Does arthroscopic knee surgery work?

A recent randomized trial from the Finnish Degenerative Meniscal Lesion Study Group was published in the New England Journal of Medicine and attempted to determine the efficacy of partial meniscectomy without osteoarthritis. Patients were randomized to either arthroscopic partial meniscectomy or sham surgery. The authors concluded that the clinical outcomes after arthroscopic partial meniscectomy were no better than those after the sham surgical procedure. However, there are several important limitations of this trial that make it difficult to generalize to the 700,000 arthroscopic partial meniscectomies performed in the United States each year. In this small sample of 146 patients, patients with traumatic meniscal tears and locking symptoms-those most likely to benefit from a partial meniscectomy-were excluded. In addition, although patients with radiographic arthritis were excluded, most of the patients in the study had degenerative changes at the time of arthroscopy. Therefore it is difficult to determine whether the patients were symptomatic from their chondral degeneration or their degenerative meniscal tear. In our opinion this study does not change the role of surgery in current clinical practice. The primary indication for arthroscopic partial meniscectomy remains symptoms of well-localized joint line pain with acute onset and mechanical symptoms such as catching or locking that have failed comprehensive nonoperative management.

Anterior cruciate ligament reconstruction in patients aged > 40 years: a case-control study.

PURPOSE: To determine the outcomes of isolated anterior cruciate ligament (ACL) reconstruction in physically active patients aged > 40 years, and to compare these results with those of a younger patient cohort who underwent the same procedure. METHODS: A retrospective review was performed on all patients aged > 40 years who underwent ACL reconstruction between 2000 and 2008. A consecutive series of patients aged ≤ 25 years who underwent the same procedure during this same time period were selected as a control group. Age, sex, graft type, concomitant injuries, complications, and a validated outcome measure (Lysholm Knee Scoring Scale) were assessed at final follow-up. RESULTS: Forty-six patients (average age, 44.9 years; 28 men, 18 women) in the older group were identified and compared with 48 patients (average age, 21 years; 23 men, 25 women) in the younger group, with an average follow-up period of 5.4 and 5.1 years, respectively. There was no statistically significant difference between the groups in terms of associated injuries. The older group had a higher degree of cartilage degeneration (P = 0.0001). Lysholm scores averaged 90.3 in the older cohort compared with 88.7 in the younger cohort, with no statistical difference between groups. CONCLUSION: The older patients had outcomes comparable with the younger patients. Age alone should not exclude ACL-deficient patients from undergoing reconstructive surgery.

Complications in brief: Anterior cruciate ligament reconstruction.

When performing reconstruction of the ACL, the major complications that can arise include missed concomitant injuries, tunnel malposition, patellar fracture, knee stiffness, and infection. We review the complications that can occur as a result of errors made before, during, and after surgery.

Poly-L/D-lactic acid anchors are associated with reoperation and failure of SLAP repairs.

