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Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. Purpose/Hypothesis: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. Study Design: Case-control study; Level of evidence, 3. Methods: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. Results: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. Conclusion: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

Background: Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair. Purpose: This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials. Results: From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, –0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, –0.06 [95% CI, –0.34 to 0.22]). Conclusion: Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements. Trial Registration: NCT00128076.

Background: The long-term outcomes of single- versus double-row fixation in arthroscopic rotator cuff repair are not currently known. Purpose: To compare the treatment effects of the single- versus double-row suture technique in arthroscopic rotator cuff repair of full-thickness tears at 10-year follow-up. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were evaluated at 10 years postoperatively. The primary outcome measure was the Western Ontario Rotator Cuff Index (WORC). Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, Constant score, strength, and incidence of revision surgery. Ultrasound was used to evaluate the rotator cuff to determine repair integrity. Statistical analyses consistent with those of the main trial were conducted. Results: Of the original 90 participants, 77 (85%) returned at a mean follow-up of 10 years. At ten year follow-up, the WORC score was higher in the double row group (79.9 [95% CI, 16.2 to 99.1]) compared with the single row group (72.9, [95% CI, 4.3 to 100]), P = .020. From baseline to 2 years, the mean change in WORC scores for the single-row group was –48.5 compared with −40.6 for the double-row group, with a between-group difference of −7.8 (95% CI, −20.4 to 4.7). From 2 to 10 years, the change in WORC scores for the single-row group was 11.5 compared with −0.2 for the double-row group, with a between-group difference of 11.7 (95% CI, −0.7 to 24.3). From baseline to 10 years, the mean between-group difference was 3.9 (95% CI, −7.8 to 15.6). Similarly, a decrease in ASES scores was observed between 2 and 10 years for the single-row group (9.2 [95% CI, 0.9 to 17.5]; P = .029), with a nonsignificant decrease in ASES scores for the double-row group (6.2 [95% CI, −3.2 to 15.6]; P = .195) as well as a decrease in Constant scores for both the single- (9.5 [95% CI, 1.4 to 17.5]; P = .020) and double-row (14.4 [95% CI, 5.6 to 23.3]; P = .001) groups. Overall, 3 participants developed a full-thickness tear after 2 years: 2 from the double-row group and 1 from the single-row group. One participant from each study group underwent revision surgery after the 2-year time point. Conclusion: A statistically significant (but likely not clinically important) difference in WORC scores was seen at 10-year follow-up in favor of double-row fixation. Between baseline and 10-year follow-up, a decrease in most outcome scores was observed in both the single- and the double-row groups. Registration: NCT00508183 ( ClinicalTrials.gov identifier).

Background: For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation. Hypothesis: There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players. Study Design: Case-control study; Level of evidence, 3. Methods: Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP. Results: A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone–patellar tendon–bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant. Conclusion: The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.

Objectives: Psychological outcomes may be important for predicting readiness to return to sport and guiding appropriate treatment intervention during rehabilitation for patients following anterior cruciate ligament (ACL) reconstruction. Motor confidence can vary based on the context or task in which it is measured, and clinician perceptions of patient confidence may not accurately reflect patient confidence for a given athletic task. The purpose of this study was to: 1) determine how confidence varies between the affected and unaffected limb, 2) compare patient-rated confidence with a clinician’s perception of patient confidence during the completion of a change-of-direction (COD) test and 3) determine how performance varies between standard hop and change of direction tests completed at six months following ACL reconstruction. Methods: 46 patients (76.36 ± 11.82 kg, 176.2 ± 8.8 cm, 24.3 ± 7.2 yrs., 19/46 Female; Table 1) completed a functional assessment at six months following ACL reconstruction with a bone-patellar-tendon-bone (n=18), quadriceps tendon (n=13) or hamstring (n=15) graft. Functional testing included the single, triple and triple crossover hops for distance and the timed 505 change-of-direction (505) test. Patients rated their confidence during the 505 tests on a scale from “0”, representing no confidence, to “10”, or complete confidence in their ability to complete the task. A single clinician indicated their perception of the patient’s confidence on a 10 cm visual analog scale, with scores converted to a 0-10 scale for agreement analysis. Results: Patient (unaffected limb median 9 (range 6-10), affected limb median 7 (3-10), Z=-5.842, ps(44) = 0.173, p=0.251) or unaffected limb (Κ = -0.048 (95%CI -0.140-0.044), p=0.346; Rs(44) = 0.12, p=0.428) during the 505 test. Completion time did not differ whether the 180 pivot was performed on the affected or unaffected limb (3.2 ±0.5 s vs. 3.2 ±0.5 s, p=0.858), while large differences in performance in the single (138 ±39 cm vs. 103 ±42 cm, p3,180) = 30.686, pConclusions: Clinician’s perceptions of patient confidence may not accurately reflect patient confidence during the 505 test, although this requires validation with a larger population of clinicians over a greater variety of tasks. Both patients and a clinician report lower confidence in their reconstructed knee during the 505 test despite comparable performance between limbs. Measuring time alone during the 505 may not accurately reflect underlying performance impairments, and measures of confidence and consideration of movement strategies or compensations may be required, alongside additional tests of lower extremity dynamic performance. Further research is required to clarify the importance of task-specific motor confidence against measures of readiness (i.e., ACL-RSI) and in the context of facilitating safe return to sport following ACL reconstruction.

