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Delayed reconstruction of chronic patellar tendon ruptures classically has yielded suboptimal results. Quadriceps contracture, distal patella mobilization, quadriceps lengthening (eg, V-Y lengthening), prolonged postoperative immobilization, residual quadriceps weakness, surgical macro failure, and loss of knee flexion are some of the complications associated with treatment for chronic patellar tendon rupture. Reinforcement hardware (eg, cerclage wire) may necessitate subsequent removal and the possibility of breaking with migration through the body. This article details the use and short-term success of a surgical technique using 2 Achilles tendon allografts for reconstruction of a chronic patellar tendon rupture.

Purpose: The purpose of this study was to compare the clinical outcome of single-row (SR) and double-row (DR) suture anchor fixation in arthroscopic rotator cuff repair with a systematic review of the published literature. Methods: We searched all published literature from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials for the following key words: shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, arthroscopicassisted, single row, double row, and transosseous equivalent. The inclusion criteria were cohort studies (Levels I to III) that compared SR and DR suture anchor configuration for the arthroscopic treatment of full-thickness rotator cuff tears. The exclusion criteria were studies that lacked a comparison group, and, therefore, case series were excluded from the analysis. Results: There were 5 studies that met the criteria and were included in the final analysis: 5 in the SR group and 5 in the DR group. Data were abstracted from the studies for patient demographics, rotator cuff tear characteristics, surgical procedure, rehabilitation, range of motion, clinical scoring systems, and imaging studies. Conclusions: There are no clinical differences between the SR and DR suture anchor repair techniques for arthroscopic rotator cuff repairs. At present, the data in the published literature do not support the use of DR suture anchor fixation to improve clinical outcome, but there are some studies that report that DR suture anchor fixation may improve tendon healing. Level of Evidence: Level III, systematic review of Levels I to III studies. Key Words: Rotator cuff—Rotator cuff tear—Arthroscopic rotator cuff repair—Single row—Double row—Transosseous equivalent.

BackgroundDetermination of appropriate treatment options for adult osteochondritis dissecans is difficult, as most published papers on surgical osteochondritis dissecans treatment report outcomes in a population consisting of both adult and juvenile patients.PurposeThis study examines the outcomes of surgical procedures in patients with adult osteochondritis dissecans.Study DesignCase series; Level of evidence, 4.MethodsThe cohort included 46 adult patients (48 knees) with adult osteochondritis dissecans of the knee who had undergone surgical treatment (debridement, drilling, loose-body removal, arthroscopic reduction and internal fixation, microfracture, osteo-chondral allograft, or autologous chondrocyte implantation). The average patient age was 34 6 9.5 years (range, 20-49) and patients were followed for 4.0 6 1.8 years. The mean defect size was 4.5 6 2.7 cm2. Outcomes were assessed via clinical assessment and established outcome scales, including the Lysholm, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner, Cincinnati, and Short Form-12.ResultsStatistically significant improvement (PConclusionPatients with adult osteochondritis dissecans of the knee, treated with surgical cartilage procedures, show durable function and symptomatic improvement at a mean 4.0 years of follow-up. Patients treated with arthroscopic reduction and internal fixation and loose-body removal demonstrated a greater improvement in outcome scores than those treated with osteochon-dral allograft.

Reconstruction of the anterior cruciate ligament (ACL) remains the most appropriate treatment for adolescent patients who are ACL deficient. This article reviews the indications for adolescent ACL reconstruction, potential risks, and the technique for allograft HISTORICAL PERSPECTIVE In the last 20 years, there has been an increase in the literature pertaining to the management of a skeletally immature patient with anterior cruciate ligament (ACL) injuries. With increasing involvement of children in sports, an increase in ACL injuries in this population has been reported.' In a survey of members of the Herodicus Society and the ACL Study Group, Kocher et al2 reported that the members studied a mean of 5.8 pediatric patients with ACL injuries annually. In addition, 78% of those surveyed stated that they had performed an ACL reconstruction on a skeletally immature patient within the previous year. Historically, ACL reconstruction in skeletally immature patients has been discouraged because of the theoretical risks of damage to the physes and the risk of growth disturbance. However, the case series data available in the literature have not supported a significant pattern of leg length discrepancy or angular deformity caused by ACL reconstruction in adolescent patients.3"10 Controversy still exists between nonoperative management and surgical reconstruction of these patients based on the potential risks of both treatment options. Nonsurgical treatment risks an unstable knee and further damages the meniscal structures and articular cartilage. Anterior cruciate ligament injuries in adolescents behave similarly to those injuries in adults; chondral and meniscal injuries are common. Operative reconstruction risks potential damage to the growth plate. Previous research has shown that 21% to 100% of pediatric patients with ACL injuries will have a concomitant meniscal injury.1'4'5'10"14 In addition, there is a risk of exacerbating initial injury or new meniscal damage if the knee remains chronically unstable.5'15'16 Growth plate arrest after ACL reconstruction, although a concern, has only been infrequently reported.2'17'18 Furthermore, the treatment of physeal arrest is soft tissue interposition, and for this reason, hamstring tendon grafts have

Background Windmill pitching produces high forces and torques at the shoulder and elbow, making the biceps labrum complex susceptible to overuse injury. Little is known about the muscle firing patterns during a windmill pitch. Hypothesis Biceps muscle activity is greater during a windmill pitch than during an overhand throw. Study Design Descriptive laboratory study. Methods Seven female windmill pitchers underwent motion analysis and surface electromyography evaluation of their biceps muscles during windmill and overhand throwing. Marker motion analysis, muscle activity, and ball release were captured simultaneously. Surface electromyography trials were collected and related to the athletes’ phases of pitching and throwing, identified based on predefined softball and baseball pitching mechanics. Results Throws were of similar velocity (24 m/s, 53 mph, P =. 71), but peak biceps brachii muscle activation during the windmill pitch was significantly greater than during the overhand throw when normalized (38% vs 19% manual muscle test, P =. 02). The highest muscle activity occurred at the 9-o'clock phase of the windmill pitch, during which the biceps brachii undergoes eccentric contraction. In the overhand throw, the highest level of biceps activity occurred during arm cocking. Conclusion In female athletes, biceps brachii activity during the windmill pitch is higher than during an overhand throw and is most active during the 9-o'clock and follow-through phases of the pitch. Clinical Relevance Repetitive eccentric biceps contractions may help explain the high incidence of anterior shoulder pain clinically observed in elite windmill pitchers. Injury prevention and treatment mechanisms should focus on the phases with the highest muscle activity.

