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Case: A 29-year-old man sustained a bilateral acute patellar tendon rupture (PTR) while jumping on a trampoline. He was initially treated with bilateral transosseous patellar tendon repairs. Bilateral rerupture occurred during a fall 10 weeks after. He subsequently underwent staged bilateral patellar tendon reconstructions using an Achilles tendon allograft. At 3-year follow-up, he has maintained full range of motion and leg strength without rerupture or other complications. Conclusion: The use of Achilles tendon allograft in the presence of inadequate and poor-quality tendon tissue for reconstruction of the patellar tendon in the revision setting is a viable and effective treatment option. [ABSTRACT FROM AUTHOR]

Background: Medial meniscus posterior root tears (MMPRTs) cause pain and dysfunction and are associated with poor clinical outcomes with nonoperative management at short-term follow-up. However, little is known about the long-term natural history of these tears. Purpose: The purpose of this study was to (1) provide an update to a previous minimum 2-year study on the natural progression of these tears and (2) evaluate long-term patient-reported and radiographic outcomes. Study Design: Case series (prognosis); Level of evidence, 4. Methods: A retrospective review was performed on a cohort of patients with untreated MMPRTs, diagnosed between 2005 and 2013, who were followed clinically using International Knee Documentation Committee (IKDC), visual analog scale for pain, and Tegner activity scores as well as radiographically at a minimum 10-year follow-up. Failure was defined as conversion to arthroplasty or a severely abnormal subjective IKDC score <75.4. Results: Overall, 5 (10%) of the original 52 patients with minimum 2-year outcomes were subsequently lost to follow-up. The remaining 47 patients (21 male, 26 female) were followed for a mean of 14 ± 2 years (range, 11-18 years). At final follow-up, 25 patients (53%) had progressed to total knee arthroplasty, 8 (17%) were deceased, and 14 (30%) had not progressed to total knee arthroplasty. The mean IKDC and Tegner activity scores for the 14 patients with remaining MMPRTs were 51.6 ± 22.2 and 3.1 ± 1.1, respectively, and the mean visual analog scale score was 4.4 ± 3.0. Radiographically, the mean Kellgren-Lawrence grade progressed from 1.2 ± 0.7 at baseline to 2.6 ± 0.5 at final follow-up (P <.001). At a minimum 10-year follow-up, 37 of 39 living patients (95%) had failed nonoperative treatment. Conclusion: Poor clinical and radiographic outcomes were associated with the nonoperative treatment of degenerative MMPRTs at long-term follow-up. This study provides a valuable update on the natural history and long-term prognosis of nonoperatively treated MMPRTs. [ABSTRACT FROM AUTHOR]

Background: Lesions that involve humeral avulsions of the glenohumeral ligament (HAGLs), although less common, are primary contributors to recurrent events of dislocation and subluxation of the glenohumeral joint. Purpose: To describe the clinical presentation, examination, and surgical outcomes of patients presenting with HAGL lesions who underwent repair using an arthroscopic or open technique. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective review of prospectively collected data was performed of skeletally mature patients without glenohumeral arthritis who presented with HAGL lesions and subsequently underwent arthroscopic or open repair between 2005 and 2017. Independent variables included patient characteristics, clinical presentation, physical examination findings, and arthroscopic findings. Dependent variables included pre- and postoperative Single Assessment Numeric Evaluation (SANE) score, Western Ontario Shoulder Instability Index (WOSI) score, and range of motion outcomes. Results: Eighteen patients diagnosed with a HAGL lesion who underwent primary arthroscopic repair (n = 7) or open repair (n = 11) were included. There were 17 male patients and 1 female patient with a mean age of 24.9 years (range, 16-38 years). Mean follow-up duration was 50.9 months (range, 24-160 months). Seventeen patients (94.4%) reported pain as the most common symptom, and 7 (38.9%) reported sensation of instability. Scores significantly improved from pre- to postoperative for the arthroscopic and open groups (P <.001): SANE (mean ± SD; arthroscopic, 30.7 ± 15.7 to 92.1 ± 12.2; open, 45.5 ± 8.50 to 90.7 ± 5.24) and WOSI (arthroscopic, 51.4 ± 11.4 to 2.49 ± 3.70; open, 45.5 ± 7.37 to 11.5 ± 5.76). The magnitude of improvement in SANE scores was significantly higher for patients treated arthroscopically (Δ60.0; open, Δ46.5; P =.012). Postoperative WOSI scores were also significantly better in the arthroscopic cohort (2.49 ± 3.70; open, 11.5 ± 5.76; P =.00094). Conclusion: Symptomatic HAGL tears present primarily with pain as opposed to instability, necessitating a high index of suspicion for injury. The tears may be treated successfully with an arthroscopic or open technique with significant improvements in patient-reported outcomes and stability. [ABSTRACT FROM AUTHOR]