Objectives: Persistent anterolateral rotatory laxity following anterior cruciate ligament reconstruction (ACLR) has been correlated with poor outcome and graft failure. We hypothesized that anterolateral complex reconstruction by way of a Lateral Extra-articular Tenodesis (LET) in combination with single bundle ACLR would reduce the risk of persistent rotatory laxity in young individuals who are deemed as being at high risk of failure. Methods: This is a pragmatic, multicenter, randomized clinical trial comparing standard hamstring tendon ACLR with combined ACLR and LET, utilizing a strip of iliotibial band (Modified Lemaire). Patients aged 25 years or less with an ACL deficient knee were included. They also had to have two of the following three criteria: 1) Grade 2 pivot shift or greater; 2) Returning to high risk/pivoting sports; 3) Generalized ligamentous laxity. The primary outcome was graft failure defined as either the need for revision ACLR or symptomatic instability associated with a positive asymmetric pivot shift, indicating persistent rotational laxity. Secondary outcome measures included the P4 pain scale, KOOS, IKDC. Patients were followed for two years with visits at 3, 6, 12 and 24 months postoperatively. A sample size of 300 per group was calculated based on a relative reduction in graft failure by 40%, with type 1 error of 5%, 80% power and 15% loss to follow-up rate. Results: 624 patients were randomized with a mean age of 18.9 (range: 14-25), 293 male. 436 (87.9%) patients presented pre-operatively with high-grade rotatory laxity (grade 2 pivot or greater) and 215 (42.1%) were diagnosed as having generalized ligamentous laxity (Beighton Score of 4 or greater). 523 of the 624 patients are at least 2 years postoperative; 29 lost to follow-up (˜5%). In the ACLR group 104/252 (41%) of patients suffered the primary outcome compared to 61/242 (25%) of the ACLR+LET patients (RR=0.61, 95%CI 0.47 to 0.79), pConclusion: The addition of LET to a hamstring autograft ACLR in young active patients significantly reduces graft failure and persistent anterolateral rotatory laxity at 2 years post operatively.

