Beighton Score, Tibial Slope, Tibial Subluxation, Quadriceps Circumference Difference, and Family History Are Risk Factors for Anterior Cruciate Ligament Graft Failure: A Retrospective Comparison of Primary and Revision Anterior Cruciate Ligament Reconstructions.

PURPOSE: To assess patient history, physical examination findings, magnetic resonance imaging (MRI) and 3-dimensional computed tomographic (3D CT) measurements of those with anterior cruciate ligament (ACL) graft failure compared with primary ACL tear patients to better discern risk factors for ACL graft failure. METHODS: We performed a retrospective review comparing patients who underwent revision ACL reconstruction (ACLR) with a primary ACLR group with minimum 1-year follow-up. Preoperative history, examination, and imaging data were collected and compared. Measurements were made on MRI, plain radiographs, and 3D CT. Inclusion criteria were patients who underwent primary ACLR by a single surgeon at a single center with minimum 1-year follow-up or ACL graft failure with revision ACLR performed by the same surgeon. RESULTS: A total of 109 primary ACLR patients, mean age 33.7 years (range 15 to 71), enrolled between July 2016 and July 2018 and 90 revision ACLR patients, mean age 32.9 years (range 16 to 65), were included. The revision ACLR group had increased Beighton score (4 versus 0; P < .001) and greater side-to-side differences in quadricep circumference (2 versus 0 cm; P < .001) compared with the primary ACLR group. A family history of ACL tear was significantly more likely in the revision group (47.8% versus 16.5%; P < .001). The revision group exhibited significantly increased lateral posterior tibial slope (7.9° versus 6.2°), anterolateral tibial subluxation (7.1 versus 4.9 mm), and anteromedial tibia subluxation (2.7 versus 0.5 mm; all P < .005). In the revision group, femoral tunnel malposition occurred in 66.7% in the deep-shallow position and 33.3% in the high-low position. The rate of tibial tunnel malposition was 9.7% from medial to lateral and 54.2% from anterior to posterior. Fifty-six patients (77.8%) had tunnel malposition in ≥2 positions. Allograft tissue was used for the index ACLR in 28% in the revision group compared with 14.7% in the primary group. CONCLUSION: Beighton score, quadriceps circumference side-to-side difference, family history of ACL tear, lateral posterior tibial slope, anterolateral tibial subluxation, and anteromedial tibia subluxation were all significantly different between primary and revision ACLR groups. In addition, there was a high rate of tunnel malposition in the revision ACLR group.

Increased posterior tibial slope results in increased incidence of posterior lateral meniscal root tears in ACL reconstruction patients.

PURPOSE: While the association with acute anterior cruciate ligament (ACL) tears has been established, other risk factors and associated pathologies which occur with a concomitant lateral meniscal posterior root tear (LMPRT) are not well defined. The purpose of this study was to compare the risk factors and concomitant pathologies between patients with LMPRT and patients without LMPRTs in the setting of a primary ACL tear. METHODS: Patients with a LMPRT identified at the time of primary ACL reconstruction by a single surgeon were identified. These patients were matched by age and sex to patients undergoing primary ACL reconstruction who were not found to have lateral meniscus root tears (control group) in a 1:1 ratio. Lateral posterior tibial slope (PTS), medial PTS, lateral femoral condyle height and depth, lateral tibial plateau depth, and lateral tibial plateau subluxation were measured on MRI. Anteroposterior full-limb alignment radiographs were used to measure the medial proximal tibia angle (MPTA), the mechanical lateral distal femoral angle (mLDFA), and the mechanical weightbearing axis for the injured extremity. RESULTS: One-hundred three patients were included in both the LMPRT group and the matched control group. Patients with a LMPRT had a significantly steeper lateral PTS (9.1° vs. 7.0°, p = 0.001), a steeper medial PTS (7.0° vs. 6.0°, p = 0.03), and a greater lateral-to-medial slope asymmetry (2.0° vs. 1.0°, p = 0.001). There were no differences in lateral femoral condyle depth or height, lateral tibial plateau depth, lateral tibial plateau subluxation, MPTA, mLDFA, or mechanical weightbearing axis between groups. There was a significantly increased incidence of medial meniscus ramp lesions in patients with lateral meniscus posterior root tears compared with controls (34.0% vs. 15.5%, odds ratio: 2.8, p = 0.002). There were no associations with concomitant ligament injuries, medial meniscus root tears, or non-ramp tears based on case/control grouping. CONCLUSION: In conclusion, LMPRTs in the setting of primary ACL injuries were associated with significantly increased lateral and medial PTSs, and increased asymmetry between lateral and medial PTSs. In addition, clinicians should be aware of the increased incidence of concurrent medial meniscal ramp lesions in patients with LMPRTs. Knowledge of these associations helps guide clinical decision-making and counselling of patients in the setting of ACL tears with concomitant LMPRTs. LEVEL OF EVIDENCE: IV.