Background: Primary device fixation and the resistance against gap formation during repetitive loading influence the quality of meniscal repair. There are limited biomechanical data comparing primary tensioning and cyclic behavior of all-inside versus inside-out repair. Hypothesis: All-inside devices provide higher initial load on the meniscal repair than inside-out fixation, and stiffer constructs show higher resistance against gap formation during cyclic loading. Study Design: Controlled laboratory study. Methods: In total, 60 longitudinal bucket-handle tears in human cadaveric menisci were created and repaired with a single stitch and randomly assigned to 4 all-inside groups (TrueSpan, FastFix 360, Stryker AIR, FiberStich) and 2 inside-out groups (suture repair [IO-S], suture tape [IO-ST]). Residual load after repair tensioning (50 N) and relief displacement were measured. Constructs underwent cyclic loading between 2 and 20 N over 500 cycles (0.75 Hz) with cyclic stiffness, gap formation, and final peak elongation measured. Ultimate load and stiffness were analyzed during pull to failure (3.15 mm/s). Results: All-inside repair demonstrated significantly higher primary fixation strength than inside-out repair. The significantly highest load (mean ± SD; 20.1 ± 0.9 N; P <.037) and relief displacement (–2.40 ± 0.32 mm; P <.03) were for the knotless soft anchoring FiberStich group. The lowest initial load (9.0 ± 1.5 N; P <.001) and relief displacement (–1.39 ± 0.26 mm; P <.045) were for the IO-S repair group. The final gap formation (500th cycle) of FiberStich (0.75 ± 0.37 mm; P <.02) was significantly smaller than others and that of the IO-S (1.47 ± 0.33 mm; P <.045) significantly larger. The construct stiffness of the FiberStich and IO-ST groups was significantly greater at the end of cyclic testing (16.7 ± 0.80 and 15.5 ± 1.42 N/mm; P <.042, respectively) and ultimate failure testing (23.4 ± 3.6 and 20.6 ± 2.3 N/mm; P <.005). The FastFix 360 (86.4 ± 4.8 N) and Stryker AIR (84.4 ± 4.6 N) groups failed at a significantly lower load than the IO-S group (P <.02) with loss of anchor support. The FiberStich (146.8 ± 23.4 N), TrueSpan (142.0 ± 17.8 N), and IO-ST (139.4 ± 7.3 N) groups failed at significantly higher loads (P <.02) due to suture tearing. Conclusion: Overall, primary fixation strength of inside-out meniscal repair was significantly lower than all-inside repair in this cadaveric tissue model. Although absolute differences among groups were small, meniscal repairs with higher construct stiffness (IO-ST, FiberStich) demonstrated increased resistance against gap formation and failure load. Clinical Relevance: Knotless single-stitch all-inside meniscal repair with a soft anchor resulted in less gapping, but the overall clinical significance on healing rates remains unclear. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to describe meniscus extrusion, present imaging characteristics, and provide clinical correlations for patients with isolated meniscus extrusion. Methods: Of the 3244 MRI reports identified as having meniscus extrusion, 20 patients were identified to have isolated meniscus extrusion (0.62%). Patients with moderate to severe chondromalacia, meniscus tears, intra-articular fractures, tumours, and ligament tears were excluded. Radiographs were reviewed and graded using Kellgren–Lawrence (K–L) scores. MRI's were reviewed for the extent of extrusion and whether or not the meniscotibial ligament was intact. Clinical presentation and management were recorded. Results: The study population consisted of 12 females and 8 males with a mean age of 40.5, diagnosed with meniscus extrusion and minimal concomitant knee pathology. 68% of patients were considered symptomatic as their knee pain correlated with the side of their meniscus extrusion and no other reason for pain was identified. The mean amount of meniscus extrusion was 2.5 mm (SD ± 1.1 mm) with 45% (9 of 20) having 3 + mm of extrusion. Meniscotibial ligament abnormality was identified in 65% of cases (13 of 20). Patients with 3 + mm of meniscus extrusion were much more likely to have associated meniscotibial ligament abnormality (100%, 9 of 9) compared to those with < 3 mm of extrusion (36%, 4 of 11) (RR 2.75, p = 0.048). The mean K–L grade obtained at the initial visit was 0.9 (95% CI 0.7–1.4) and the mean K–L grade obtained on final follow-up was 1.3 (95% CI 0.8–2.8) (n.s.) at a mean of 44.7 months. No correlation was found between K–L grade, gender, age, acute injury, and BMI in relation to meniscotibial ligament abnormality or amount of meniscal extrusion. Conclusions: Meniscus extrusion often occurs in the presence of significant knee pathology, predominantly with meniscus tears or osteoarthritis. Isolated meniscus extrusion is a rare occurrence that may present clinically with knee pain, commonly to the side in which the extrusion occurs. In patients with three or more millimetres of meniscus extrusion, an intact meniscus and minimal knee pathology, meniscotibial ligament abnormality is likely. This may provide an opportunity to treat the meniscotibial ligament abnormality with meniscus centralisation technique and decrease the amount of meniscus extrusion. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether chondral fragments without bone have the potential to heal after fixation. Controversy exists and opinions differ regarding the optimal treatment of chondral defects after pure chondral fracture. Purpose: To determine clinical and radiographic outcomes after internal fixation of traumatic chondral fragments repaired to bone in the knee. Study Design: Case series; Level of evidence, 4. Methods: A retrospective clinical and radiographic evaluation of 10 male patients with a mean age of 14.6 years (range, 10-25 years) at the time of surgery was performed. Eight of 10 patients were skeletally immature. Patients were selected by operating surgeons per the presence of a large displaced pure chondral fragment on magnetic resonance imaging and confirmed on intraoperative inspection. All patients had a diagnosed traumatic displaced pure chondral fracture of the knee (without bone) and underwent internal fixation with minimum 1-year follow-up. Validated patient-reported and surgeon-measured outcomes were collected pre- and postoperatively. All patients were evaluated at a mean 56 months postoperatively. Results: At surgery, the mean defect size that was primarily repaired with the displaced chondral fragment was 1.9 × 2.0 cm. With minimum 1-year follow-up, there were no clinical failures. All 8 patients who had subsequent magnetic resonance imaging follow-up had radiographic evidence of complete healing of the chondral fragment back to bone. At a mean follow-up of 56 months (range, 13-171 months; median, 36 months), patients had a mean International Knee Documentation Committee score of 94.74 (range, 87.4-100), a mean Marx Activity Scale score of 14.4 (range, 8-16), and a mean Tegner Activity Scale score of 7 (range, 5-9). At final follow-up, all patients except 1 returned to sports. Conclusion: The treatment of large traumatic chondral fragments is controversial. In this select series of 10 young patients who underwent primary repair with internal fixation, there were no failures clinically. Patients demonstrated excellent short-term clinical and radiographic results after fixation of these relatively large chondral fragments in the knee. [ABSTRACT FROM AUTHOR]