Objectives: The purpose of this study was to 1) determine the rates of popeye deformity following biceps tenotomy versus tenodesis 2) identify predictors for developing a deformity, and 3) report the subjective and objective outcomes in patients with a popeye deformity. Methods: Data for this study were collected as part of a randomized clinical trial comparing tenodesis versus tenotomy in the treatment of lesions of the long head of biceps tendon. Patients 18 years of age or older undergoing arthroscopic shoulder surgery with intraoperative confirmation of a lesion of the long head of the biceps tendon randomized to one of these techniques were included. The primary outcome measure for this sub-study was the rate of a popeye deformity at 24-months post-operative as determined by an evaluator blinded to group allocation. Secondary outcomes were presence/absence of a popeye deformity based on patients responding to the following question: “Do you notice a bulge on the front of your upper arm above your elbow?” If yes, patients indicated their satisfaction with the appearance of their arm on a 10 cm visual analog scale (VAS) with 0=“Unsatisfactory” and 10=“Satisfactory” as the anchors. Patients were also asked to indicate if they experienced pain or cramping on a VAS, and complete the American Shoulder and Elbow Score (ASES) and the Western Ontario Rotator Cuff score (WORC). Isometric elbow flexion and supination strength (ratio of affected and unaffected) were also measured. Kappa was calculated to measure interrater reliability between patient and evaluator on the presence of a deformity, and logistic regression was used to identify possible predictors of its occurrence. Pearson correlations were performed to identify factors associated with dissatisfaction in appearance. Results: Fifty-seven participants were randomly assigned to each group of which 42 in the tenodesis group and 45 in the tenotomy group completed a 24-month follow-up. The overall incidence of popeye deformity based on clinical assessment was 21%, 9.5% (4/42) in the tenodesis group and 33% (15/45) in the tenotomy group. The odds of a popeye deformity resulting from a tenotomy was 4.3 times that of tenodesis (OR 4.3, 95% CI: 1.25-14.76; p=0.018). Gender was tending towards significance with males having 7.3 greater odds of a perceived deformity (p=0.067), while age and BMI were not predictive. There were no differences between those with and without a perceived deformity with respect to subjective and functional outcome measures. Based on patient self-assessment, the overall incidence of a deformity was 18%, 25% in the tenotomy group and 10% in the tenodesis group. The odds of a patient reporting a popeye deformity following tenotomy was 3.66 relative to tenodesis (OR=3.66, CI 95% 1.08-12.44; p=0.038). Gender, BMI, and age were not predictive of self-report of a popeye. Those with and without a self-reported popeye deformity differed with respect to pain (p=0.001), cramping (0.039), and WORC scores (pConclusions: The odds of observing a popeye deformity based on clinical assessment following tenotomy was 4.3 times higher than tenodesis at 24-months post-operative. Male gender may contribute to increased incidence, while age and BMI were not major contributors to the presence/absence of a popeye. In patients who reported a popeye deformity, increasing age was associated with increased satisfaction in the appearance of the arm.

Failure analysis was performed for two humeral tray components which fractured in vivo after only 6 and 9 months. Implant retrieval analysis indicated that the components failed due to fatigue failure initiating from a small radius fillet at the interface of the trunnion and tray regions. Finite element simulations revealed the small radius fillet to have resulted in a large stress concentration and confirmed the possibility for fatigue failure in 6 months. The stress concentration caused by both the small radius fillet and the insufficient tray thickness contributed to the premature fatigue failure of the humeral trays.

Background: External rotation (ER) bracing has been shown to improve labral reduction in cadaveric studies, but this has not translated to universal improvement in re-dislocation rates in clinical series. Purpose: To systematically review and critically appraise the literature that investigates how well the labrum is actually reduced by ER in patients who have had an anterior shoulder dislocation. Study Design: Systematic review. Methods: We conducted a systematic review of the literature using the online databases Medline, EMBASE, and the Cochrane Controlled Trial Register. Studies were included if they reported on the difference in labral reduction after ER and internal rotation bracing in patients who had a traumatic anterior shoulder dislocation. Results: Of the 6 studies included, 5 assessed labral reduction on magnetic resonance imaging and 1 arthroscopically. Each study reported an overall improvement in labral reduction with ER, but anatomic reduction was not commonly achieved. This was despite the use of extreme positions that are unlikely to be well tolerated. Conclusion: External rotation results in anatomic reduction of the labrum in only 35% of cases. We postulate that failure to reduce the labrum may be a contraindication to ER bracing and propose further study to determine whether acute MRI could be used to help identify patients in whom ER achieves labral reduction in a comfortable position. This approach also has the advantage of avoiding the significant inconvenience of ER bracing in those in whom the labrum does not reduce and are therefore theoretically less likely to benefit. However, it is a novel strategy with significant resource implications and therefore warrants further study.

Benefits of graft harvest from the side contralateral to the anterior cruciate ligament (ACL)-deficient leg have been identified when using bone-patellar tendon-bone autografts in ACL reconstruction (ACLR). As hamstring tendon autografts are becoming more commonly used, a study examining the effect of contralateral graft harvest of semitendinosus gracilis (STG) tendons on patient quality of life was conducted.To evaluate if ACLR using a hamstring tendon autograft results in better patient quality of life if the graft is harvested from the leg contralateral to the ACL rupture compared with the ipsilateral leg.Randomized controlled trial; Level of evidence, 1.A total of 100 participants between 16 and 50 years of age with a complete ACL tear were randomly assigned to undergo ACLR using either the ipsilateral or contralateral leg as the STG graft donor. Primary outcome measures were the ACL Quality of Life questionnaire (ACL-QOL), concentric knee flexion and extension strength at 60 and 240 deg/s, International Knee Documentation Committee (IKDC) knee assessment form, early postoperative pain and diary of analgesic use, and rate of reruptures. Outcome measures were evaluated before surgery and at 3, 6, 12, and 24 months after surgery.The ACL-QOL score improved over time for both groups (P.001), and there were no significant differences between groups at any time point (P = .528). Significant differences in knee flexion and extension strength were found at 3 months after surgery. There were no differences between groups in IKDC knee assessment scores or rerupture rates.There does not appear to be any measurable benefit or drawback in quality of life to the use of an STG graft from the unaffected limb. In light of this finding, further research to examine other possible effects on agility and balance as well as time and ability to return to sport should be conducted. Longer term follow-up beyond 2 years would allow for a more thorough evaluation of the risk of reruptures or contralateral reruptures using this novel approach.

Objectives: The purpose of this prospective randomized, double blinded controlled trial was to compare patient-reported outcomes and clinical results between arthroscopic Bankart repair with and without arthroscopic infraspinatus remplissage in patients with anterior shoulder instability with a Hill-Sachs lesion. Failure to recognize and address large Hill Sach’s defects during arthroscopic stabilization surgery for glenohumeral instability is known to lead to high rates of recurrence. Arthroscopic remplissage has evolved in recent years as a reproducible technique with a proposed benefit of decreased dislocations. However, there are no high level clinical studies to conclusively support its efficacy in reducing redislocations. Methods: One hundred and four patients, aged 14 years and older, with a confirmed Hill Sach’s lesion on ultrasound, CT or MRI, were randomized intraoperatively after confirming an engaging Hill Sach’s lesion to either undergo arthroscopic infraspinatus remplissage (REMP) or no remplissage during arthroscopic Bankart repair (NO REMP). Exclusion criteria included a glenoid defect >15% of the AP glenoid diameter, significant shoulder arthropathy, infection, or medical comorbidities. The primary outcome measure was the Western Ontario Shoulder Instability score (WOSI). Secondary outcomes included the Simple Shoulder Test (SST), the American Shoulder and Elbow Society standardized assessment of shoulder function (ASES), active range of motion, stability tests, and incidence of revision surgery. Study time points were pre-, 3-, 6-, 12-, and 24-months post-operative. Significance level was 0.05. Results: A summary of demographics and outcomes are presented in Table 1. There were 53 patients (45 men, 8 women) randomized to REMP and 52 (46 men, 6 women) patients to NO REMP. The groups were comparable with regard to age, body mass index (BMI), and gender distribution). Both groups demonstrated a similar improvement in all subjective scores over time to 12-months post-operative with no difference between the groups (collection of data to 24-months post-operative is ongoing until 2019). The WOSI significantly improved from pre- to 12-months post-operative in both study groups. There were no differences between groups at any time point. ASES scores and SST scores followed a similar pattern. Additionally, there were no differences in range of motion between groups at any time point. There were 2/53 re-dislocations in REMP postoperatively compared to 6/52 in NO REMP; this difference was not significant (p=0.161). There were no differences between groups in reports of limitations in participation in sport attributed to the operated shoulder up to 12-months post-operative. Conclusion: Based on this study, there is no difference in subjective outcome scores and redislocations rates between remplissage and no remplissage for an engaging Hill Sach’s lesion while performing arthroscopic Bankart stabilization. As data continues to be gathered to 24-months post-operative including MRI, longer term benefits or drawbacks may become evident. Table 1. Subjective outcomes by group - Mean (SD). NO REMP REMP p-value WOSI (%): Pre 43 (21.7) 43.1 (17.5) 0.904 WOSI (%): 12 mo 79.1 (19.8) 81.1 (14.9) 0.645 ASES (%): Pre 69.2 (22.3) 74.1 (18.2) 0.239 ASES (%): 12 mo 89.1 (11.5) 89.1 (14.3) 0.990 SST (/12): Pre 9.1 (2.4) 8.9 (2.8) 0.675 SST (/12): 12 mo 11.4 (1.3) 11.5 (1.0) 0.631 Limited by shoulder in return to sport (0-100): 12 mo 27.4 (31.3) 20.9 (24.3) 0.351

Background The EndoPearl is an adjunct to bioabsorbable interference screw fixation in the femoral tunnel in anterior cruciate ligament (ACL) reconstruction. The purpose of the study was to assess the clinical effectiveness of the EndoPearl using the KT-1000 Knee Arthrometer and the Mohtadi ACL Quality of Life (ACL-QOL) Questionnaire. Hypothesis The application of the EndoPearl in hamstring ACL reconstruction has no significant benefit when compared to conventional treatment in KT-1000 and ACL-QOL Questionnaire outcomes. Study Design Prospective single-blind randomized clinical trial. Methods ACL reconstruction with autogenous semitendinosus and gracilis tendons was performed on 35 patients. Preoperatively, 3 months, 6 months, and 18 months postoperatively, patients’ knees were evaluated using the KT-1000 Knee Arthrometer and the ACL-QOL Questionnaire. Results Statistically significant differences were achieved in terms of KT-1000 side-to-side differences between the study group and the control group at 6 months and 18 months postoperatively; the mean side-to-side differences are significantly less in the study group when compared to the control group. Statistically significant differences were not detected when comparing the ACL-QOL Questionnaire between the two groups at all time intervals. Conclusion The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased laxity up to 18 months postoperatively in terms of KT-1000 side-to-side differences.

Objectives: To compare subjective patient-reported outcomes and objective clinical results between biceps tenotomy and tenodesis in patients with lesions of the long head of biceps tendon (LHBT). Methods: The study is a prospective, randomized, controlled trial targeting patients +18 years undergoing arthroscopic shoulder surgery to manage a lesion of the LHBT (+/- rotator cuff repair). Patients were excluded if they had previous surgery on their affected shoulder or any other significant medical comorbidity that could alter the effectiveness of the surgical intervention. Patients were allocated intraoperatively to undergo tenodesis or tenotomy via computer randomization once a LHBT lesion was confirmed. The primary outcome measure was the American Shoulder and Elbow Society standardized assessment of shoulder function (ASES). Secondary outcomes included: Western Ontario Rotator Cuff index (WORC), surgery time, patient reported pain and cramping, presence of a cosmetic deformity, elbow flexion and supination strength, and power. Study time points were pre, and 3, 6, 12, and 24 months post-operative. Magnetic resonance imaging (MRI) was conducted at 12-months post-operative. Results: Fifty-six participants were randomly assigned to each group. Table 1 summarizes the results to 12-months post-operative (collection of data to 24-months post-operative is ongoing until 2017). There were no significant differences in ASES score at pre- or post-surgery time points. In addition, no significant differences were found in WORC, surgery time, pain, or cramping. There was one significant difference in strength identified, the ratio of affected versus unaffected elbow flexion strength was greater in the tenodesis group (0.9 (SD=0.2)) versus the tenotomy group (0.8 (SD=0.3)) at 6-months post-operative. Otherwise, there were no differences in strength ratio identified for elbow flexion or supination strength or power at any time point. At 12-months post-surgery, the relative risk of cosmetic deformity in the tenotomy group relative to the tenodesis group based on patient report was 1.36 (p=0.41) with 12 out of 33 patients in the tenotomy group reporting a bulge in their upper arm compared to 8 out of 30 in the tenodesis group. Similar results were found based on clinical evaluation with a relative risk of 1.7 (p=0.36). MRI findings were available on 40 patients at the 12-month post-operative period. Of 23 in the tenodesis group, one was not intact and retracted 18 cm and two were partially torn. Of the 17 in the tenotomy group, none appeared retracted. Conclusion: Arthroscopic treatment of lesions of LHBT, whether tenodesis or tenotomy, was shown to have favourable results. Elbow flexion strength favoured tenodesis at 6-months, but otherwise there were no significant differences between groups. As data continues to be gathered to 24-month post-operative, longer-term benefits and drawbacks of each procedure may become evident. Table 1. Demographies and outcome measures by group. Tenodesis Tenotomy p-value Randomized (Men/Women) 56 (46/10) 56 (43/13) 0.48 Mean (SD) age (yrs) 58.8 (10.6) 56.0 (8.2) 0.13 Total surgery time (mins) 88 (42) 77 (36) 0.33 ASES: Pre 48.1 (17.7) 47.7 (15.8) 0.91 3-months 65.6 (19.1) 61.1 (22.3) 0.29 6-months 75.5 (18.3) 71.6 (23.5) 0.38 12-months 79.6 (20.3) 77.9 (20.2) 0.74 WORC: Pre 34.5 (15.5) 36.5 (13.2) 0.5 3-months 54.9 (20.4) 54.5 (21.0) 0.94 6-months 69.1 (21.3) 62.5 (22.7) 0.16 12-months 75.3 (21.4) 72.6 (22.8) 0.65 Pain: 3-months 5.3 (3.2) 5.9 (3.0) 0.34 6-months 6.6 (2.9) 6.5 (3.6) 0.96 12-months 7.8 (2.6) 7.1 (3.1) 0.31 Cramping: 3-months 7.4 (3.0) 8.1 (2.6) 0.26 6-months 7.7 (2.6) 7.8 (2.9) 0.88 12-months 8.3 (2.4) 7.7 (3.0) 0.4 Elbow flex strength (affected/unaffected ratio): 3-months 0.78 (0.4) 0.79 (0.2) 0.92 6-months 0.90 (0.2) 0.80 (0.3) 0.04* 12-months 0.98 (0.3) 0.90 (0.2) 0.2 Supination strength (affected/unaffected ratio): 3-months 0.88 (0.3) 0.88 (0.3) 0.99 6-months 1.01 (0.2) 0.92 (0.3) 0.25 12-months 1.01 (0.2) 1.03 (0.3) 0.83 Power (affected/unaffected ratio): 3-months 0.53 (0.3) 0.55 (0.2) 0.72 6-months 0.78 (0.4) 0.72 (0.3) 0.42 12-months 0.81 (0.3) 0.74 (0.3) 0.33 *Significant at p

Proprioceptive function of the knee was quantified and compared in three groups of patients: those with ante rior cruciate ligament deficiency, with hamstring ten dons-ligament augmentation device anterior cruciate ligament reconstructions, and with bone-patellar ten don-bone anterior cruciate ligament reconstructions. A total of 32 subjects, including 6 uninjured control sub jects, were tested for threshold to perception of passive motion of the knee. All other sensory input was neu tralized and testing occurred in the 30° to 40° range of knee flexion. The noninvolved contralateral knee served as a control for each subject. Each leg was moved at 0.5 deg/sec into flexion or extension in a random sequence. The variables of age, KT-1000 ar thrometer scores, injury-to-surgery interval, injury-to- followup interval, and patient satisfaction were statisti cally analyzed for correlation with threshold to perception of passive motion of the knee. Control sub jects showed no statistically significant differences in threshold between their two knees. The three test groups all showed significantly higher values in the involved knee compared with the noninvolved knee ( P < 0.01). However, no statistically significant differ ences were found between the groups, including con trols, with respect to mean threshold to perception of passive motion. According to these results, anterior cruciate ligament reconstruction did not improve pro prioception in the patients in this study.

Objectives: The primary objective of this study was to determine if quality of life and function are different following arthroscopic versus open tennis elbow release surgery. Based on retrospective studies, both approaches have been found to be beneficial, but no prospective randomized comparison has been conducted to date. Methods: Following a minimum six-months of conservative treatment, seventy-one patients (>16 yrs old) were randomized intraoperatively to undergo either arthroscopic or open lateral release. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), a 5-question VAS Pain Scale, and grip strength. Study assessments took place pre-, and 6-week, 3-, 6-, and 12-months post-surgery. Comparisons between groups and within groups over time were conducted using repeated measures ANOVA. A minimal clinically significant difference for the DASH had been previously identified as 15 points, and was used to compare groups as well at 12-months post-operative (Beaton et al. 2001). Results: Fifteen women and 19 men underwent the open procedure with a mean age of 47.1 years (6.7) and 13 women and 21 men were in the arthroscopic group with a mean age of 45.0 (6.9). No pre-surgery differences were found between groups based on age, sex, DASH or VAS scores. Both groups demonstrated a significant improvement in subjective measures and grip strength by 12-months post-surgery, and no significant differences were found between groups at any time point. The DASH, our primary outcome, decreased from a mean (SD) of 47.5 (14.5) pre-surgery to 21.9 (21.8) at 12-months post-surgery in the Open group and from 52.7 (16.0) to 22.6 (21.1) in the Arthroscopic group. VAS-pain scores (%) decreased in the Open group from 62.5 (17.2) pre-operatively to 30.0 (26.5) at 12-months. In the arthroscopic group, scores decreased from 63.7 (15.9) to 26.2 (24.6). Grip strength (kg) increased on the affected side from 23.6 (14.9) to 29.3 (16.3) and 21.4 (15.4) to 29.8 (15.4) for Open and Arthroscopic groups, respectively. The number of participants to reach the minimum clinically significant change did not differ between groups, 17 in the open group and 19 in the arthroscopic group. Ten in each group did not reach this threshold. Based on post hoc regression analysis, no factors (age, gender, WCB status, or smoking status) were found to be significant predictors of DASH or VAS outcome at 12-months post-surgery. However, this study was not adequately powered to draw any specific conclusions in this regard. The only significant difference between study groups was that the arthroscopic technique resulted in longer surgery time, 34.0 versus 22.5 minutes (p=0.005). Conclusion: Based on this study, there is no difference between arthroscopic and open tennis elbow release surgery in subjective outcome, specifically DASH and VAS pain scale, or in function, specifically, grip strength, at 12-months post-operative. Therefore, there may not be any benefit to the increased experience and operating room time required to perform a lateral release arthroscopically versus an open approach.

Background: Pulling the long head of the biceps tendon into the joint at arthroscopy is a common method for evaluation of tendinopathic lesions. However, the rate of missed diagnoses when using this technique is reported to be as high as 30% to 50%. Hypothesis: Tendon excursion achieved using a standard arthroscopic probe does not allow adequate visualization of extra-articular sites of predilection of tendinopathy. Study Design: Descriptive laboratory study. Methods: Seven forequarter amputation cadaveric specimens were evaluated. The biceps tendon was tagged to mark the intra-articular length and the maximum excursions achieved using a probe and a grasper in both beach-chair and lateral positions. Statistical analyses were performed using analysis of variance to compare means. Results: The mean intra-articular and extra-articular lengths of the tendons were 23.9 and 82.3 mm, respectively. The length of tendon that could be visualized by pulling it into the joint with a probe through the anterior midglenoid portal was not significantly different when using either lateral decubitus (mean ± SD, 29.9 ± 3.89 mm; 95% CI, 25.7-34 mm) or beach-chair positions (32.7 ± 4.23 mm; 95% CI, 28.6-36.8 mm). The maximum length of the overall tendon visualized in any specimen using a standard technique was 37 mm. Although there was a trend to greater excursion using a grasper through the same portal, this was not statistically significant. However, using a grasper through the anterosuperior portal gave a significantly greater mean excursion than any other technique (46.7 ± 4.31 mm; 95% CI, 42.6-50.8 mm), but this still failed to allow evaluation of Denard zone C. Conclusion: Pulling the tendon into the joint with a probe via an anterior portal does not allow visualization of distal sites of predilection of pathology. Surgeons should be aware that this technique is inadequate and can result in missed diagnoses. Clinical Relevance: This study demonstrates that glenohumeral arthroscopy does not allow visualization of common areas of pathology of the long head of the biceps tendon.