Treatment of the overhead throwing athlete is among the more challenging aspects of orthopaedic sports medicine. Awareness and understanding of the throwing motion and the supraphysiologic forces to which the structures of the shoulder are subjected are essential to diagnosis and treatment. Pain and dysfunction in the throwing shoulder may be attributed to numerous etiologies, including scapular dysfunction, intrinsic glenohumeral pathology (capsulolabral structures), extrinsic musculature (rotator cuff), or neurovascular structures. Attention to throwing mechanics and appropriate stretching, strength, and conditioning programs may reduce the risk of injury in this highly demanding activity. Early discovery of symptoms, followed by conservative management with rest and rehabilitation with special attention to retraining mechanics may mitigate the need for surgical intervention. Prevention of injury is always more beneficial to the long-term health of the thrower than is surgical repair. An anatomic approach is used in this report, focusing on common etiologies of pain in the overhead thrower and emphasizing the clinical presentation and treatment.

Patellofemoral kinematics after a limited resurfacing of the trochlea was investigated. Patellofemoral contact pressure, area, and force were measured for intact state; after creation of a 20-mm full-thickness trochlear defect; and after trochlear resurfacing implant (Arthrosurface) in serial flexion positions (45 degrees, 60 degrees, 75 degrees). In the defect state, edge loading and peak contact forces were highest at the periphery. The chondral defect increased peak contact force (13 to 18 N, P < .01) and peak contact pressure (23 to 31 kg/cm2, P < .02) compared with the intact state. Peak contact pressure and force were restored to 90% (P < .01) and 88% (P < .01). Implantation of the device restored contact area to 85% of the intact state. Limited resurfacing of the trochlea restores contact area, peak pressure, and peak force to the intact state. These findings highlight the potential clinical use of limited patellofemoral resurfacing in trochlear chondral defects.

BackgroundAnteromedialization of the tibial tuberosity has been shown to decrease mean total contact pressures of the lateral trochlea and to shift contact pressures to the medial trochlea.HypothesisModifying the anteromedialization osteotomy to a straight anteriorization osteotomy of the tibial tuberosity can decrease trochlear contact pressures without a resultant medial shift of forces to the medial trochlear contact area.Study DesignControlled laboratory study.MethodsTen cadavers were tested before and after straight anteriorization tibial tuberosity osteotomy by loading the extensor mechanism with 89.1 and 178.2 N at 0°, 30°, 60°, and 90° of flexion following a validated patellofemoral joint loading protocol. Contact pressures were measured with electroresistive pressure sensors placed directly on the trochlea.ResultsThe mean trochlear contact pressures after osteotomy decreased significantly ( P < .05) for loads of 89.1 and 178.2 N at both 30° (23% and 20%, respectively) and 60° (18.7% and 31.9%, respectively) of knee flexion. The peak contact pressures decreased significantly ( P < .05) for loads of 89.1 and 178.2 N at 30° (24.3% and 27.0%, respectively) and 60° (31.9% and 24.5%, respectively) and for loads of 89.1 N at 90° (13.4%) of knee flexion.ConclusionThe authors demonstrated significantly decreased trochlear contact forces after straight anteriorization osteotomy of the tibial tuberosity, without a significant resultant medial shift of the center of force.Clinical RelevanceStraight anteriorization of the tibial tuberosity may be a useful adjunct for patients with medial articular defects of the patellar or trochlea in whom anteromedialization would be otherwise contraindicated.

Background There is increasing interest in comparing the efficacy of single-bundle versus double-bundle anterior cruciate ligament reconstruction. Challenging this comparison, however, has been the lack of an established consensus on the success of single-bundle reconstruction. Hypothesis The current outcomes of single-bundle reconstruction can be clarified from a large unbiased body of evidence for future comparisons with double-bundle reconstructions. Study Design Systematic review. Methods A systematic review of 11 randomized, controlled trials comparing patellar tendon and hamstring tendon grafting is reported. The respective outcomes of each group were combined to assist the orthopaedic surgeon in assessing the current success of single-bundle reconstruction. The primary factors assessed were tibial subluxation and side-to-side differences in laxity. Secondary outcomes included concomitant injuries and treatments, complications, graft failure, range of motion, and radiographic evidence of degenerative changes. Results In this review of 1024 single-bundle anterior cruciate ligament reconstructions, 495 concomitant meniscal tears, 95 chondral injuries, and 2 posterior cruciate ligament tears were noted. The complication rate was 6%, and graft failure 4%. Reported pivot-shift test results were negative in 81 % of cases; reported Lachman tests were negative in 59% cases; and KT-1000 arthrometer side-to-side differences were ≤5 mm in 86% of cases. Flexion and extension deficits were reported in 9 of 11 studies through mean range of motion or deficit ranges. Radiographic changes of articular surface abnormalities were observed in 7% of the knees at follow-up investigation. Conclusion Systematic review of a significant body of unbiased outcome data on single-bundle anterior cruciate ligament reconstruction demonstrates it to be a safe, consistent surgical procedure affording reliable results. Clinical Relevance These results may be used to assist orthopaedic surgeons in evaluating the benefit and practicality of pursuing new anterior cruciate ligament reconstruction techniques over standard single-bundle anterior cruciate ligament reconstruction.

The majority of current techniques to reconstruct the anterior cruciate ligament (ACL) focus on replacing the native 2-bundle ACL with a single-bundle graft. Subjective complaints of instability may persist despite a seemingly normal appearance of the ACL graft. Upon closer inspection, many such failures are noted to be due to vertically oriented grafts. Critical evaluation of ACL revision surgery has led to the recognition that surgeons may inadvertently create a vertically oriented graft, essentially replacing only the anteromedial bundle of the ACL and thus losing the rotational stability provided by the posterolateral bundle. This article describes a "hybrid" single-bundle ACL reconstruction technique using a transtibial drilled femoral tunnel and standard ACL instrumentation, which offers an alternative to the double-bundle ACL reconstruction, providing anterior-posterior, as well as rotational stability, effectively replacing portions of both the anteromedial and anteromedial bundles of the ACL with a single, obliquely oriented graft positioned more laterally on the intercondylar notch.

Advances in surgical technique and implants for arthroscopic rotator cuff repair have generated an interest in the indications and application of doubleand singlerow repairs. Recently, a variation of the double-row technique, known as the transosseous equivalent repair, has also been described. Previous reports of unacceptably high failure rates after arthroscopic repair of large and massive rotator cuff tears have led to the scrutiny of both this technique and the implants used. Biomechanically, double-row techniques are superior to single-row with respect to restoring the anatomic footprint, minimizing gap formation, and providing a greater load to failure at time equals zero. Furthermore, the recently described transosseous equivalent fixation technique provides improved footprint restoration, greater contact pressure across the bone-tendon interface, and an increased load to failure when compared to doublerow repair. Although the biomechanical data are encouraging, clinical studies are still in progress to assess the efficacy of double-row versus single-row techniques, particularly with regard to tendon healing. The potential advantages may be offset by the added surgical time, required technical expertise, and potential increase in cost. The purpose of this study is to review the biomechanical, histological, and in vivo results of double-row and transosseous equivalent arthroscopic rotator cuff repairs while also discussing our indications and technique for double-row repairs.

Posterior wall blowout is an important potential source of anterior cruciate ligament reconstruction failures that can be avoided if surgeons adhere to proper technique and are vigilant in confirming appropriate femoral tunnel placement. This article reviews techniques for avoidance, recognition, and salvage of posterior wall blowouts in anterior cruciate ligament reconstruction surgery.

Biceps tenodesis is a common procedure performed for tendinopathy of the long head of the biceps brachii (LHB). Indications include partial-thickness LHB tear, tendon subluxation with or without subscapularis tear, and failed conservative management of bicipital tenosynovitis. Biceps tenodesis may also be performed for superior labrum anterior to posterior tears. Evaluation of biceps stability is important in the treatment of LHB pathology. We advocate a technique of subpectoral biceps tenodesis. Interference screw fixation has demonstrated biomechanical superiority in laboratory models. If there are any concomitant operations, such as rotator cuff repair, the postoperative rehabilitation protocol may need to be adjusted. Overall, subpectoral biceps tenodesis with interference screw fixation has had excellent clinical outcomes and low complication rates.

Background: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed procedure that is highly successful in restoring knee stability and function. The incidence of early ACLR complications and the risk factors for these complications are not well defined. Purpose: To determine the incidence of 30-day complications and patient and surgical risk factors for complications after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent ACLR between 2005 and 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database using Current Procedural Terminology billing codes. Postoperative complications in the 30-day period after surgery were identified. Potential patient and surgical risk factors for 30-day complications after ACLR were analyzed using univariate and multivariate analyses. Results: A total of 4933 patients were identified. Major complications occurred in 27 patients (0.55%), and minor complications occurred in 43 patients (0.87%), with overall complications occurring in 66 patients (1.34%). The most common complications were symptomatic deep venous thrombosis requiring treatment (n = 27; 0.55%), return to the operating room (n = 18; 0.36%), superficial infections (n = 10; 0.20%), deep infections (n = 7; 0.14%), and pulmonary embolism (n = 6; 0.12%). A single mortality (0.02%) occurred. Multivariate analyses demonstrated that smoking, dyspnea, a history of chronic obstructive pulmonary disease, and recent weight loss were all risk factors for the development of overall complications, although in combination, these factors accounted for only 3% of the variance in the complication rate. Conclusion: ACLR has a low incidence of complications (1.34%) in the early postoperative period, with the most common being symptomatic venous thromboembolic disease requiring treatment, return to the operating room, and infections. Because ACLR is an elective procedure, surgeons should use this information to counsel patients on risks and to guide their decision making about patient selection.

We conducted an online survey of National Hockey League (NHL), Major League Soccer (MLS), and US Olympic/World Cup Ski/Snowboard (Olympic) team orthopedic surgeons to determine practice patterns relating to anterior cruciate ligament (ACL) reconstruction in elite athletes. Of the 94 team orthopedic surgeons surveyed, 47 (50%) responded. Mean (SD) experience as a team physician was 7.73 (5.33) years for NHL, 6.77 (6.64) years for MLS, and 1.14 (0.36) years for Olympic. Mean (SD) number of ACL reconstructions performed in 2012 was 101 (51) for NHL, 78 (38) for MLS, and 110 (105) for Olympic. Overall, 33 surgeons (70.2%) indicated they would use bone-patellar tendon-bone (BPTB) autograft to treat their starting athletes. Twenty-one (44.7%) drilled the femoral tunnel through a transtibial portal, 36.2% through an anteromedial portal, and 12.8% by a 2-incision technique. All the surgeons used a single-bundle technique. Thirty-three (70.2%) did not recommend a brace for their elite athletes during play on return to sport (RTS). Twenty-seven NHL and MLS surgeons (81.8%) recommended RTS only after an athlete has passed a series of RTS tests (eg, Vail, single-leg hop). Most of the NHL, MLS, and Olympic team orthopedic surgeons who were surveyed perform their ACL reconstructions using BPTB autograft, using a single-bundle technique, and through a transtibial portal, and do not require bracing for their athletes returning to sport. Most required their athletes to complete a series of RTS tests before resuming competitive play.

Background: Anterior cruciate ligament (ACL) rupture is a significant injury in male Major League Soccer (MLS) players in the United States. Purpose: To determine (1) return-to-sport (RTS) rate in MLS following ACL reconstruction (ACLR), (2) timing of RTS, (3) performance upon RTS, and (4) the difference in RTS and performance between players who underwent ACL reconstruction (ACLR) and controls. Study Design: Case-control study; Level of evidence, 3. Methods: MLS players undergoing ACLR between 1996 and 2012 were evaluated. Player data were extracted from publically available sources. All demographic data were analyzed. A control group of players matched by age, body mass index (BMI), sex, position, performance, and MLS experience (occurred at 2.6 years into career, designated “index year”) was selected from the MLS during the same years as those undergoing ACLR. The RTS and performance in the MLS were analyzed and compared between cases and controls. Student ttests were performed for analysis of within- and between-group variables. Results: A total of 52 players (57 knees) that met inclusion criteria underwent ACLR while in the MLS. Mean player age was 25.6 ± 3.98 years. Forty players were able to resume play (77%). Of the 40 players (45 knees), 38 (43 knees; 95%) resumed play the season following ACLR (mean, 10 ± 2.8 months after surgery). Mean career length in the MLS after ACLR was 4.0 ± 2.8 years. The revision rate was 10%. There was a significant increase in the incidence of ACL tears in the MLS by year ( P < .001), and there was a significantly ( P= .002) greater number of ACL tears on the left knee as opposed to the right. Performance in the MLS upon RTS after ACLR was not significantly different versus preinjury. There was no significant difference in survival in the MLS between cases and controls after ACLR or index year. The only significant performance differences between cases and controls were that cases had significantly greater shots taken per season ( P= .005) and assists ( P= .005) than did controls after the index year. Conclusion: There is a high RTS rate in the MLS following ACLR. Nearly all players resumed play the season after surgery. Performance was not significantly different from preinjury. Only 2 performance measures (shots taken and assists) were significantly different between cases and controls. A significantly greater number of ACL tears occur in the left versus the right knee.

ACL (anterior cruciate ligament) reconstruction is one of the most commonly performed and studied procedures in modern sports medicine. A multitude of objective and subjective patient outcome measures exists; however, nonstandardized reporting patterns of these metrics may create challenges in objectively analyzing pooled results from different studies. The goal of this study was to document the variability in outcome reporting patterns in high-impact orthopaedic studies of ACL reconstruction.All clinical studies pertaining to ACL reconstruction in four high-impact-factor orthopaedic journals over a five-year period were reviewed. Biomechanical, basic science, and imaging studies were excluded, as were studies with fewer than fifty patients, yielding 119 studies for review. Incorporation of various objective and subjective outcomes was noted for each study.Substantial variability in reporting of both objective and subjective measures was noted in the study cohort. Although a majority of studies reported instrumented laxity findings, there was substantial variability in the type and method of laxity reporting. Most other objective outcomes, including range of motion, strength, and complications, were reported in50% of all studies. Return to pre-injury level of activity was infrequently reported (24% of studies), as were patient satisfaction and pain assessment following surgery (8% and 13%, respectively). Of the patient-reported outcomes, the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores were most often reported (71%, 63%, and 42%, respectively).Substantial variability in outcome reporting patterns exists among high-impact studies of ACL reconstruction. Such variability may create challenges in interpreting results and pooling them across different studies.

Purpose To assess the quality and variability found across anterior cruciate ligament (ACL) rehabilitation protocols published online by academic orthopaedic programs. Methods Web-based ACL physical therapy protocols from United States academic orthopaedic programs available online were included for review. Main exclusion criteria included concomitant meniscus repair, protocols aimed at pediatric patients, and failure to provide time points for the commencement or recommended completion of any protocol components. A comprehensive, custom scoring rubric was created that was used to assess each protocol for the presence or absence of various rehabilitation components, as well as when those activities were allowed to be initiated in each protocol. Results Forty-two protocols were included for review from 155 U.S. academic orthopaedic programs. Only 13 protocols (31%) recommended a prehabilitation program. Five protocols (12%) recommended continuous passive motion postoperatively. Eleven protocols (26%) recommended routine partial or non–weight bearing immediately postoperatively. Ten protocols (24%) mentioned utilization of a secondary/functional brace. There was considerable variation in range of desired full-weight-bearing initiation (9 weeks), as well as in the types of strength and proprioception exercises specifically recommended. Only 8 different protocols (19%) recommended return to sport after achieving certain strength and activity criteria. Conclusions Many ACL rehabilitation protocols recommend treatment modalities not supported by current reports. Moreover, high variability in the composition and time ranges of rehabilitation components may lead to confusion among patients and therapists. Level of Evidence Level II.

Purpose To compare the cost-effectiveness within the United States health care system of arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy. Methods An expected-value decision analysis was constructed comparing the costs and outcomes of patients undergoing arthroscopic rotator cuff repair and reverse total shoulder arthroplasty for large and massive rotator cuff tears (and excluding cases of cuff-tear arthropathy). Comprehensive literature search provided input data to extrapolate costs and health utility states for these outcomes. The primary outcome assessed was that of incremental cost-effectiveness ratio (ICER) of reverse total shoulder arthroplasty versus rotator cuff repair. Results For the base case, both arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an ICER of $15,500/quality-adjusted life year (QALY) and $37,400/QALY, respectively. Arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes. Arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY. Conclusions Arthroscopic rotator cuff repair—despite high rates of tendon retearing—for patients with large and massive rotator cuff tears may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty and when assuming no detrimental impact of previous surgery on outcomes after arthroplasty. Clinical judgment should still be prioritized when formulating treatment plans for these patients. Level of Evidence Level II, economic decision analysis.

The number of primary anterior cruciate ligament (ACL) tears is rapidly increasing. In patients who wish to return to their preoperative level of function, specifically as it pertains to participation in sports, the gold standard of treatment following an ACL tear remains an anterior cruciate ligament (ACL) reconstruction. Despite a majority of good/excellent results following primary ACL reconstruction, there is a growing subset of patients with persistent or recurrent functional instability who require revision ACL reconstruction. Preoperative planning for revision ACL reconstruction requires a careful understanding of the root cause of ACL failure, including possible technical causes of primary ACL failure and the presence of combined knee pathology that was not addressed at the index ACL reconstruction. The decision to perform 2-stage revision ACL reconstruction is multifactorial and is reached by technical considerations that may make a 1-stage revision less optimal, including tunnel widening, arthrofibrosis, active infection, and others. Concomitant knee pathology such as meniscal deficiency, malalignment (including an increase in posterior tibial slope), chondral lesions, and other ligamentous laxity may also require a staged approach to treatment. This evidence-based review covers the indications for 2-stage revision ACL reconstruction, surgical techniques, evidence for and technique of bone grafting prior ACL tunnels, and outcomes of 2-stage revision stratified by initial cause of ACL reconstruction failure. With proper preoperative planning and an understanding of the cause of failure following the primary ACL reconstruction, revision ACL reconstruction can offer excellent outcomes in the motivated patient. [ Orthopedics. 2016; 39(3):e456–e464.]

Background: Overuse injuries to the elbow in the throwing athlete are common. Ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, is performed on both recreational and high-level athletes. There is no current literature regarding the incidence and demographic distribution of this surgical procedure in relation to patient age, location within the Unites States, and sex. Purpose: To determine the current demographic distribution of UCLR within the US population included in the PearlDiver database. Study Design: Descriptive epidemiology study. Methods: A retrospective analysis of the PearlDiver supercomputer database, a private-payer database, was performed to identify UCLR procedures performed between 2007 and 2011. The Current Procedural Terminology (CPT) code 24346 (reconstruction of the ulnar collateral ligament of the elbow with the use of a tendinous graft) was used. Results: Between 2007 and 2011, a total of 790 patients underwent UCLR. The average (±SD) annual incidence was 3.96 ± 0.38 per 100,000 patients for the overall population but was 22 ± 3.4 for patients aged 15 to 19 years. The overall average annual growth was 4.2%. There were 695 males and 95 females. The 15- to 19-year-old patients accounted for significantly more procedures than any other age group (56.8%; P < .001), followed by 20- to 24-year-olds (22.2%). The incidence of UCLR in the 15- to 19-year-old group increased at an average rate of 9.12% per year ( P = .009). Significantly more UCLR procedures were performed in the southern United States than in any other region ( P < .001). The number of procedures significantly increased over time ( P = .039). Conclusion: According to this database of a privately insured population, UCLR was performed significantly more in patients aged 15 to 19 than any other age group. The average annual incidence of UCLR per 100,000 people for patients aged 15 to 19 was 22 ± 3.4. Further, this database showed that the number of UCLR procedures is increasing over time. Further work should address risk reduction efforts in this at-risk population.

Objectives: Purpose: Overuse injuries to the elbow in the throwing athlete are common. Ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, is performed on both recreational and high-level athletes. There is no current literature regarding the incidence and demographic distribution of this surgical procedure in relation to age, location within the Unites States (U.S.), and gender. The purpose of this study is to determine the current demographic distribution of UCLR within the U.S. Methods: Methods: A retrospective analysis of private payer database using the PearlDiver Supercomputer (Warsaw, IN) was performed to identify UCLR procedures performed between the years of 2007-2011. The Current Procedural Code (CPT) 24346 (reconstruction of the ulnar collateral ligament of the elbow with the use of a tendinous graft) was used. Statistical analysis was performed as appropriate using STATA (Version 12.1; Statacorp; College Station, TX, USA). Results: Results: Between 2007-2011, 790 patients underwent UCLR. The overall average annual incidence was 2.16+/- 0.27 per 100,000 patients, but was 31.9 +/-3.9 for patients aged 15-19. The average annual growth was 5.72%. There were 695 males and 95 females. Fifteen to 19 year olds accounted for significantly more procedures than any other age group 56.8% (pConclusion: Conclusion: UCLR was performed significantly more in patients aged 15-19 than any other age group. The average annual incidence of UCLR per 100,000 people for patients aged 15-19 is 31.9. The number of UCLR is increasing over time. Further work should address risk-reduction efforts in this at-risk population.

To investigate the potential causes of diminished knee extension after acute anterior cruciate ligament (ACL) injury using both surface electromyography (sEMG) analysis of the quadriceps and hamstrings, and gait analysis to assess muscle action and tone.Consecutive patients with an acute ACL tear underwent sEMG and gait analysis within 2 weeks of injury, before ACL reconstruction. Standard motion analysis techniques were used and sEMG data were collected simultaneously with gait data. T-tests were used to determine differences between the ACL-deficient and control subjects in knee flexion angles, peak external knee joint moments, and total time that a muscle was activated ("on") during gait. External knee moments were expressed as a percentage of body weight times height.Ten patients (mean age 24 ± 4 years) were included at a mean 10.2 days between injury and analysis; 10 uninjured, matched control subjects were included for comparison. There were significant increases in minimum flexion angle at heel strike (5.92 ± 3.39 v -3.49 ± 4.55, P.001) and midstance (14.1 ± 6.23 v 1.20 ± 4.21, P.001) in the injured limb compared with controls. There were significantly lower maximum external extension moments at heel strike (-0.99 ± 0.46 v -2.94 ± 0.60, P.001) and during the second half of stance in the injured limb compared with controls (-0.56 ± 1.14 v -3.54 ± 1.31, P.001). The rectus femoris was "on" significantly less during gait in the injured leg compared with controls (49.1 ± 7.76% v 61.0 ± 14.8%, P = .044). There were no significant differences in hamstring activity "on" time during gait (P.05).In patients with acute ACL injury, the ACL-deficient limb does not reach as much extension as controls. Although the rectus femoris is "on" for shorter periods during the gait cycle, there is no difference in hamstring time on during gait. This information may help clinicians better understand muscle function and gait patterns in the acute time period after ACL injury.Level III, case control study.

Purpose To determine practice patterns of Major League Baseball (MLB) team orthopaedic surgeons in addressing the controversial topics of ulnar collateral ligament (UCL) tears, type II SLAP tears, and partial-thickness rotator cuff tear. Methods Seventy-four MLB team orthopaedic surgeons were surveyed via an online survey system. A 14-question survey was used to assess surgeon experience, technique, and graft choice for UCL reconstruction (UCLR), treatment of type II SLAP tears, and other common pathologic conditions. Results Thirty team orthopaedic surgeons (41%) responded (mean experience as team physicians: 9.37 ± 6.33 years). Seventeen (56.7%) surgeons use the docking technique for UCLR whereas 20% use the modified Jobe technique. Nineteen (63.3%) use palmaris longus autograft in UCLR. Overall, 28 (93.3%) do not routinely perform elbow arthroscopy or perform an obligatory transposition of the ulnar nerve in patients without preoperative ulnar nerve symptoms. Twenty-eight (93.3%) would repair a type II SLAP tear, whereas only 1 (3.3%) would debride the tear. No surgeon would perform a concomitant biceps tenodesis, either open or arthroscopic. Conclusions Most MLB team orthopaedic surgeons perform a UCLR using the docking technique with a palmaris longus autograft without concomitant elbow arthroscopy or obligatory transposition of the ulnar nerve. The overwhelming majority of these surgeons would also treat an operative type II SLAP tear with a SLAP repair. Clinical Relevance The number of UCLRs and SLAP repairs performed on MLB pitchers has significantly increased over the past 10 years. To properly treat these conditions in elite, college, and recreational athletes, it is important to understand how the surgeons who take care of the most elite-level athletes treat them, and how they are able to reproducibly attain excellent outcomes. This study shows how these common shoulder and elbow injuries are treated by those surgeons who care for the most elite overhead-throwing athletes in the world.

To assess the ability of 3-dimensional (3D) magnetic resonance imaging (MRI, 1.5 and 3 tesla [T]) to quantify glenoid bone loss in a cadaveric model compared with the current gold standard, 3D computed tomography (CT).Six cadaveric shoulders were used to create a bone loss model, leaving the surrounding soft tissues intact. The anteroposterior (AP) dimension of the glenoid was measured at the glenoid equator and after soft tissue layer closure the specimen underwent scanning (CT, 1.5-T MRI, and 3-T MRI) with the following methods (0%, 10%, and 25% defect by area). Raw axial data from the scans were segmented using manual mask manipulation for bone and reconstructed using Mimics software to obtain a 3D en face glenoid view. Using calibrated Digital Imaging and Communications in Medicine images, the diameter of the glenoid at the equator and the area of the glenoid defect was measured on all imaging modalities.In specimens with 10% or 25% defects, no difference was detected between imaging modalities when comparing the measured defect size (10% defect P = .27, 25% defect P = .73). All 3 modalities demonstrated a strong correlation with the actual defect size (CT, ρ = .97; 1.5-T MRI, ρ = .93; 3-T MRI, ρ = .92, P.0001). When looking at the absolute difference between the actual and measured defect area, no significance was noted between imaging modalities (10% defect P = .34, 25% defect P = .47). The error of 3-T 3D MRI increased with increasing defect size (P = .02).Both 1.5- and 3-T-based 3D MRI reconstructions of glenoid bone loss correlate with measurements from 3D CT scan data and actual defect size in a cadaveric model. Regardless of imaging modality, the error in bone loss measurement tends to increase with increased defect size. Use of 3D MRI in the setting of shoulder instability could obviate the need for CT scans.The goal of our work was to develop a reproducible method of determining glenoid bone loss from 3D MRI data and hence eliminate the need for CT scans in this setting. This will lead to decreased cost of care as well as decreased radiation exposure to patients. The long-term goal is a fully automated system that is as approachable for clinicians as current 3D CT technology.

Background: As the health care system in the United States (US) transitions toward value-based care, there is an increased emphasis on understanding the cost drivers and high-value procedures within orthopaedics. To date, there has been no systematic review of the economic literature on anterior cruciate ligament reconstruction (ACLR). Purpose: To evaluate the overall evidence base for economic studies published on ACLR in the orthopaedic literature. Data available on the economics of ACLR are summarized and cost drivers associated with the procedure are identified. Study Design: Systematic review. Methods: All economic studies (including US-based and non–US-based) published between inception of the MEDLINE database and October 3, 2014, were identified. Given the heterogeneity of the existing evidence base, a qualitative, descriptive approach was used to assess the collective results from the economic studies on ACLR. When applicable, comparisons were made for the following cost-related variables associated with the procedure for economic implications: outpatient versus inpatient surgery (or outpatient vs overnight hospital stay vs >1-night stay); bone–patellar tendon–bone (BPTB) graft versus hamstring (HS) graft source; autograft versus allograft source; staged unilateral ACLR versus bilateral ACLR in a single setting; single- versus double-bundle technique; ACLR versus nonoperative treatment; and other unique comparisons reported in single studies, including computer-assisted navigation surgery (CANS) versus traditional surgery, early versus delayed ACLR, single- versus double-incision technique, and finally the costs of ACLR without comparison of variables. Results: A total of 24 studies were identified and included; of these, 17 included studies were cost identification studies. The remaining 7 studies were cost utility analyses that used economic models to investigate the effect of variables such as the cost of allograft tissue, fixation devices, and physical therapy, the percentage and timing of revision surgery, and the cost of revision surgery. Of the 24 studies, there were 3 studies with level 1 evidence, 8 with level 2 evidence, 6 with level 3 evidence, and 7 with level 4 evidence. The following economic comparisons were demonstrated: (1) ACLR is more cost-effective than nonoperative treatment with rehabilitation only (per 3 cost utility analyses); (2) autograft use had lower total costs than allograft use, with operating room supply costs and allograft costs most significant (per 5 cost identification studies and 1 cost utility analysis); (3) results on hamstring versus BPTB graft source are conflicting (per 2 cost identification studies); (4) there is significant cost reduction with an outpatient versus inpatient setting (per 5 studies using cost identification analyses); (5) bilateral ACLR is more cost efficient than 2 unilateral ACLRs in separate settings (per 2 cost identification studies); (6) there are lower costs with similarly successful outcomes between single- and double-bundle technique (per 3 cost identification studies and 2 cost utility analyses). Conclusion: Results from this review suggest that early single-bundle, single (endoscopic)-incision outpatient ACLR using either BPTB or HS autograft provides the most value. In the setting of bilateral ACL rupture, single-setting bilateral ACLR is more cost-effective than staged unilateral ACLR. Procedures using CANS technology do not yet yield results that are superior to the results of a standard surgical procedure, and CANS has substantially greater costs.

In athletes, significant advances in anterior cruciate ligament reconstruction techniques and rehabilitation have led to improved surgical outcomes and increased expectations for return to play. Although an expeditious return to sport has become an achievable and often realistic goal, the factors that most influence safe, timely, and successful return to play remain unknown. The literature offers mainly anecdotal evidence to guide the team physician in the decision-making process, with a paucity of criteria and consensus guidelines available to help determine return to sport. Attempts have been made to introduce criteria-based progression in the rehabilitation process, but validation of subjective and objective criteria has been difficult. Nevertheless, several pertinent factors in the preoperative, intraoperative, and postoperative periods may affect return to play following anterior cruciate ligament reconstruction. Further research is warranted to validate reliable, consensus guidelines with objective criteria to facilitate the return to play process.

Background Assessments used to measure outcomes associated with rotator cuff pathology and after repair are varied. This lack of standardization leads to difficulty drawing comparisons across studies. We hypothesize that this variability in patient-reported outcome measures and objective metrics used in rotator cuff studies persists even in high-impact, peer reviewed journals. Methods All studies assessing rotator cuff tear and repair outcomes in 6 orthopedic journals with a high impact factor from January 2010 to December 2014 were reviewed. Cadaveric and animal studies and those without outcomes were excluded. Outcome measures included range of motion (forward elevation, abduction, external rotation, and internal rotation), strength (in the same 4 planes), tendon integrity imaging, patient satisfaction, and functional assessment scores. Results Of the 156 included studies, 63% documented range of motion measurements, with 18% reporting range of motion in all 4 planes. Only 38% of studies reported quantitative strength measurements. In 65% of studies, tendon integrity was documented with imaging (38% magnetic resonance imaging/magnetic resonance anrhrogram, 31% ultrasound, and 8% computed tomography arthrogram). Finally, functional score reporting varied significantly, with the 5 most frequently reported scores ranging from 16% to 61% in studies, and 15 of the least reported outcomes were each reported in ≤6% of studies. Conclusions Significant variability exists in outcomes reporting after rotator cuff tear and repair, making comparisons between clinical studies difficult. Creating a uniformly accepted, validated outcomes tool that assesses pain, function, patient satisfaction, and anatomic integrity would enable consistent outcomes assessment after operative and nonoperative management and allow comparisons across the literature.

Tunnel malposition has been identified as the single most common technical error leading to failure of primary anterior cruciate ligament reconstruction. Revision of malpositioned or widened tunnels remains a challenging procedure that requires thorough preoperative planning. This article will discuss the management of tunnel complications during revision anterior cruciate ligament reconstruction.

While a single-incision arthroscopy-assisted reconstruction of the ACL is our preferred technique for primary ACL reconstructions, under certain circumstances the two-incision approach is recommended. All ACL surgeons should be familiar with this technique. In revision cases or in the case of posterior wall blow-out, the two-incision technique provides an excellent alternative. Advantages of this technique are numerous. The problem of graft-tunnel mismatch is minimized, and the problem of screw divergence or screw laceration of the graft is eliminated. The disadvantage rests only in the additional incision required. The technical aspects of this procedure are similar to those described in the single-incision technique. Overall, results using the two incision technique compare favorably with those of a single-incision.

Summary:The single-incision endoscopic-guided ACL reconstruction using patellar tendon autograft is advocated for its high ultimate strength, bone to bone healing, and interference fixation. Optimal outcomes are obtained when attention is paid to crucial technical aspects of the procedure. In additi

Summary:Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction has been performed at Rush Medical Center since January 1986. Since then, over 3000 arthroscopically assisted ACL reconstructions have been performed at this institution by the 2 senior authors. The surgical procedure

Macrotraumatic extensor mechanism complications do occur after central third patellar tendon harvest for anterior cruciate ligament (ACL) reconstruction and include intraor postoperative patella fracture and patellar tendon rupture. These are significant complications that often require additional surgery. Intraoperative precision when harvesting the patellar tendon, bone grafting the donor sites and implementing contemporary postoperative rehabilitation and bracing protocols may minimize their occurrence.

Summary:Autologous bone-patellar tendon-bone autograft is a common choice for anterior cruciate ligament reconstruction and from both biologic and biomechanical perspectives is well-suited for this purpose. A centrally harvested, 10 mm wide patellar tendon graft has an estimated initial load-to-fail

Summary: Stable graft fixation is critical to successful ACL reconstruction. Graft migration must be prevented during the 6 to 12-week postoperative period that is required for graft-tunnel incorporation. Maximizing interference screw fixation, avoiding pitfalls of screw insertion, managing graft-tunnel mismatch, and alternative fixation techniques are discussed. Key Words: Anterior cruciate ligament—Graft— Fixation. Contemporary rehabilitation protocols after anterior cruciate ligament (ACL) reconstruction stress early postoperative knee motion and weight bearing to reduce morbidity secondary to stiffness, delayed strength recovery, and anterior knee pain. In the first weeks after surgery the weakest link of the reconstructed ACL is not the graft itself but rather the fixation sites. Resultant graft forces during an accelerated rehabilitation protocol are estimated to range between 150 N and 450 N.24,28,51,52,61,68 Therefore, the stability of initial graft fixation is critical and must be strong enough to withstand these forces and prevent graft migration during the six to twelve week period that is required for graft-tunnel incorporation. 16,44,50,67 Patellar tendon allograft incorporation may be delayed compared with autografts, 37 and when this graft is used fixation may need to provide additional primary stability beyond 12 weeks. It has been estimated that ACL graft failure is responsible for 0.7% to 8% of cases of recurrent instability after reconstruction. Furthermore, errors in surgical technique are the primary cause of early graft failure. 29,32,34 In addition to inadequate primary fixation, technical factors which should be considered include nonanatomic tunnel placement, graft impingement from an inadequate notchplasty, improper graft tensioning, graft material problems and failure to address injured secondary stabilizers. In the absence of these problems early construct failures are almost universally related to loss of fixation. The purpose of this manuscript is to discuss interference screw fixation with a focus on avoiding pitfalls of insertion, strategies for managing graft-tunnel mismatch, and graft fixation alternatives which may be required in primary or revision situations.

Summary: Instrumented arthrometry is an important treatment adjunct for anterior cruciate ligament (ACL)-deficient patients before and after patellar tendon reconstruction, which provides objectivity to other subjective outcome measures and allows for accurate comparison between studies. Increasing numbers of clinical reports are using arthrometry to objectively report anterior displacements. Arthrometry measurements allow the worldwide orthopaedic community to accurately compare and evaluate reported subjective results. It should be noted that patient satisfaction and subjective evaluations by the examiner and patient may overestimate the presumed ligamentous stability, and in these cases, the KT arthrometer provides important objectivity. This objective data may be the only means of early detection of laxity after ACL reconstruction. In this article, a review of the available data regarding arthrometry before and after patellar tendon ACL reconstruction is presented as well as a rationale for selecting a maximum manual side-to-side difference of 3 mm or an absolute laxity of 10 mm as the diagnostic criteria for ACL deficiency. Knee laxity testing data should be incorporated into the objective preoperative and postoperative evaluation of the ACL-deficient patient, and the goal of reconstruction should be to match the contralateral normal knee. Arthrometry data are important to the researcher for objective evaluation and comparison of populations and to clinicians for objective outcomes in individual patients after patellar tendon ACL reconstruction. Key Words: Arthrometry—KT—Laxity—Patellar tendon graft—ACL reconstruction—Outcomes. During the last 4 decades, advances in the understanding and treatment of knee instability have progressed at a rapid rate. Refinements in physical examination techniques, improved radiographic modalities, advances in the principles of ligament healing and rehabilitation, improved surgical techniques, and the constant integration of new technology as it becomes validated have contributed to an improved ability to care for the patient with an anterior cruciate ligament (ACL)-deficient knee. During the 1980s, several ligament testing devices were developed in an attempt to quantitate anteroposterior (AP) displacement of the knee joint. The Lachman, pivot shift, and anterior drawer physical examination tests often vary from examiner to examiner, making comparison difficult. Objective, quantitative ligament testing devices provide the opportunity to compare populations of patients more accurately, and allow for objective evaluation of individual patients before and after ACL reconstruction. Clinical studies that evaluate the results of ACL reconstruction should use objective quantifiable instrumented ligament testing in addition to the subjective clinical grading reported by various authors. This is especially true when evaluating new technology or methods. The KT-2000 and its predecessor, the KT-1000 arthrometer, have most often been reported in the literature and will provide the basis for most of this article.

Sumamry: Rehabilitation protocols after bone-patellar tendon-bone anterior cruciate ligament reconstruction have become significantly more aggressive over the past decade. Key concepts of an accelerated rehabilitation protocol include immediate full weight bearing, unrestricted range of motion, early closed kinetic exercises, and return to play by 4 months. Additional components of a successful rehabilitation program include appropriate timing of surgery, adequate postoperative analgesia, use of cryotherapy, and diligent surveillance for the development of postoperative motion complications. In addition to thorough patient evaluation and meticulous surgical technique, a comprehensive rehabilitation protocol for the reconstructed knee is an essential part of the overall treatment algorithm of the anterior cruciate ligamentinjured extremity. This article reviews a variety of different factors involved in successful rehabilitation after anterior cruciate reconstruction using patellar bone-tendon-bone autograft and presents a comprehensive rehabilitation protocol.

Precise graft harvesting techniques are critical in performing successful anterior cruciate ligmaent reconstruction. Our experience has led us to believe that improper graft harvest makes the procedure more difficult and may impact the result. The purpose of this manuscript is to discuss the pearls and pitfalls pertinent to patellar tendon harvesting for ACL reconstruction.

Loss of motion of the knee is a challenging dilemma to both the patient and the treating physician. The causes of arthrofibrosis are many but can usually be traced to a traumatic event, intra-articular/ligament knee surgery, knee arthroplasty, and possibly sepsis. Prevention is the best form of treatment, but when this entity does present, early recognition and a supervised physical therapy program are often successful. If conservative treatment fails, operative intervention is warranted. The purpose of this article is to discuss how to appropriately evaluate a patient with loss of knee motion, understand the pathogenesis and classification of arthrofibrosis, review our operative technique and postoperative management of these difficult patients, review the results in the literature concerning arthrofibrosis, and make the reader aware of possible concerns and the future direction of treatment of patients with arthrofibrosis.

Despite the marked advances in treatment and highly predictable success of anterior cruciate ligament (ACL) reconstruc- tion, an approximate 10% to 15% failure rate is noted in the literature. The mechanism of failure is often difficult to ascertain and is often multifactorial. A strong patient-physician relationship must be estab- lished to proceed with revision ACL reconstruction. After the deci- sion has been made to proceed with revision ACL reconstruction extensive preoperative planning is warranted. Revision ACL recon- tructions are a ''salvage'' procedure to allow the patient to perform activities of daily living. A return to sports is a possibility, but the patient's expectations should be realistic and individualized. This article focuses on the surgical technique of revision anterior cruciate ligament reconstruction with patellar tendon allograft.

BackgroundThere are conflicting reports of allograft performance, immune response, tissue incorporation, and rerupture rates when used for anterior cruciate ligament reconstruction.PurposeTo evaluate the clinical outcome of a fresh-frozen, nonirradiated, patellar tendon allograft for primary anterior cruciate ligament reconstruction surgery.Study DesignCase series; Level of evidence, 4.MethodsPatients who underwent endoscopic primary anterior cruciate ligament reconstruction with allograft tissue a minimum of 2 years ago were evaluated with physical examinations, the KT-1000 arthrometer, functional testing, radiographic evaluation, subjective assessment, and outcomes tools.ResultsFifty-nine patients (60 knees) were evaluated at an average of 51 months after surgery. Ninety-four percent of patients were mostly or completely satisfied. A negative pivot shift test result was noted in 90% of subjects. The KT-1000 arthrometer side-to-side differences were = 3 mm in 95% of patients, and no patient exceeded 5 mm. The mean International Knee Documentation Committee score was 78 (SD = 19), and the mean Lysholm score was 82 (SD = 17). There were no clinical symptoms consistent with graft rejection or infection. Radiographic evaluation demonstrated infrequent significant tunnel widening.ConclusionsUse of a fresh-frozen, nonirradiated allograft for primary reconstruction of the anterior cruciate ligament is a successful procedure both subjectively and functionally for restoring stability in patients selected for allograft reconstruction. In the patients selected for this surgical procedure, clinical, arthrometric stability testing, and subjective satisfaction were comparable to our previously published cohort studies using patellar tendon autograft at similar postoperative follow-up.

High ankle sprains, or syndesmotic injuries, are a distinct entity from the more common inversion ankle sprain. Dorsiflexion of the ankle, external rotation of the leg, or a combination of both can disrupt the syndesmotic ligament complex, including the anterior and posterior tibiofibular ligaments. Diagnostic maneuvers, such as the squeeze test and the external rotation test, plus radiographic findings help make the diagnosis. Less severe sprains can be treated nonoperatively with protected weight bearing, but grade 3 sprains require surgical anatomic reduction of the syndesmotic joint. If misdiagnosed or managed incorrectly, syndesmotic injuries can lead to unfavorable late sequelae. Clinicians should set realistic expectations for a long recovery period and slow return to sports.

BackgroundIn published comparative studies, it remains unknown if arthroscopic techniques for performing Bankart repair for anterior shoulder instability equal the success of open repair.HypothesisThe current literature supports a lower rate of recurrent instability after open Bankart repair compared to arthro-scopic repair with bioabsorbable tacks or transglenoid sutures.Study DesignMeta-analysis.MethodsA Medline search identified all randomized controlled trials or cohort studies that directly compared open repair to arthroscopic techniques of Bankart repair for traumatic, unilateral, recurrent anterior instability. Data collected from each study included patient demographics, surgical technique, rehabilitation, outcome, and complications.ResultsSix studies met all inclusion criteria. There were 172 patients in the arthroscopic group (90 patients with transglenoid sutures, 77 patients with arthroscopic tacks, and 5 patients with suture anchors) and 156 patients in the open group. The groups were similar in demographic characteristics. When comparing the arthroscopic to the open group, there was a significantly higher rate of recurrent dislocation (12.6% vs 3.4%; P = .01) and total recurrence (recurrent dislocation or subluxation) (20.3% vs 10.3%; P = .01). In addition, there was a higher proportion of patients with an excellent or good postoperative Rowe score in the open group (88%) than in the arthroscopic group (71%) (P = .01).ConclusionsArthroscopic Bankart repair using transglenoid sutures or bioabsorbable tacks results in a higher rate of recurrence of instability compared to open techniques. Studies comparing open repair to newer arthroscopic techniques using suture anchor fixation and capsular plication are necessary.

Posterior cruciate ligament (PCL) reconstruction is infrequently performed, technically challenging, and has less predictable results compared with its anterior cruciate ligament (ACL) counterpart. Creation of a transtibial tunnel has been associated with catastrophic neurovascular complications, as well as tunnel malpositioning. This technical note reports the use of the femoral PCL tunnel to visually access the posterior slope for tibial tunnel creation. This technique modification allows concurrent placement of instruments through an inferomedial and/or posteromedial portal to facilitate PCL insertional debridement, placement of the tibial aimer, and creation of the tunnel. We feel that this technical modification provides superior visualization of this anatomic area.

Background The lowest contact pressure point is presumed to be the best site to harvest an osteochondral plug and minimize morbidity. Hypothesis Patellofemoral contact pressures are not uniform and are lowest along the medial patellofemoral articulation. Study Design Controlled laboratory study. Methods Seven cadaveric knees were tested with an electroresistive, dynamic pressure sensor placed onto the femoral side of the patellofemoral joint. The extensor mechanism was loaded with 89.1 N and 178.2 N, and the knee was manually cycled 3 times (0°-105°) per load. Mean trochlear pressures were calculated. Results Mean contact pressures were greatest in the central trochlea (5.80 kgf/cm2), followed by the lateral (2.56 kgf/cm2) and medial trochlea (1.60 kgf/cm2) at 89.1 N (P < .05). At 178.2 N, pressures increased to 9.47, 5.81, and 2.75 kgf/cm2, respectively (P < .05). Lateral trochlear pressures decreased moving distally from 1.25 to 0.50 kgf/cm2 at 89.1 N and 4.57 to 1.29 kgf/cm2 at 178.2 N. Conclusions Contact pressures are lowest along the medial trochlea and decrease distally along the lateral trochlea. Clinical Relevance Osteochondral plugs from the medial femoral trochlea may be desirable if trochlear size permits. If harvesting from the lateral femoral trochlea, consider harvesting distally near the sulcus terminalis.