Purpose: Multiple techniques have been described in the literature for reconstruction of the medial collateral ligament. The purpose of this study is to describe functional outcome, range of motion, and knee stability following anatomic MCL reconstruction utilizing an Achilles tendon bone allograft after multiligament knee injury.Methods: A comprehensive search of a single-hospital multiligament knee injury (MLKI) procedural database was conducted to identify all patients that underwent reconstruction of the MCL utilizing an Achilles tendon bone allograft and with 2-year clinical follow-up. Medical charts were retrospectively reviewed to determine each patient's knee dislocation (KD) grade, final range of motion, stability on clinical examination, and the incidence of complications and reoperations. KOOS, IKDC, and Marx scores were also collected.Results: Thirty-two knees in 32 patients (21 males and 11 females) with a mean age of 30 years (range 15-51) were followed for an average of 40 months (range 28-87 months) following MCL reconstruction with Achilles tendon bone allograft. For patients with multiligament knee injuries, there were 14 KD-I (11 ACL/MCL; 3 MCL/PCL; 1 MCL/ACL/LCL; 1 MCL/PCL/LCL), 12 KD 3-M, and 3 KD-IV. One patient underwent isolated revision MCL reconstruction. At final follow-up, clinically significant valgus laxity was observed in only 1 patient (3%). All patients were able to achieve full extension of the knee and the average flexion was 121.1 ± 19.6. The average IKDC score was 67.6 ± 19.9 (range 27.7-98.9), the average KOOS score 77.1 ± 16.8 (range 31-100). The average Marx score was 4.9 (range 0-16, SD 5.2). Thirty-one of 32 (96%) patients reported being satisfied with results of the surgery. Knee dislocation grades were significantly correlated with post-operative outcome measures.Conclusion: In a series utilizing a modified Marx Achilles tendon, MCL reconstruction in the setting of MLKI demonstrated satisfactory clinical and functional outcomes, as well as patient satisfaction at short- to mid-term follow-up. Furthermore, knee dislocation grades were demonstrated to correlate with post-operative IKDC, KOOS, and Marx scores.Level Of Evidence: Type IV. [ABSTRACT FROM AUTHOR]

Background: Iliopsoas fractional lengthening (IFL) continues to be a controversial procedure in hip arthroscopy. Hypothesis: Patients who underwent arthroscopic surgery for femoroacetabular impingement (FAI) and a labral tear either with or without IFL would experience favorable outcomes, and there would be no difference in postoperative patient-reported outcomes (PROs) between the 2 groups at minimum 2-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Data from July 2009 and April 2015 were retrospectively reviewed. Patients were eligible if they had hip arthroscopy for both FAI and labral tear treatment with IFL and without IFL. IFL was indicated for painful internal snapping. Minimum postoperative follow-up was set to 2 years. The authors calculated the modified Harris Hip Score, International Hip Outcome Tool–12, Hip Outcome Score–Activity of Daily Living Score, Hip Outcome Score–Sports Specific Subscale, Non-Arthritic Hip Score, visual analog scale for pain, patient satisfaction, minimal clinically important difference (MCID), and the percentage of patients who achieved patient acceptable symptomatic state (PASS). Revision surgeries and conversions to total hip arthroplasty (THA) were documented. Results: 351 hips (307 patients) met the necessary inclusion criteria in the IFL cohort, with a mean ± SD follow-up time of 42.5 ± 18.1 months. For the control cohort, 392 hips (354 patients) were included, with a mean ± SD follow-up time of 43.9 ± 19.6 months. Both groups showed significant postoperative improvement in 2-year follow-up PROs. The group with iliopsoas lengthening showed comparable results to the control group with respect to PRO improvement, MCID, PASS, and rates of revision or THA conversion. Conclusion: This comparative cohort study demonstrated that treatment of painful internal snapping syndrome with arthroscopic IFL, in the setting of FAI and a labral tear, is a safe procedure with good short- to mid-term follow-up results and associated improvement in PROs. Patients who underwent IFL showed similar outcomes compared with a control group treated for FAI and labral tear without IFL. In appropriately selected patients, arthroscopic IFL did not adversely affect clinical outcomes compared with patients who did not need IFL. [ABSTRACT FROM AUTHOR]

Purpose: To determine the cyclic displacement and ultimate failure loads of two clinically relevant suture configurations for repair of medial and lateral meniscus root tears.Methods: A total of 10 matched pair fresh-frozen, human meniscus specimens were randomly assigned to either simple cinch or locking loop meniscus-suture fixation techniques for transtibial pull-out repair in either medial (n = 10 matched pairs) or lateral (n = 10 matched pairs) meniscal root tears. The menisci were subjected to cyclic tensioning at 10-30 N for 1000 cycles at 0.5 Hz, and then post-cycling load to failure was performed at a tensile rate of 0.5 mm/s.Results: For both the medial and lateral meniscus, there was significantly less displacement with the cinch stitch at 100, 500 and 1000 cycle counts (p < 0.05). In respect to ultimate load, there was no significant difference in type of repair between the two suture configurations. When comparing ultimate load to failure from the medial to the lateral side, the ultimate load to failure was significantly greater for both suture configurations in the lateral meniscus root repair (p < 0.05). However, there was no significant difference in cyclic displacement between the medial and lateral meniscus.Conclusions: The cinch stitch was significantly better at resisting displacement compared to the locking loop stitch configuration, and had similar ultimate load to failure. The lateral meniscus root repair construct has higher failure loads compared to the medial meniscus, independent of suture configuration. [ABSTRACT FROM AUTHOR]