PURPOSE: This study investigates factors associated with failure and reoperation after glenoid labrum repair. METHODS: We studied a nonconcurrent cohort of consecutive patients undergoing arthroscopic superior labrum repair at a single institution by 2 fellowship-trained surgeons over a 10-year period. RESULTS: There were 348 patients included in this study with a mean age of 33.4 years (95% confidence interval [CI], 32.1 to 35.9) and a mean clinical follow-up of 12.3 months (95% CI, 10.9 to 13.8). The overall reoperation rate was 6.3%, with a revision labrum repair rate of 4.3%. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with Workers' Compensation claims (odds ratio [OR], 4.6; P < .001; 95% CI, 1.8 to 11.7), the use of tobacco (OR, 12.0; P = .03; 95% CI, 1.2 to 114.9), and the use of absorbable poly-L/D-lactic acid (PLDLA) anchors (100% correlation, P < .001). The OR for having repeat surgery was 12.7 (95% CI, 4.9 to 32.9; P < .001) with poly-96L/4D-lactic acid (Mini-Revo; Linvatec, Largo, FL) and also increased with the use of poly-70L/30D-lactic acid (Bio-Fastak and Bio-Suturetak; Arthrex, Naples, FL) anchor material (P = .04) after removal of the patients exposed to poly-96L/4D-lactic acid anchors. The rates of repeat surgery with PLDLA anchors from Linvatec and PLDLA anchors from Arthrex were 24% and 4%, respectively. None of the patients treated with nonabsorbable suture anchors (polyether ether ketone or metallic) returned to the operating room (P < .001). After we controlled for associated factors in a multivariate analysis, the use of absorbable anchors, in particular poly-96L/4D-lactic acid anchors (OR, 14.7; P < .001), and having a work-related injury (OR, 8.1; P < .001) remained independent factors associated with both repeat surgery and revision superior labrum repair. CONCLUSIONS: Bioabsorbable PLDLA anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors. Our recommendation is that glenoid labrum repairs be performed with nondegradable material and, specifically, that the use of anchors composed of PLDLA material should be avoided.

Eminence-based medicine versus evidence-based medicine: level V evidence in sports medicine.

Through extensive survey analysis, we investigated expert opinion in sports medicine. The study had 3 purposes: to provide clinical guidance for cases in which the correct action is not necessarily apparent, to examine expert opinion itself, and to delineate areas of future study. A total of 500 members of the American Medical Society for Sports Medicine and the American Orthopaedic Society for Sports Medicine evaluated a set of 25 statements on unresolved issues in sports medicine. The following 10 statements were deemed false: "It's okay for 12-year-old pitchers to throw curve balls; it's the pitch count that matters"; "Resistance training ('weight lifting') should be avoided until physeal closure"; "Jogging during pregnancy is to be avoided"; "At an athletic event, if sideline coverage is offered by an emergency medical technician and athletic trainer, there is little additional benefit from having a physician present"; "Contact sport athletes who sustain a second concussion should be excluded from contact sports permanently"; "The utility of pre-season medical screening is derived from the history; as such, student-athletes should complete a questionnaire, with physical examination reserved for only those with a positive relevant history"; "Femoroacetabular impingement is a myth-the designation of anatomic variation as disease"; "An AC (acromioclavicular) separation in a contact athlete should not be treated surgically if the athlete won't give up the sport; it will fail"; "Ankle taping induces weakness and atrophy of the dynamic stabilizers of the ankle"; "Only autografts should be used in ACL (anterior cruciate ligament) surgery, as allografts have an unnecessary high failure rate in clinical practice." One statement was accepted as true: "Surgery to treat anterior (patello-femoral) knee pain in a patient with normal patellar mechanics and stability is contraindicated." In short, expert opinion may be a helpful adjunct to clinical practice. Expert opinion cannot replace individual judgment and certainly does not trump the primary medical literature. Yet when better evidence is lacking, expert opinion is valuable for even the staunchest practitioner of evidence-based medicine.

Traumatic Hip Dislocation in an NCAA DI Football Player with Occult Sequelae: A Case Report.

BACKGROUND AND PURPOSE: American football generates the most sports-related injuries in the United States, with tackling as the leading injury mechanism. Overall injury rate at the collegiate level has been reported as 8.61 per 1,000 athlete exposures (AEs) - twice the rate of high school levels; competition injury rates are reported as high as 36.94/1000 AEs. Traumatic hip dislocation is an uncommon injury typically arising from high-energy axial impact with only 2-5.5% occurring during sports activities. CASE DESCRIPTION: A 22-year-old NCAA Division I football defensive back who experienced extreme left hip pain following contact with another player with his hip flexed during a game was diagnosed with a type 1 posterior hip dislocation, a grade 1 medial collateral ligament sprain with concomitant posterior thigh and hip muscle strains. Key impairments were limited left lower extremity motor performance, range of motion deficits, left hip pain, and diminished function and weight-bearing ability. OUTCOMES: The athlete reintegrated into typical defensive back off-season training approximately four to five months post injury without restrictions, however presented with new anterior hip pain seven months post injury revealing occult sequelae requiring surgical intervention. He was able to return to full play the following football season. DISCUSSION: This case report describes the successful return to sport of a Division I football player who sustained a traumatic posterior hip dislocation and complicated course including surgical intervention secondary to associated sequelae. LEVEL OF EVIDENCE: 5.

Prediction of ACL Injuries from Vertical Jump Kinetics in Division 1 Collegiate Athletes.

BACKGROUND: The incidence of ACL injuries continues to rise secondary to an increase in sport participation. Evidence supports the use of force plate testing to quantify kinetics during rehabilitation after injury and recovery; however, there is limited current research regarding if jump kinetics can identify athletes who are at higher risk for injury. Altered kinetics could potentially lead to abnormal force dissipation and resultant injury. PURPOSE: The purpose of this investigation was to identify whether the force-time variables from vertical jumps could predict ACL injuries in collegiate athletes. STUDY DESIGN: Retrospective cohort. METHODS: Vertical jump testing is performed by all healthy varsity collegiate athletes at several intervals throughout the athletic year at a Division I institution using a commercially available force plate system with dedicated software. Athletes who sustained an ACL injury between 1/1/15 and 6/1/19 were identified (n=16) and compared to healthy athletes who participated in the same sports (n = 262). ACL injuries were considered for this study if they occurred no more than 10 weeks after a jump test. The outcome variables were load, explode, and drive, operationally defined as the average eccentric rate of force development, average relative concentric force, and concentric relative impulse, respectively, which the system normalized to T scores. Mann-Whitney U tests were used to assess group differences for load, explode, drive, and the ratio between the variables. Logistic regression was used to determine if the battery of variables could predict whether or not an athlete would sustain an ACL injury. The p-value was set to 0.10 for the Mann-Whitney U tests, and 0.05 for the logistic regression. RESULTS: Significant differences between the ACL and healthy groups were seen for explode (p=0.08), drive (p=0.06), load:explode ratio (p=0.06), and explode:drive ratio (p=0.03). Explode and drive, when entered into the regression equation, showed the ability to predict injury, χ 2 = 6.8, df = 2, p=0.03. CONCLUSIONS: The vertical jump force plate variables were able to identify athletes who sustained an ACL injury within 66 days of testing. Athletes who sustained an ACL injury demonstrated altered kinetics and less ability to transmit forces during the vertical jump. LEVEL OF EVIDENCE: 3.

Implementation of an Injury Prevention Program in NCAA Division I Athletics Reduces Injury-Related Health Care Costs.

BACKGROUND: The estimated cost per year of injuries in collegiate athletics has been reported to be billions of dollars in the United States. Injury prevention programs are often assessed only by their ability to reduce injuries, and there is little evidence of any potential reduction in associated health care costs. PURPOSE: To investigate changes in injury-related health care costs at a National Collegiate Athletic Association (NCAA) Division I university after the implementation of an injury prevention program. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were 12 sports teams that used the injury prevention program (user group) and 16 teams that did not implement the program (nonuser group). The injury surveillance and prevention system (Sparta Science) utilized a commercially available force-plate system to assess kinematic variables, flag high-risk athletes, and guide individual conditioning programs. Data were obtained from 3 academic years before (2012-2014) and 2 academic years after (2015-2016) implementation of the Sparta Science system. The number of injuries and associated health care costs (surgery, clinic visits, imaging, and physical therapy) were compared between users and nonusers. RESULTS: Total average annual injuries did not change significantly between users and nonusers after implementation of the program; however, users demonstrated a 23% reduction in clinic visits as compared with a 14% increase for nonusers (P = .049). Users demonstrated a 13% reduction in associated health care encounters, compared with a 13% increase for nonusers (P = .032). Overall health care costs changed significantly for both groups, with an observed 19% decrease ($2,456,154 to $1,978,799) for users and an 8% increase ($1,177,542 to $1,270,846) for nonusers (P < .01 for both). Costs related to associated health care encounters also decreased by 20% for users as compared with a 39% increase for nonusers (P = .027). CONCLUSION: This study demonstrated the ability to significantly reduce injury-related health care costs in NCAA Division I athletes via a comprehensive injury surveillance and prevention program utilizing force-plate technology. Given the substantial and appropriate focus on value of care delivery across the US health care system, we recommend the continued study of sports injury surveillance and prevention programs for reducing injury-related health care costs.

A Rare Incident of Intraarticular Fibromatosis of the Knee: A Case Report.

CASE: Our patient is a 34-year-old male aHthlete who presented for consultation after left knee discomfort and pressure for greater than 2 years. Advanced imaging revealed a nonspecific intraarticular suprapatellar lesion with subsequent ultrasound-guided core biopsy demonstrating a spindle cell proliferation consistent with superficial fibromatosis. Thus, the patient underwent an open en bloc surgical resection by a fellowship-trained orthopaedic oncologist. CONCLUSION: As the first reported case of intraarticular fibromatosis of the knee, this case highlights the importance of a thoughtful approach to the management of nonspecific intraarticular lesions through a comprehensive and collaborative strategy to decrease patient morbidity and optimize outcomes.

The Comma Sign: The Coracohumeral Ligament and Superior Glenohumeral Ligament Exhibit Similar Quantitative Characteristics With Terminal Confluence at the Subscapularis Insertion.

PURPOSE: The purpose of this morphologic cadaveric study was to quantitatively define the composition of the previously described comma tissue along with its relation to the subscapularis tendon insertion. METHODS: Fresh frozen cadaveric shoulder specimens were included for analysis. The coracohumeral ligament (CHL) was exposed at its origin along the base of the coracoid process and freed laterally along its course to the lesser tuberosity adjacent to the bicipital groove. The superior glenohumeral ligament (SGHL) was identified and traced along its course deep to the CHL within the rotator interval with insertion onto the superior aspect of the lesser tuberosity. The midpoint diameters of the SGHL and CHL and their composite insertional diameters on the subscapularis tendon insertion and lesser tuberosity were measured with digital calipers. The mean diameter was determined from 3 measurements taken of each ligament. RESULTS: Eight specimens were included. With the use of digital calipers, the mean midpoint diameters of the SGHL and CHL were identified as 5.99 mm (range, 5.25-6.91 mm) and 5.13 mm (range, 4.28-5.72 mm), respectively. The composite insertional diameter of the SGHL and CHL on both the lesser tuberosity and humeral insertion of the subscapularis tendon was 9.93 mm (range, 6.69-12.05 mm). At its insertion, the SGHL and CHL comprised 54% and 46% of the comma tissue, respectively. Additionally, all specimens were identified as showing a confluence of the SGHL and CHL composite insertion with the subscapularis tendon at the point of its humeral head insertion. CONCLUSIONS: The comma tissue is a pivotal structure for the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of the midpoint diameter, insertional diameter, and composite distribution of the CHL and SGHL provided by this morphologic cadaveric analysis may aid surgeons in their efforts to restore the native anatomy. CLINICAL RELEVANCE: Subscapularis tendon tears have often been under-addressed during rotator cuff repair. The comma tissue has been described as an anatomic structure that can aid in the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of this important arthroscopic landmark may aid surgeons in their efforts to restore the native anatomy.

Arthroscopic Diagnosis of Occult Posterolateral Meniscocapsular Separations: Another Hidden Lesion.

PURPOSE: The purpose of this study was to describe the surgical findings and clinical outcomes in a series of patients with occult posterolateral meniscocapsular separations diagnosed arthroscopically after a negative magnetic resonance imaging (MRI) scan. METHODS: A retrospective analysis of prospectively collected data of consecutive patients who underwent surgical arthroscopy with repair of an occult posterolateral meniscocapsular separation by 2 fellowship-trained orthopaedic sports medicine surgeons at a single institution was performed. All lesions were identified arthroscopically in the posterolateral aspect of the lateral compartment as a distinct pathologic separation between the posterolateral capsule and adjacent meniscal tissue with increased excursion on probing. Clinical examination notes, MRI scans, and operative reports were reviewed. Patient-reported outcome measures were assessed via patient questionnaire. RESULTS: A total of 6 patients were included for analysis. MRI evaluation of the lateral meniscus was unrevealing in 4 patients, suggesting a possible tear of the body of the lateral meniscus in one patient and demonstrating a parameniscal cyst abutting the anterior root of the lateral meniscus in another patient. Arthroscopic examination revealed meniscocapsular separations of the posterolateral meniscus in all 6 knees, with 2 knees demonstrating concomitant bucket-handle meniscus tears. Patient-reported outcomes were determined for 67% of study patients. The average reported International Knee Documentation Committee score was 63.8, the average Knee Outcome Survey Activities of Daily Living Scale score was reported as 63, the 12-Item Short Form Survey (SF-12) Physical score averaged 46.8 with an average SF-12 Mental score of 59.9. CONCLUSIONS: The diagnosis of occult posterolateral meniscocapsular separations (MCS) could be missed on advanced imaging, such as MRI, so arthroscopic diagnosis may be required. This study indicates that arthroscopic diagnosis and repair of occult posterolateral MCS results in good functional and clinical outcomes. LEVEL OF EVIDENCE: IV, therapeutic case series.

The Disabilities of the Arm, Shoulder, and Hand questionnaire in intercollegiate athletes: validity limited by ceiling effect.

HYPOTHESIS: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire has been validated as an effective upper extremity specific outcome measure. Normative scores have not been established for young athletes. This study was conducted to establish normative DASH scores for intercollegiate athletes. We hypothesized that DASH scores in intercollegiate athletes differ from published values obtained from the general population. MATERIALS AND METHODS: The DASH questionnaire was administered to 321 athletes cleared for full participation in intercollegiate sports. Their scores were compared with normative values in the general population and 2 other age-matched cohorts. RESULTS: Intercollegiate athletes had significantly better upper extremity function compared with the general population (1.37 +/- 2.96 vs 10.10 +/- 14.68, P < .001) and an age-matched cohort of employed adults (1.37 +/- 2.96 vs 5.40 +/- 7.57, P < .0001). The DASH was 0 for 65.1%. Within this cohort, men reported better upper extremity function than women (0.98 vs 1.82, P = .010). Athletes participating in overhead sports reported worse upper extremity function than nonoverhead athletes (1.81 vs 0.98, P = .042). DISCUSSION: We report normative DASH values for a group of intercollegiate athletes and show a significant difference between the scores of these athletes and the general population. Within our cohort of competitive athletes, overhead sports and female gender are associated with significantly lower DASH scores and sports module scores. The utility of using these results are limited by a substantial ceiling effect in this population of competitive athletes. Differences within our cohort and differences between our cohort and other populations are minimized by this ceiling effect. Various upper extremity outcome measures may be similarly limited by a ceiling effect and should be examined for appropriateness before use. CONCLUSION: Intercollegiate athletes report significantly greater upper extremity function than the general population; however, validity of the DASH in these athletes is limited and population differences may be minimized by a substantial ceiling effect.

Profile of upper extremity strength and function in division 1 collegiate athletes.

OBJECTIVES: To profile shoulder strength and functional test scores in collegiate athletes across various sports. DESIGN: Cross-sectional. SETTING: Pre-participation physical screens for varsity athletes at a Division I university. PARTICIPANTS: 476 healthy Division 1 collegiate athletes (270 males; 27 varsity sports). MAIN OUTCOME MEASURES: Two trials of each 1. Isometric peak force (PF) using hand-held dynamometry for shoulder internal rotation (IR), external rotation (ER), and forward elevation (FE) in kg; 2. Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), quantified by number of touches. RESULTS: PF values (mean(SD), dominant/non-dominant) for females were: IR = 8.7(2.6)/8.7(6.2); ER = 8.2(2.5)/7.9(2.5); FE = 8.0(2.5)/8.0(2.7); CKCUEST scores were 21.8(3.9). PF values for males were: IR = 12.0(3.8)/11.9(3.6); ER = 10.7(3.4)/10.7(3.5); FE = 10.7(3.5)/10.4 (3.5); CKCUEST scores were 26.0(4.1) touches. CONCLUSIONS: Normative values should be used as an athlete's baseline for the CKCUEST. This may help target athletes who are at a higher risk of upper extremity injury and help with goals or return to sport readiness during the rehabilitation process.

USE OF AN UPPER EXTREMITY FUNCTIONAL TESTING ALGORITHM TO DETERMINE RETURN TO PLAY READINESS IN COLLEGIATE FOOTBALL PLAYERS: A CASE SERIES.

BACKGROUND/PURPOSE: Return to play decision making for upper extremity injuries is challenging due to a lack of evidence-based protocols and testing. Current guidelines utilize tests and measures with minimal evidence on re-injury risks and prediction. The purpose of this case series is to highlight a functional testing algorithm for upper extremities injuries and the outcomes for the patients that followed it. STUDY DESIGN: Case series. CASE DESCRIPTIONS: Six subjects (18 - 21 years old) who underwent shoulder capsulolabral repair secondary to recurrent instability and/or unyielding pain are included. All subjects underwent a criterion-based rehabilitation program before being assessed with the authors' upper extremity functional testing algorithm. The upper extremity functional testing algorithm consists of measures of active range of motion (AROM), passive range of motion (PROM), peak isometric force, a fatigue testing battery, and the closed kinetic chain upper extremity stability test (CKCUEST) to assess readiness for return to sport. OUTCOMES: All athletes achieved > 90% symmetry on at least two out of three tests during a fatigue testing protocol and at least 25 touches on the CKCUEST. All of the athletes returned to unrestricted football the season following surgical intervention. None of the athletes sustained an additional glenohumeral subluxation, dislocation, or upper extremity injury requiring surgical intervention for the remainder of their athletic careers (six years). DISCUSSION: The presented cases help to illustrate the effectiveness of the upper extremity functional testing algorithm to assess return to sport readiness for male collegiate football athletes. The algorithm included testing of AROM/PROM and strength that is typically used, but also included the CKCUEST and fatigue testing to further challenge and assess the upper extremity prior to returning to sports. LEVEL OF EVIDENCE: 4.

Cape-like Anomalous Confluence of the Long Head of the Biceps and Rotator Cuff in the Presence of a SLAP Tear: A Case Report.

CASE: A 25-year-old woman sustained an acute tear of her superior anterior-posterior labrum with arthroscopic identification of an anomalous origin of the long head of the biceps arising exclusively from the supraspinatus tendon with no attachment to the supraglenoid tubercle or superior labrum. CONCLUSION: This is the first report of a symptomatic superior labrum anterior-posterior tear in a patient with a rare anatomic confluence of the long head of the biceps to the supraspinatus. We recommend addressing the labral pathology with utilization of a standard technique because satisfactory results can be realized with isolated labral fixation to the glenoid, despite the absence of an attached biceps tendon.

Rehabilitation and functional outcomes in collegiate wrestlers following a posterior shoulder stabilization procedure.

STUDY DESIGN: Case series. CASE DESCRIPTION: Five consecutive collegiate Division I wrestlers, with a mean age of 20.2 years (range, 18-22 years), were treated postsurgical stabilization to address posterior glenohumeral joint instability. All received physical therapy postoperatively, consisting of range-ofmotion, strengthening, and plyometrics exercises, neuromuscular re-education, and sport-specific training. Functional outcome scores using the Penn Shoulder Score questionnaire were recorded at postsurgical initial evaluation and discharge. Isometric shoulder strength, measured with a handheld dynamometer at discharge, was compared with measurements made during preseason screening. OUTCOMES: Postsurgery, upon initial physical therapy evaluation, scores on the Penn Shoulder Score questionnaire ranged from 37 to 74 out of 100. All 5 wrestlers improved with rehabilitation such that their scores at discharge ranged from 81 to 91 out of 100. Mean external rotation-internal rotation strength ratio for the involved shoulder was 73.5% (range, 55.9%-88.7%) preseason and 80.9% (range, 70.2%-104.1%) postrehabilitation. Four patients were able to return to wrestling over a period of 1 season, with no episodes of reinjury to their surgically repaired shoulder. DISCUSSION: Current research on posterior glenohumeral instability is limited, due to the relatively rare diagnosis and infrequent need for surgical intervention. Providing a structured physical therapy program following this surgical procedure appeared to have assisted in a return to full functional activities and sports. LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2009;39(7):550-559, Epub 24 February 2009. doi:10.2519/jospt.2009.2952.

Meniscus tissue engineering on the nanoscale: from basic principles to clinical application.

The meniscus is a fibrocartilaginous tissue uniquely adapted to enable load transmission in the knee. Although the meniscus was once considered a useless remnant of joint formation, removal of all or part of the meniscus initiates osteoarthritis. Surgical repair methods focus on fragment stabilization or biologic enhancement of healing. An alternative approach based on tissue-engineering principles involves the development of new materials for implantation. Our meniscus tissue-engineering efforts aim to recapitulate the architectural features and mechanical anisotropies essential to native tissue function. We use a novel scaffold production technology called electrospinning, in which organized three-dimensional arrays of ultrafine biodegradable fibers are generated. Using these scaffolds as micropatterns for directed growth, we have generated constructs with mechanical properties and architectural features comparable to native meniscus. This review details our progress and outlines the remaining hurdles that must be addressed to translate this work into clinical implementation.

Surgeon Agreement on the Presence of Pathologic Anterior Instability on Shoulder Imaging Studies.

BACKGROUND: In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI). PURPOSE: To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship-trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated. RESULTS: The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38). CONCLUSION: Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.

MRI of HAGL lesions: four arthroscopically confirmed cases of false-positive diagnosis.

OBJECTIVE: The purpose of this article is to present the cases of four consecutive patients with preoperative MR diagnosis of humeral avulsion of the glenohumeral ligament (HAGL) who had no evidence of HAGL at arthroscopy. CONCLUSION: These four cases suggest that the diagnosis of HAGL should be reserved for arthroscopy and illustrate the difficulty in distinguishing HAGL from other abnormalities of the inferior glenohumeral ligament complex with MRI. Thus, MRI findings classically associated with HAGL should be more broadly described as defects of the inferior glenohumeral ligament complex. This terminology more accurately describes the abnormalities of the inferior glenohumeral ligament complex that may be depicted by MRI.

Acute and chronic management of posterolateral corner injuries of the knee.

Isolated injury to the PLC of the knee is rare. More commonly seen is injury to the PLC combined with other ligamentous and bony knee injuries, such as ACL and PCL tears and tibial plateau fractures. Prompt recognition and treatment of PLC injuries is important as failure to do so can compromise the success of PLC repair or reconstruction, as well as the success of associated ACL or PCL reconstructions. Clinical management of the PLC is dictated by the severity of injury and timing of diagnosis. A general treatment algorithm can be followed based on grade of injury, but individualized treatment is necessary for each patient and must be based on an understanding of the biomechanics of the injury and of surgical principles.