Clinical Characteristics and Outcomes After Anatomic Reconstruction of the Proximal Tibiofibular Joint.

PURPOSE: To assess the most common presenting symptoms, clinical outcomes, and satisfaction after anatomic reconstruction of the proximal tibiofibular joint (PTFJ) with a free semitendinosus autograft. METHODS: Consecutive patients with minimum 2-year follow-up after isolated anatomic PTFJ reconstruction were retrospectively reviewed. Patients were evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Lysholm Knee Survey score along with a simple numeric patient satisfaction score (0-10, with 10 rated as perfect). Statistical analysis was performed with paired t tests, with P < .05 considered significant. RESULTS: The study included 16 PTFJ reconstruction surgical procedures in 15 patients with isolated proximal tibiofibular instability verified by an examination under anesthesia (4 reconstructions in male patients vs 12 in female patients); the average age was 37.9 ± 14.6 years, with an average follow-up period of 43.2 months (range, 22-72 months). Of the 13 patients with complete follow-up, 11 (84.6%) were able to return to full desired activities and previous level of sport. Fourteen patients presented with concomitant common peroneal nerve pathology. Two patients had a subsequent complication. No patients needed an additional procedure. Significant (P < .05) improvement occurred across all WOMAC domains and in the WOMAC total score, from 31.4 (±14.9) preoperatively to 15.2 (±15.5) postoperatively. Lysholm Knee Survey scores significantly (P < .05) improved from 51.2 (±17.2) to 75.0 (±18.0). Patients' overall satisfaction was rated 7.6 (± 2.7) of 10. CONCLUSIONS: At an average follow-up of 43.2 months, anatomic PTFJ reconstruction for isolated PTFJ instability provided improvement in clinical outcomes, a return to activities, and a low risk of complications or need for additional procedures. CLINICAL RELEVANCE: PTFJ reconstruction with hamstring tendon graft is a promising surgical treatment that improves patient satisfaction when conservative treatment of PTFJ instability fails. LEVEL OF EVIDENCE: Level IV, case series.

The Influence of Naproxen on Biological Factors in Leukocyte-Rich Platelet-Rich Plasma: A Prospective Comparative Study.

PURPOSE: To quantify and compare normative catabolic and anabolic factor concentrations in leukocyte-rich platelet-rich plasma (LR-PRP) at various time points, including baseline, 1 week after initiating naproxen use, and after a 1-week washout period. METHODS: Asymptomatic healthy donors aged between 18 and 70 years were recruited (average age, 36.6 years; range, 25-64 years). Subjects were excluded from the study if they were actively taking any prescribed medications or nonsteroidal anti-inflammatory drugs (NSAIDs) or if they had any of the following at present or previously: blood or immunosuppression disorders, cancer, osteonecrosis, rheumatoid arthritis, avascular necrosis, NSAID intolerance, gastrointestinal or peptic ulcer disease, or kidney dysfunction. The anabolic factors vascular endothelial growth factor, fibroblast growth factor 2, platelet-derived growth factor AB (PDGF-AB), and platelet-derived growth factor AA (PDGF-AA) and the catabolic factors interleukin (IL) 1ß, IL-6, IL-8, and tumor necrosis factor α in LR-PRP were measured. Peripheral blood was drawn at 3 time points: baseline, after 1 week of naproxen use, and after a 1-week washout period. RESULTS: The angiogenic factors PDGF-AA (44% decrease in median) and PDGF-AB (47% decrease) significantly declined from baseline (P < .05) after 1 week of naproxen use. There was a significant recovery (P < .05) of PDGF-AA (94% increase) and PDGF-AB (153% increase) levels after the 1-week washout period, with a return to baseline levels. The catabolic factor IL-6 also had a significant decline from baseline (77% decrease in median, P < .05) after 1 week of naproxen use. After a 1-week washout period, the IL-6 level was similar to the baseline level (130% increase, P < .05). CONCLUSIONS: Naproxen use diminished several biological factors in LR-PRP; however, a 1-week washout period was sufficient for the recovery of PDGF-AA, PDGF-AB, and IL-6 to return to baseline levels. Tumor necrosis factor α, IL-1ß, IL-8, vascular endothelial growth factor, and fibroblast growth factor 2 did not show differences between the 3 time points of data collection. Discontinuing NSAIDs for a minimum of 1 week before LR-PRP treatment may improve certain biological factor levels. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Editorial Commentary: Is the Anterolateral Ligament Always Injured in Knee Dislocations? Does It Matter?

Anterolateral ligament injuries with knee dislocations appear to be very common. In particular, those that occur with fibular (lateral) collateral ligament injuries are very frequent. Although the majority of injuries in this magnetic resonance imaging study appear to be at the proximal attachment of the anterolateral ligament, caution is advised because there is still no clear agreement as to the anatomic attachment site of the anterolateral ligament on the femur. Distal-based anterolateral ligament injuries, either bony or soft tissue Segond variants, have a large consensus in the peer-reviewed literature as to their anatomic attachment sites and injury pattern identification.

The Role of Blood Flow Restriction Therapy Following Knee Surgery: Expert Opinion.

Blood flow restriction (BFR) therapy is becoming increasingly popular in musculoskeletal injury rehabilitation. In particular, this form of therapy is being utilized more often in the postoperative setting following knee surgery, including anterior cruciate ligament reconstruction. BFR therapy provides patients and clinicians an alternative treatment option to standard muscle strengthening and hypertrophy guidelines in the setting of postoperative pain, weakness, and postoperative activity restrictions that contribute to muscle atrophy. The ability to complete exercise in a low load environment and achieve similar physiological adaptations as high-intensity strength training makes this modality appealing. With poor patient-related outcomes associated with continued muscle atrophy, pain, and muscle weakness, some researchers have investigated BFR training postoperatively following arthroscopic knee surgery with promising results. However, owing to the current paucity of research studies, inconsistency among reported protocols, and mixed results, it may be some time before a mass adoption of BFR therapy is made into the world of orthopaedic rehabilitation. Although the current data is inconclusive, we choose to utilize BFR in postoperative knee patients, regardless of weight-bearing status, for whom maintenance of existing muscle mass or improvement of decreased postoperative strength levels is important. Therefore, the purpose of this expert opinion is to review the background of BFR, describe the clinical evidence of BFR following knee surgery, and report the authors' current recommendations for application of BFR postoperatively.

A History of Anterior Cruciate Ligament Reconstruction at the National Football League Combine Results in Inferior Early National Football League Career Participation.

PURPOSE: To evaluate whether players with a history of an anterior cruciate ligament reconstruction (ACLR) before the National Football League (NFL) Combine played or started fewer games and/or participated in fewer eligible snaps compared with NFL Combine participants without a history of knee injury or surgery. METHODS: We performed a retrospective review of all players who participated in the NFL Combine between 2009 and 2015 and who had a history of an ACLR. NFL Combine participants were included if they had a previous ACLR or combined anterior cruciate ligament (ACL) injury and nonoperatively managed medial collateral ligament injury. The number of games started, number of games played, draft number, overall draft pick, and snap percentage for each position were determined. The mean value of each outcome metric was compared between case and control players. RESULTS: We identified 110 players who had an ACL injury (n = 76) or a combined ACL and medial collateral ligament injury (n = 34). Players in the ACLR group had a significantly worse mean draft pick number (difference of 30.2, P = .002) and mean draft round (difference of 0.8, P = .019) versus controls. Compared with control players, players in the ACLR group started and played significantly fewer games in both season 1 (difference of 2.7 games started, P < .001; difference of 2.7 games played, P < .001) and season 2 (difference of 7.4 games started, P < .001; difference of 3.0 games played, P = .003) and had a significantly lower snap percentage in both season 1 (difference of 23.1%, P < .001) and season 2 (difference of 24.0%, P < .001). CONCLUSIONS: Athletes at the NFL Combine who previously underwent an ACLR had significantly lower early-career NFL player metrics, including fewer games started, fewer games played, and a lower snap percentage, than uninjured controls. Defensive linemen, defensive backs, and linebackers were the 3 most affected positions. Players with a prior ACLR and combined meniscal-chondral pathology had significantly lower numbers of games started and games played in seasons 1 and 2 and a significantly lower season 2 snap percentage. LEVEL OF EVIDENCE: Level III, case-control study.

An Overview of Clinically Relevant Biomechanics of the Anterolateral Structures of the Knee.

Residual anterolateral rotatory laxity following injury and reconstruction of the anterior cruciate ligament (ACL) has become a popular topic and has generated interest in characterizing the relative contribution from the anterolateral structures of the knee. Studies have reported on the anatomic and biomechanical features of the anterolateral ligament (ALL), revealing a role in restraining internal tibial rotation in both ACL-intact and ACL-deficient knees. The Kaplan fibers of the iliotibial band have also been reported to provide significant restraint to internal tibial rotation. The ACL is the primary restraint to anterior tibial translation, and both the proximal and distal bundles of the iliotibial band, with a divergent orientation, also provide significant static restraint against internal tibial rotation, and each bundle may have a distinct individual role. In the setting of ACL deficiency, subsequent sectioning of the ALL and Kaplan fibers led to further increases in anterior tibial translation. Residual rotatory laxity that may be seen clinically following ACL reconstruction may be attributable to an associated anterolateral structure injury even in the setting of an anatomic ACLR, leading to consideration for a concomitant anterolateral structure reconstruction. Studies evaluating the kinematic influence of anatomic ALL reconstruction or lateral extra-articular tenodesis have focused on internal rotation, axial plane translation, and anterior tibial translation, with variable results having been reported. Further, despite the long history of anterolateral structure reconstruction, most commonly with a lateral extra-articular tenodesis, the clinical use of these combined techniques is still in its relative infancy, and long-term patient outcomes have yet to be published for relative comparisons.

Inflammatory synovial biomarkers and state of the tibiofemoral joint in the post-surgical settings: a narrative review.

Background and Objective: Knee surgery attempts to restore the native biomechanics of the knee, improve stability, and decrease the progression of osteoarthritis (OA). However, despite improvements in surgical techniques, tissue degradation and OA are common after knee surgery, occurring in higher rates in surgical knees compared to non-surgical knees. The aim of this study is to analyze previous literature to determine which synovial fluid biomarkers contribute to knee tissue degradation and decrease patient outcomes in the post-surgical setting of the knee. Methods: A narrative review of relevant literature was performed in July 2023. Studies reporting on synovial biomarkers associated with the post-surgical knee were included. Key Content and Findings: The literature reported that proinflammatory synovial biomarkers cause cartilage degradation and turnover which eventually leads to OA. The associated biomarkers are typically present prior to physical symptoms so understanding which one's correlate to OA is important for potential therapeutic treatments in the future. Studying the preoperative, early postoperative, and late postoperative synovial biomarkers will allow physicians to develop an improved understanding of how these biomarkers progress and correlate to knee tissue degradation and OA. This understanding could lead to further developments into potential treatment options. Research into inhibiting or reversing these inflammatory biomarkers to slow the progression of knee tissue degradation has already begun and has reported some promising results but is currently limited in scope. Conclusions: Synovial fluid biomarkers in the post-surgical knee setting may contribute to decreased patient outcomes and the progression of knee tissue degradation. There is no current consensus on which of these biomarkers are the most detrimental or associated with decreased patient outcomes. With an improved understanding of the individual biomarkers, potential personalized therapeutic treatment could be used by physicians in the future to improve patient outcomes after surgery.

Effect of anti-inflammatory treatments on patient outcomes and concentrations of inflammatory modulators in the post-surgical and post-traumatic tibiofemoral joint setting: a narrative review.

Background and Objective: There are several anti-inflammatory therapeutic options that can be used in the context of post-surgical and post-traumatic knee settings. Each of these options carries with it certain benefits, as well as potential issues depending on the duration and administration of each therapy. An understanding of how these anti-inflammatory drugs modulate various biomarkers of inflammation is also necessary in understanding how they can affect patient and objective outcomes following acute knee injury or surgery. This review covers the many traditional therapeutic options that have been used in treating knee injuries, as well as some natural therapeutics that have shown anti-inflammatory properties. Methods: A current review of the literature was conducted and synthesized into this narrative review. Key Content and Findings: Many traditional anti-inflammatory therapeutics have been shown to be beneficial in both post-traumatic and post-surgical tibiofemoral joint settings at reducing inflammation and improving patient outcomes. However, many of these treatments have risks associated with them, which becomes problematic with prolonged, repeated administration. Natural anti-inflammatory compounds may also have some benefit as adjunctive treatment options in these settings. Conclusions: There are multiple different therapeutic options that can be used in acute knee settings, but the specific mechanism of injury or surgical context should be weighed when determining the best clinical approach.

Comparative Outcomes Occur After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: A Prospective Multicenter Randomized Controlled Equivalence Trial.

BACKGROUND: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear. PURPOSE/HYPOTHESIS: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided t test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney U test was used to compare postoperative patient-reported outcome measures between groups. RESULTS: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group (P = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) (P = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] (P = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) (P = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) (P = .184). CONCLUSION: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.

Global Forum: Orthopaedic Physicians in the Winter and Summer Olympic Games.

In training for and performing in the sporting competitions of the Olympic Games, athletes endure a variety of injuries that can lead to the development of a chronic musculoskeletal condition. Injury surveillance studies are in place for each event to collect epidemiological data in an attempt to enhance injury prevention for future Winter and Summer Olympic Games. Periodic health evaluations also are used to screen for injuries and monitor athletes' health in order to take measures to reduce the risk of reinjury. Orthopaedic physicians work to improve sport-specific injury prevention protocols to create a safe environment for competition and ultimately reduce the occurrence of injuries throughout the Olympic Games.

Injury of the Meniscus Root.

Meniscus root tears biomechanically disrupt normal joint loading and lead to joint overload with the possible development of spontaneous osteonecrosis of the knee and early-onset osteoarthritis. Proper identification and treatment of meniscal root tears has been proven to restore joint loading and improve patient outcomes.

High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Impaction fractures of the posterolateral tibial plateau have been previously described to occur in association with anterior cruciate ligament (ACL) tears; however, the effect of these injuries on patient-reported outcomes (PROs) after ACL reconstruction (ACLR) is not well known. PURPOSE: (1) To assess the effect of posterolateral tibial plateau impaction fractures on preoperative clinical knee stability assessed by the Lachman and pivot-shift examinations and (2) to assess the effect of impaction fractures on PROs after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing ACLR for primary ACL tears with available magnetic resonance imaging (MRI) scans were included in this study. MRI scans were reviewed for the presence of posterolateral tibial plateau impaction fractures, which were classified according to the morphological variant. Associations with clinical laxity determined by an examination under anesthesia were assessed using binary logistic regression. Also, 2-year postoperative PROs (12-Item Short Form Health Survey [SF-12] Mental Component Scale and Physical Component Scale [PCS], Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Tegner scores) were modeled using multiple ordinal logistic regression to assess the effect of posterolateral tibial plateau impaction fracture classification while adjusting for other covariates. Pearson correlation coefficients (PCCs) were used to assess for correlations between postoperative PROs and the amount of tibial plateau bone loss present. RESULTS: Displaced posterolateral tibial plateau impaction fractures were present in 407 (49.3%) of 825 total knees included in this study. Knees with type IIIB impaction fractures had an increased likelihood of having a high-grade pivot shift (odds ratio, 2.3; P = .047), with no other impaction fracture types showing a significant association. There were no significant associations between posterolateral tibial plateau impaction fracture type and a higher Lachman grade. Of the 599 eligible knees with 2-year follow-up, postoperative information was obtained for 419 (70.0%). Patients improved in all PROs at a mean of 3.0 years after ACLR (P < .001). Multiple ordinal logistic regression demonstrated a posterolateral tibial plateau impaction fracture as an independent predictor of the postoperative Lysholm score, with higher grade impaction fractures showing decreased Lysholm scores. Pearson correlation testing demonstrated weak but statistically significant correlations between sagittal bone loss of posterolateral tibial plateau impaction fractures and SF-12 PCS (PCC = -0.156; P = .023), WOMAC total (PCC = 0.159; P = .02), Lysholm (PCC = -0.203; P = .003), and Tegner scores (PCC = -0.151; P = .032). CONCLUSION: When classified into distinct morphological subtypes, high-grade posterolateral tibial plateau impaction fractures were independently associated with decreased postoperative outcomes after ACLR when controlling for other demographic or clinical variables. Patients with large depression-type posterolateral tibial plateau impaction fractures (type IIIB) had an increased likelihood of having high-grade pivot-shift laxity on clinical examination under anesthesia.

Clinical Presentation and Outcomes Associated With Fabellectomy in the Setting of Fabella Syndrome.

BACKGROUND: Clinical outcomes pertaining to isolated lateral fabellectomy in the setting of fabella syndrome are limited to small case reports at this time. PURPOSE: To assess the most common presenting symptoms, clinical outcomes, and satisfaction after fabella excision in the setting of fabella syndrome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients with a minimum of 21-month follow-up after isolated fabellectomy for fabella syndrome were reviewed retrospectively. Clinical outcome scores of the following domains were collected: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Lysholm knee survey, along with a simple numeric patient satisfaction score (range, 1-10; 10 = "very satisfied"). Statistical analysis was performed using paired t tests for all clinical outcome data. RESULTS: A total of 11 isolated fabella excisions were included in 10 patients with isolated lateral-sided knee pain in the setting of fabella syndrome (8 males, 2 females), with a mean age of 36.9 years (range, 23-58 years) and a mean follow-up of 2.4 years (range, 21-47 months). A total of 8 patients (80%) were able to return to full desired activities, including sports. Only 5 of 11 (45%) excisions had concomitant lateral femoral condyle cartilage pathology. There were significant improvements across multiple WOMAC domains, and the WOMAC total score improved from 28.5 ± 17.6 preoperatively to 11.6 ± 10.2 postoperatively (P < .05). Lysholm scores significantly improved from 66.6 ± 23.1 preoperatively to 80.2 ± 13.9 postoperatively (P = .044). Overall patient-reported satisfaction was 8.8 ± 1.6. CONCLUSION: Fabella excision in the setting of fabella syndrome demonstrated improvements in clinical outcome scores, high rate of returning to preinjury level of activities, and low risk of complications or need for additional surgical procedures.

Comprehensive review of the physical exam for glenohumeral instability.

Glenohumeral instability is a common pathology of the shoulder joint, especially among young athletes. Despite advancements in technology and the widespread use of diagnostic imaging, a careful history and physical examination still remain the cornerstone of diagnosing patients with shoulder instability. Due to the involvement of many static and dynamic stabilizers, proficient physical examination can be challenging. With a systematic approach to clinical evaluation, the clinician can recognize characteristic patterns of relevant signs and symptoms and make an accurate diagnosis.

Type II Medial Meniscus Root Repair With Peripheral Release for Addressing Meniscal Extrusion.

Medial meniscal root tears are often disabling injuries that can occur in isolation during low-velocity, deep knee flexion maneuvers in middle-aged patients. The most common meniscal root tear pattern is a radial tear near the root attachment (type II). Root tears are often associated with meniscal extrusion, identified on magnetic resonance imaging. Relocation of the meniscal root to its anatomic center is a reported current difficulty faced by surgeons during surgical repair. However, this can be achieved via sufficient peripheral release of the posteromedial capsular attachment of the medial meniscus. The purpose of this Technical Note is to describe the authors' current surgical technique for medial meniscus root repair with a peripheral release for addressing meniscal extrusion. Classifications: level I (knee); level II (meniscus).

Patellar Tendon Tenotomy for Treatment of Patella Baja and Extension Deficiency.

Extension loss due to patella baja is a rare but devastating postoperative complication associated with knee surgery. The most common causes of patella baja are prolonged postoperative immobilization, over-distalization of the patellar tendon during patella-related surgical procedures (i.e., tibial tubercle osteotomy and patellar tendon reconstruction), and inadequate knee range-of-motion exercises postoperatively. Patella baja can cause significant functional limitations owing to knee-related stiffness, pain, and weakness. Arthroscopy with scar tissue debridement is the standard of care for patients with arthrofibrosis in whom conservative treatment has failed. However, when this surgical approach fails, patients with continued patella baja may be candidates for open patellar tendon tenotomy as a salvage procedure.

Acromioclavicular and Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Instability.

Numerous operative techniques have been described for acromioclavicular and coracoclavicular ligament reconstruction for the treatment of acromioclavicular joint instability. Injuries of this nature are commonly sustained by contact-sport athletes in high-impact collisions or falls. Traumatic injury to the acromioclavicular joint and ligamentous structures can range in severity, as can the degree of subsequent joint instability. Injuries classified between Type I and Type III are generally treated nonoperatively, whereas Type-IV injuries may be treated similarly to the treatment described in this article for Type-V injuries. The use of free tendon grafts in conjunction with suspensory devices has demonstrated reliable postoperative outcomes and low rates of unplanned reoperation. We present a surgical technique involving harvest of a semitendinosus autograft from the hamstrings, in addition to allograft augmentation. These free tendon grafts reestablish acromioclavicular joint stability following Rockwood Type-V or VI injuries to the joint. Note that there are differences in the outcomes of free tendon graft, suspensory devices, and modified Weaver-Dunn techniques commonly used to treat acromioclavicular joint instability. Although comparable outcomes have been reported for these modalities, treatment with hook plates and Kirschner wires has demonstrated the highest complication rates when used with this procedure. The Weaver-Dunn technique has been found to yield the lowest postoperative American Shoulder and Elbow Surgeons scores among the aforementioned techniques. Additionally, although other procedures may be less invasive, this technique is beneficial because it reinforces horizontal stability in addition to the vertical stability provided by other procedures, resulting in optimal overall shoulder stability. The procedure is performed as follows: (1) harvest the semitendinosus hamstring autograft, (2) dissect the acromioclavicular joint and prepare the acromion by passing sutures through a drilled tunnel, (3) prepare the coracoid in a fashion similar to that of the acromion, (4) prepare the clavicle and establish the trapezoid-clavicular attachment using an AC TightRope (Arthrex), (5) reduce the clavicle via contraction of the AC TightRope, (6) pass grafts and perform fixation of the trapezoid, (7) perform fixation of the acromioclavicular and conoid ligaments, and (8) skin closure with sutures. We acknowledge the inherent potential for complications when performing this procedure, and this is addressed at the appropriate points of concern throughout the video.

Ortho-Biologics for Ligament Repair and Reconstruction.

Biologics enhance tissue healing by stimulating the recovery processes for restoration of native or near-native tissue in addition to symptom management. The most popular biological modalities currently used include hyaluronic acid, growth factors therapy, platelet-rich plasma, and bone marrow aspirate concentrate. These treatment protocols are thought to facilitate and signal with cells or bioactive factors to improve ligament interventions by enhanced graft incorporation and strength, gene activation, and other mechanisms. Various growth factors regulate and improve cellular activities and proliferation, extracellular matrix deposition, and differentiation of mesenchymal stem cells into fibroblasts in the repair process of torn ligaments.