Purpose: Medial meniscus posterior root tears (MMPRTs) are recognized as a source of pain and dysfunction, but treatment options remain a challenge. The purpose of the study was to determine (1) the efficacy of partial meniscectomy to treat MMPRTs compared to a matched group of non-operatively treated MMPRTs, and (2) risk factors for worse clinical and radiographic outcome.Methods: This retrospective comparative study was performed to include patients with complete, isolated MMPRTs with documented clinical symptoms and were treated with arthroscopic partial meniscectomy (PMM) and a minimum 2-year follow-up. These patients were then matched by age, gender, and BMI to patients with the same diagnosis who were treated non-operatively. Clinical and radiographic outcomes were compared between the two groups. Analysis was performed to determine risk factors for worse clinical and radiographic outcome in the PMM group alone.Results: Overall, 52 patients were included in the study. Twenty-six patients (9M:17F) with a mean age of 55 ± 9 and a mean BMI of 32.8 ± 5.3 were treated with PMM and followed for 5.5 ± 2.0 years (range 2.3-9.3 years). In the PMM group, final median Tegner score was 3, mean IKDC score was 67.8 ± 20, and more patients had grade II or higher arthritis at final follow-up than baseline (91.3 vs. 36%, p < 0.01). Overall, 14 of the 26 patients (54%) treated operatively progressed to total knee arthroplasty at a mean of 54.3 months. There was no significant difference in final Tegner scores, IKDC, K-L grades, progression to arthroplasty, or overall failure rate between the PMM group and non-operative group. Following PMM, female patients had lower final IKDC scores (44.0 ± 2.8 vs. 74.6 ± 16.7, p = 0.02) compared to males, as well as a higher rate of arthroplasty (70.6 vs. 20.0%, p = 0.009). Higher BMI correlated with lower IKDC scores (r = -0.91, p = 0.01) and meniscal extrusion was associated with higher rate of arthritis at final follow-up (p = 0.02).Conclusion: Partial meniscectomy for a complete MMPRT provides no benefit in halting arthritic progression. Patients who undergo PMM for MMPRTs still progress to significant arthritis, poor clinical outcomes and a high arthroplasty rate (54%) at over 5-year follow-up. Female gender, increased BMI, and meniscus extrusion were associated with worse outcome.Study Design: Level III. [ABSTRACT FROM AUTHOR]

Purpose: Medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy are commonly used to treat recurrent lateral patellar instability, yet there are limited available data on return to sport (RTS) following these procedures. The purpose of this study is to evaluate patient factors associated with excellent functional outcomes, including successful RTS, following surgical stabilization including MPFL reconstruction in competitive athletes with recurrent lateral patellar instability.Methods: Athletes undergoing primary MPFL reconstruction for recurrent lateral instability from 2005 to 2013 were identified at a single institution. Concomitant procedures, such as tibial tubercle osteotomy (TTO), were included. Patient demographic information, including BMI, gender, age, and pre-injury Tegner score, was recorded. In addition, radiographs were reviewed for pre-operative patellar height (Caton-Deschamps index) and trochlear dysplasia (Dejour classification). All patients underwent a standardized rehabilitation/post-operative protocol, with isokinetic strength and functional testing being performed at 6 months post-operatively. Final Tegner scores, RTS status, subjective instability ratings, and Kujala scores were collected at a minimum of 2 years. Chi-squared analysis for categorical variables and Wilcoxon rank-sum analysis for continuous variables were used to determine the relationship between the previously mentioned patient and knee characteristics with isokinetic data, RTS status, or Kujala scores.Results: Thirty-nine athletes (23 male, 16 female) at a mean age of 17.5 ± 2.9 years (range, 13-26) underwent primary MPFL reconstruction (32 autografts, seven allografts) for recurrent patellar instability with a mean follow-up of 47.0 ± 16.4 months. Sixteen patients (41%) underwent concomitant tibial tubercle osteotomies. Isokinetic data collected at 6 months post-operatively demonstrated mean knee flexion and extension strength deficits of 15.8 ± 10.1% and 21.4 ± 14.3%, respectively, compared to the contralateral leg (p < 0.001 for both). Patients who underwent concomitant tibial tubercle osteotomy (p = 0.04), males (p = 0.01) and those with patella alta (p = 0.04) had weaker 6-month isokinetic testing. Thirty-three of the thirty-nine (85%) athletes were able to RTS at a mean of 8.1 ± 3.9 months. Patients undergoing MPFL with concomitant TTO (p = 0.02) returned to sport at a slower rate. One patient (3%) reported an episode of recurrent dislocation requiring revision surgery. Kujala and Tegner scores at final follow-up were 91.1 ± 6.3 and 6 (range, 4-9), respectively.Conclusion: Surgical stabilization including MFPL reconstruction for recurrent lateral patellar instability is an effective procedure for returning athletes to competitive sports. However, strength deficits persist at 6 months after surgery, especially in those undergoing concomitant TTO, which may delay return to sport. Physicians can use these results to counsel patients that return to competitive sports is safe with good clinical outcomes and low rate of recurrence at 4-year follow-up; however, predisposing factors, like a lateralized tibial tubercle, should be addressed if necessary, but athletes should be counselled that a slower recovery and longer return to sport time may be expected.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Background: The technique of hip arthroscopic surgery is advancing and becoming more commonly performed. However, most current reported results are limited to short-term follow-up, and therefore, the durability of the procedure is largely unknown. Purpose: To perform a multicenter analysis of mid-term clinical outcomes of arthroscopic hip labral repair and determine the risk factors for patient outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Prospectively collected data of primary hip arthroscopic labral repair performed at 4 high-volume centers between 2008 and 2011 were reviewed retrospectively. Patients were assessed preoperatively and postoperatively with the visual analog scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS) at a minimum of 5 years’ follow-up. Factors including age, body mass index (BMI), Tönnis grade, and cartilage grade were analyzed in relation to outcome scores, and revision rates were determined. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery and open hip surgery. Results: A total of 303 patients (101 male, 202 female) with a mean age of 32.0 years (range, 10.7-58.9 years) were followed for a mean of 5.7 years (range, 5.0-7.9 years). Patients achieved mean improvements in VAS of 3.5 points, mHHS of 20.1 points, and HOS-SSS of 29.3 points. Thirty-seven patients (12.2%) underwent revision arthroscopic surgery, and 12 (4.0%) underwent periacetabular osteotomy, resurfacing, or total hip arthroplasty during the study period. Patients with a BMI >30 kg/m2 had a mean mHHS score 9.5 points lower and a mean HOS-SSS score 15.9 points lower than those with a BMI ≤30 kg/m2 (P < .01). Patients aged >35 years at surgery had a mean mHHS score 4.5 points lower and a HOS-SSS score 6.7 points lower than those aged ≤35 years (P = .03). Patients with Tönnis grade 2 radiographs demonstrated a 12.5-point worse mHHS score (P = .02) and a 23.0-point worse HOS-SSS score (P < .01) when compared with patients with Tönnis grade 0. Conclusion: Patients demonstrated significant improvements in VAS, mHHS, and HOS-SSS scores after arthroscopic labral repair. However, those with Tönnis grade 2 changes preoperatively, BMI >30 kg/m2, and age >35 years at the time of surgery demonstrated significantly decreased mHHS and HOS-SSS scores at final follow-up. [ABSTRACT FROM AUTHOR]

Background: The cases of patients with medial compartment osteoarthritis who were ≤55 years old and had a proximal tibial osteotomy (PTO) or medial unicompartmental knee arthroplasty (UKA) were compared. Outcomes included postoperative activity level, function, and survivorship free of revision to total knee arthroplasty.Methods: Between 1998 and 2013, data were available for 240 patients between 18 and 55 years old with medial compartment arthritis and varus malalignment who were treated either with PTO (57 patients) or with UKA (183 patients). The mean age was 42.7 years for the 57 patients (41 men and 16 women) in the PTO group versus 49.2 years for the 183 patients (82 men and 101 women) in the UKA group. The Tegner activity level and Lysholm knee scores were evaluated at 3 months and at 1, 2, and 5 years postoperatively as well as at the time of the final follow-up. The end point for survival was defined as revision to total knee arthroplasty. A Wilcoxon rank-sum test was used to evaluate the difference between the groups with respect to the Tegner and Lysholm scores at the respective follow-up intervals. Multivariate regression was used to assess potential confounders.Results: Preoperatively, the PTO and UKA groups had similar Tegner (3.0 ± 1.3 and 2.6 ± 0.09, respectively) and Lysholm scores (69.5 ± 7.3 and 71.6 ± 5.4). Postoperatively, the UKA group had significantly superior mean Tegner scores compared with the PTO group at 3 months (3.82 and 2.02, respectively), at 2 years (4.33 and 3.75), and at the time of the final follow-up (4.48 and 3.08), while the Lysholm scores were higher at 3 months (88.0 and 76.3) and at the final follow-up (90.0 and 80.2) (p < 0.01 for all). Multivariate analysis showed UKA to be an independent predictor of activity level at 3 months, 1 year, and 2 years, as well as at the final follow-up. The survivorship was 77% in the PTO group at an average of 7.2 years and 94% in the UKA group at an average of 5.8 years (p < 0.01). The average time to failure was 98 months (range, 38 to 169 months) in the PTO group and 42 months (range, 2 to 123 months) in the UKA group (p < 0.01).Conclusions: In this comparative cohort study of young patients with isolated unicompartmental arthritis, those treated with UKA reached a higher level of activity early after surgery and it persisted at mid-term follow-up. The UKA group had earlier, but less frequent, revision to total knee arthroplasty.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Hip arthroscopy for young patients with femoroacetabular impingement (FAI) has been successful, but the efficacy of hip arthroscopy in older patients is not clearly defined. Purpose: To evaluate the clinical outcomes of patients 55 years and older who are undergoing hip arthroscopy and to compare outcomes with those of patients younger than 55 years. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 201 (63 male, 138 female) patients undergoing primary hip arthroscopy for FAI without radiographic arthritis (Tönnis grade <3) were isolated from a prospective database and stratified by age to <55-year and ≥55-year groups. Patients were evaluated preoperatively and 1 and 2 years postoperatively using the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS: functional scores, as well as Activities of Daily Living [ADL] and Sport subscales). A Wilcoxon signed rank sum test was used to evaluate the differences in outcome scores between the cohorts at each interval. Results: The <55-year group included 174 patients (mean age, 37 ± 12 years), and the ≥55-year group included 27 patients (mean age, 61 ± 5 years). The minimum follow-up time was 2 years in each group. Preoperative Tönnis grades and mHHS scores (59 vs 59; P = .75) were similar between groups. The ≥55-year cohort underwent labral debridement more frequently (78% vs 36%; P =.02) and were more likely to have full-thickness cartilage defects (22% vs 4%; P = .04). Despite this, the mHHS in both groups improved significantly from baseline, without significant differences at 1 year (86 [≥55 years] vs 81 [<55 years]; P = .53) or 2 years (73.88 [≥55 years] vs 79.54 [<55 years]; P = .06). However, at a minimum 2-year follow-up, patients <55 years had significant improvements over patients ≥55 years in the HOS subscales for ADL score (85.6 vs 75.2; P = .03), ADL rating (80.1 vs 70.0; P = .004), Sport score (70.2 vs 55.6; P = .04), and Sport rating (70.2 vs 58.0; P = .04). Conclusion: Although younger patients had superior HOS outcomes reported at 2 years compared with older patients after hip arthroscopy for FAI, both groups had significant improvement compared with their baseline. These data suggest that carefully selected patients 55 years and older without radiographic arthritis may benefit from hip arthroscopy. [ABSTRACT FROM AUTHOR]

Background: Cadaveric skills laboratories and virtual reality simulators are two common methods used outside of the operating room to improve residents' performance of knee arthroscopy. We are not aware of any head-to-head comparisons of the educational values of these two methodologies. The purpose of this prospective randomized trial was to assess the efficacy of these training methods, compare their rates of improvement, and provide economic value data to programs seeking to implement such technologies.Methods: Orthopaedic surgery residents were randomized to one of three groups: control, training on cadavera (cadaver group), and training with use of a simulator (simulator group). Residents completed pretest and posttest diagnostic knee arthroscopies on cadavera that were timed and video-recorded. Between the pretest and posttest, the control group performed no arthroscopy, the cadaver group performed four hours of practice on cadavera, and the simulator group trained for four hours on a simulator. All tests were scored in a blinded, randomized fashion using the validated Arthroscopy Surgical Skill Evaluation Tool (ASSET). The mean improvement in the ASSET score and in the time to complete the procedure were compared between the pretest and posttest and among the groups.Results: Forty-five residents (fifteen per group) completed the study. The mean difference in the ASSET score from the pretest to the posttest was -0.40 (p = 0.776) in the control group, +4.27 (p = 0.002) in the cadaver group, and +1.92 (p = 0.096) in the simulator group (p = 0.015 for the comparison among the groups). The mean difference in the test-completion time (minutes:seconds) from the pretest to the posttest was 0:07 (p = 0.902) in the control group, 3:01 (p = 0.002) in the cadaver group, and 0:28 (p = 0.708) in the simulator group (p = 0.044 for the comparison among groups). Residents in the cadaver group improved their performance at a mean of 1.1 ASSET points per hour spent training whereas those in the simulator group improved 0.5 ASSET point per hour of training.Conclusions: Cadaveric skills laboratories improved residents' performance of knee arthroscopy compared with that of matched controls. Residents practicing on cadaveric specimens improved twice as fast as those utilizing a high-fidelity simulator; however, based on cost estimation specific to our institution, the simulator may be more cost-effective if it is used at least 300 hours per year. Additional study of this possibility is warranted. [ABSTRACT FROM AUTHOR]

Background: The outcome for arthroscopic treatment of femoroacetabular impingement (FAI) can worsen with increasing arthritis. However, there remains a subset of hips with relatively maintained joint space but with acetabular subchondral edema and cystic change with unknown outcome on magnetic resonance imaging (MRI). Purpose: (1) To correlate MRI findings of subchondral acetabular edema/cystic change with arthroscopy grading of articular cartilage and (2) to determine whether postoperative outcome was worse for patients with subchondral edema/cystic change compared with a matched control group. Study Design: Cohort study; Level of evidence, 3. Methods: The records of all patients who underwent arthroscopic hip surgery for FAI at a single institution between 2007 and 2013 were reviewed for subchondral edema/cyst on preoperative MRI. Lesions were characterized by grade using an established classification system and were correlated with arthroscopic articular cartilage changes. A matched cohort of patients without evidence of subchondral edema or cyst was identified. Minimum 2-year outcomes were compared using prospectively collected Hip Outcome Score (HOS) activities of daily living and sport subscales as well as the modified Harris Hip Score (mHHS). Results: Overall, 104 patients were included. Thirty-six patients (18 men, 18 women) with a mean age of 41 years (range, 19-67 years) had subchondral edema, with or without the presence of cystic acetabular changes, at minimum 2-year follow-up (range, 24-60 months). Two patients who underwent total hip replacement were excluded in the outcome score comparison. Thirty-one of 34 patients (91%) had a grade 4 full-thickness cartilage lesion at the time of diagnostic arthroscopy. The mean mHHS was inferior for all patients with subchondral edema/cystic change (79.9 ± 18.7 vs 86.6 ± 12.5; P = .03), and the HOS was also lower (69.1 ± 27.0 vs 79.5 ± 21.4; P = .02). The overall success rate was 67% for all patients with subchondral edema/cystic change compared with 85% in the control group (P = .04). Conclusion: The presence of a subchondral edema with an acetabular cyst on MRI is indicative of a full-thickness cartilage lesion at the time of arthroscopy. These patients have inferior outcomes for arthroscopic treatment of FAI compared with patients with similar age and activity level without MRI subchondral cystic changes. [ABSTRACT FROM AUTHOR]

Background: Limited information exists on the clinical use of a synthetic osteochondral scaffold plug for cartilage restoration in the knee. Purpose/Hypothesis: The purpose of this study was to compare the early magnetic resonance imaging (MRI) appearance, including quantitative T2 values, between cartilage defects treated with a scaffold versus a scaffold with platelet-rich plasma (PRP) or bone marrow aspirate concentrate (BMAC). The hypothesis was that the addition of PRP or BMAC would result in an improved cartilage appearance. Study Design: Cohort study; Level of evidence, 3. Methods: Forty-six patients with full-thickness cartilage defects of the femur were surgically treated with a control scaffold (n = 11), scaffold with PRP (n = 23), or scaffold with BMAC (n = 12) and were followed prospectively. Patients underwent MRI with a qualitative assessment and quantitative T2 mapping at 12 months after surgery. An image assessment was performed retrospectively by a blinded musculoskeletal radiologist. The cartilage phase was measured by cartilage fill and quantitative T2 values on MRI. A comparison between groups after cartilage repair was performed. Results: The control scaffold group consisted of 8 male and 3 female patients (mean age, 38 years; mean body mass index [BMI], 25 kg/m2), the PRP group had 15 male and 8 female patients (mean age, 39 years; mean BMI, 26 kg/m2), and the BMAC group consisted of 8 male and 4 female patients (mean age, 36 years; mean BMI, 26 kg/m2). The PRP-treated (P = .002) and BMAC-treated (P = .03) scaffolds had superior cartilage fill compared with the control group. With quantitative methods, the PRP group demonstrated a mean T2 value (49.1 ms) that was similar to that of the control scaffold group (42.7 ms; P = .07), but the BMAC group demonstrated a mean T2 value (60.5 ms) closer to that of superficial hyaline cartilage (P = .01). The stratification of T2 values between the deep and superficial zones was not observed in any of the groups. Conclusion: In this comparative study, patients treated with scaffold implantation augmented with BMAC had improved cartilage maturation with greater fill and mean T2 values closer to that of superficial native hyaline cartilage at 12 months. Further work will determine if this translates into improved clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: The lateral tibial posterior slope (LTPS) has been reported in multiple studies to correlate with an increased risk for native anterior cruciate ligament (ACL) tearing. To date, no study has examined the effect of an increased LTPS as measured on magnetic resonance imaging (MRI) on the likelihood of ACL graft failure. Hypothesis: An increased LTPS as measured on MRI would correlate with an increased risk for ACL graft failure. Study Design: Case-control study; Level of evidence, 3. Methods: Fifty-eight patients were initially identified who experienced graft failure after primary ACL reconstruction and underwent revision between 1998 and 2009. Exclusion criteria were clinical follow-up of less than 4 years, graft failure occurring greater than 2 years after primary surgery, skeletal immaturity, deep infection, lack of available preoperative MRI, and history of trauma to the proximal tibia. This left 35 patients with early (within 2 years) failure of primary ACL reconstruction. These patients were matched to 35 control participants who had undergone ACL reconstruction with a minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age, sex, date of primary surgery, and graft type. The LTPS was then determined on MRI in a blinded fashion. Results: The mean time to failure in patients in the study group was 1 year (range, 0.6-1.4 years). The mean follow-up of those in the matched control group was 6.9 years (range, 4.0-13.9 years). The mean LTPS in the early ACL failure group was found to be 8.4°, which was significantly larger than that in the control group at 6.5° (P = .012). The odds ratio for graft failure considering a 2° increase in the LTPS was 1.6 (95% CI, 1.1-2.2) and continued to increase to 2.4 (95% CI, 1.2-5.0) and 3.8 (95% CI, 1.3-11.3) with 4° and 6° increases in the LTPS, respectively. No significant association was identified between graft type and graft failure. Conclusion: An increased LTPS is associated with an increased risk for early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring the LTPS as part of the preoperative assessment of ACL-injured patients. [ABSTRACT FROM AUTHOR]

The article focuses on a cohort study identifying the prevalence of multiligament knee injuries (MLKI) in the medial patellofemoral ligament (MPFL) to determine if tears of the MPFL would cause symptomatic patellar instability. It states over a four-year study period, nearly 60 percent of patients who underwent surgery for MLKI had evidence of an MPFL tear detected by magnetic resonance imaging. It mentions while MLKI patients frequently suffered MPFL tears, it rarely results in instability.

The article focuses on the role of knee arthroscopy in the treatment of osteoarthritis (OA) of the knee in the middle aged athletes. It states that the results of the arthroscopic debridement in symptomatic arthritis and in patients without mechanical symptoms are inconsistent and short lived. It also mentions that the counseling of the patients regarding the limited positive effects of the arthroscopic procedure should be done before the reconstructive surgery in the future.

Background: There is limited information regarding direct comparisons of the outcome of osteochondral autograft transfer (OAT) mosaicplasty and microfracture for the treatment of isolated articular cartilage defects of the knee. The purpose of this retrospective comparative study was to compare the general health outcomes, knee function, and Marx Activity Rating Scale scores for patients treated with OAT or microfracture for symptomatic chondral defects of the femoral condyles or trochlea. We hypothesized that the patients in the two treatment groups would have similar clinical outcomes at intermediate-term follow-up. Methods: Ninety-six patients with full-thickness cartilage defects of the femoral condyles or trochlea were treated with either OAT mosaicplasty (n = 48) or microfracture (n = 48). The average age of the patients (thirty-two male and sixteen female in each group) at the time of surgery was 29.7 years in the OAT group and 32.5 years in the microfracture group. Patients were prospectively evaluated at baseline and at one, two, three, and five years postoperatively with use of validated clinical outcome measures including the Short Form-36 (SF-36) physical component, International Knee Documentation Committee (IKDC), Knee Outcome Survey activities of daily living, and Marx Activity Rating Scale instruments. Comparisons between outcomes before and after treatment or between outcomes after microfracture and mosaicplasty were made with use of two-tailed tests. Results: At the time of the latest follow-up, both groups demonstrated significant increases in SF-36 physical component, Knee Outcome Survey activities of daily living, and IKDC scores compared with baseline. These scores did not differ significantly between the two groups at any of the follow-up time points. However, the OAT group demonstrated a significantly greater improvement in the Marx Activity Rating Scale scores from baseline to the two-year (p = 0.001), threeyear (p = 0.03), and five-year (p = 0.02) time points compared with the microfracture group. Conclusions: In the present retrospective comparative study, the hypothesis that patients treated with microfracture or OAT mosaicplasty for symptomatic articular cartilage defects of the femoral condyles or trochlea would have similar clinical outcomes at intermediate-term follow-up was affirmed for general health outcome and for knee function. However, patients treated with OAT mosaicplasty maintained a superior level of athletic activity compared with those treated with microfracture. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Fresh-stored osteochondral allografts have been used successfully to resurface large chondral and osteochondral defects of the knee. However, there are limited data available for the return to athletic activity.Purpose: To review the rate of return to athletic activity after osteochondral allograft transplantation in the knee and to identify any potential risk factors for not returning to sport.Study Design: Case series; Level of evidence, 4.Methods: Forty-three athletes were treated with fresh-stored osteochondral allograft transplantation for symptomatic large chondral or osteochondral defects of the knee from 2000 to 2010. The average age of the athletes (30 men, 13 women) was 32.9 years (range, 18-49 years). Patients were prospectively evaluated by International Knee Documentation Committee (IKDC), activities of daily living scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and Cincinnati Sports Activity Scale scores. A multivariable regression analysis was performed to identify potential risk factors for failure to return to sport at the preinjury level.Results: At an average 2.5-year follow-up, limited return to sport was possible in 38 of 43 athletes (88%), with full return to the preinjury level achieved in 34 of 43 athletes (79%). In these 34 athletes, time to return to sport was 9.6 ± 3.0 months. Age ≥25 years (P = .04) and preoperative duration of symptoms greater than 12 months (odds ratio, 37; P = .003) negatively affected the ability to return to sport. In the athletes who returned to their previous level of competition, IKDC (P < .001), KOOS (P = .02), and Marx Activity Rating Scale (P < .001) scores were all significantly greater than in those athletes who did not return to sport.Conclusion: Osteochondral allograft transplantation in an athletic population for chondral and osteochondral defects in the knee allows for a high rate of return to sport. Risk factors for not returning to sport included age ≥25 years and preoperative duration of symptoms ≥12 months. [ABSTRACT FROM PUBLISHER]

The article reports on research which was conducted to investigate the efficacy of epidural steroid injections used to treat lumbar disc herniations in National Football League football players. Researchers evaluated the cases of 17 players who received the injections for herniations between 2003 and 2010 to investigate the impact the injections had on the players' ability to return to play. They concluded that the injections are a safe and effective therapeutic option in the treatment of disc herniation.

Background: Using comprehensive gait analysis and strength testing, we previously investigated the early (2-month) functional outcome after THA using two-incision and mini-posterior surgical approaches and found an advantage for the mini-posterior approach. Benefits included improved muscle strength, a less antalgic gait, and better hip function as reflected by changes in hip moments during level walking and stair climbing. We questioned how these differences in function would fare with longer followup. Questions/purposes: We determined whether the observed early functional advantages for the mini-posterior technique over the two-incision technique were still present 1 year postoperatively. Patients and Methods: We prospectively enrolled 22 patients with primary degenerative arthritis of the hip; of these, 21 completed gait and strength testing at 2 months, and 19 completed comprehensive gait and strength testing at 1 year (11 two-incision hips, eight mini-posterior hips). The 19 patients included 11 men and eight women with a mean age of 65 years (range, 40-85 years) and a mean (BMI) of 29 (range, 21-39). Results: At 1 year postoperatively, the patients who had the mini-posterior THA had greater improvement in hip flexion strength and internal rotation strength, greater increase in hip flexor internal moment, and greater increase in single-leg stance time on level ground over the patients who had the two-incision THA. Conclusions: Compared with the two-incision approach, patients undergoing mini-posterior THA had persistently better function, including hip flexor and internal rotator muscle strength, hip flexor internal moment, and single-leg stance during level walking. Level of Evidence: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was (1) to describe a staged protocol for management of the dislocated knee and (2) to describe clinical and functional outcomes for patients who received initial spanning external fixation as part of this protocol. Method: Nine knees in 9 patients, consisting of 6 males and 3 females, mean age 30.4 (range 19-44) years with diagnosis or presumption of knee dislocation were treated with a protocol of stabilization with external fixator. Mean follow-up was 24 (range 13-42) months. Indications for spanning external fixation included significant vascular injury, gross instability on examination with failure to maintain joint reduction, open knee dislocation, inability to tolerate mobilization in a brace. The standard protocol involved vascular examination including ankle-brachial index, ligamentous examination (under anesthesia when applicable), stabilization with temporary joint spanning external fixator, thromboprophylaxis, reconstructive knee surgery, and standard rehabilitation. Results: Mean range of motion (ROM) was 97.4° (range 80°-150°, SD 20.75, median 127.5). Median IKDC score was 80 (range 30-95), and mean Lysholm score was 76.7 (range 46-95). Heterotopic ossification (HO) was noted in 4 knees (44%). Conclusion: The treatment algorithm utilized in this series for management of the dislocated knee demonstrated satisfactory clinical and functional outcomes. This staged protocol provides a management option for those patients who may be best served with initial spanning joint external fixation. Larger prospective studies are needed to fully understand the merit of staged protocols in this setting. [ABSTRACT FROM AUTHOR]

Background: The medial patellofemoral ligament (MPFL) is the primary restraint to extreme lateral displacement and is typically disrupted with an acute lateral patellar dislocation. Patients who fail a comprehensive nonoperative program and experience recurrent lateral patellar instability episodes are candidates for surgical treatment. Current surgical procedures include a variety of proximal realignment techniques, including repair or reconstruction of the MPFL along with distal realignment of the tibial tubercle when indicated.Purpose: The objective of this study was to review the clinical, functional, and radiographic outcomes of isolated MPFL repair for recurrent lateral patellar dislocation.Study Design: Case series; