries: a technical note.

Patients with complex distal clavicle and acromioclavicular (AC) joint injuries are at risk of loss of reduction, especially when plates are removed postoperatively. The purpose is to review the authors' preferred technique for treatment of distal clavicle and AC joint injuries utilizing combined suture button and plate fixation, aiming to optimize biomechanical strength of fixation and limit loss of reduction after implant removal. Pre-contoured locking plates or hook plates were utilized atop suture buttons to maintain reduction and optimize biomechanical strength. At final follow-up over one year after plate removal and suture button retention in thirteen patients, reduction was maintained to coracoclavicular interval 1.5 ± 1.4 mm less than contralaterally. DASH scores at final follow-up averaged 5.7 ± 2.5 (range: 3.3 - 11.7). Placing suture button fixation prior to and beneath plate fixation in complex AC joint injuries and distal clavicle fractures allows for maintained fixation and prevents loss of reduction after plate removal.

What Factors Correlate With Length of Stay and Readmission After Limb Lengthening Procedures? A Large-database Study.

BACKGROUND: Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures. QUESTIONS/PURPOSES: (1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission? METHODS: Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses. RESULTS: Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only. CONCLUSION: When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Allograft Medial Patellofemoral Ligament Reconstruction in Adolescent Patients Results in a Low Recurrence Rate of Patellar Dislocation or Subluxation at Midterm Follow-Up.

PURPOSE: To evaluate rates of recurrent instability in adolescent patients with medial patellofemoral ligament (MPFL) reconstruction with allograft and associations of anatomic risk factors with complications. METHODS: A retrospective review identified patients of a single surgeon who underwent MPFL reconstruction with allograft for recurrent patellar instability with minimum 2-year follow-up. Surgical management was recommended after a minimum 6 weeks of nonoperative management and included MPFL reconstruction with gracilis allograft using a double-bundle technique. Preoperative radiographs were evaluated to assess physeal closure, lower-extremity alignment, trochlear morphology, and Insall-Salvati and Caton-Deschamps ratios. Magnetic resonance images were reviewed to evaluate the MPFL, trochlear morphology, and tibial tubercle trochlear groove distance (TT-TG). Descriptive statistics were used to characterize data. The primary outcome was recurrent instability. RESULTS: 20 patients (24 knees; 18 knees in 14 females and 6 knees in 6 males; average age 15.7 years; range 11.5 to 19.6) underwent MPFL reconstruction with allograft (mean ± standard deviation follow-up 5.2 ± 1.7 years; range 2.2 to 8.1). Physes were open in 9 knees. The Insall-Salvati ratio was 1.09 ± 0.16, and the Caton-Deschamps index was 1.17 ± 0.15. Preoperatively, 19 patients were noted to have trochlear dysplasia, and TT-TG was 15.3 ± 3.9 mm. Three of 4 knees (16.7%) with non-hardware-related complications had open physes: 3 (12.5%) had recurrent instability, 2 of which underwent subsequent operation, and 1 sustained a patella fracture after a fall, requiring open reduction and internal fixation. The average Insall-Salvati ratio of these 4 patients was 1.21 ± 0.20, Caton-Deschamps index was 1.18 ± 0.17, and TT-TG was 17.5 ± 3.3 mm, none of which were statistically different from the group without complications. There were no clinically noted growth disturbances postoperatively. CONCLUSIONS: MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with good outcomes at midterm follow-up, few complications, and a low rate of recurrent instability. LEVEL OF EVIDENCE: IV, case series.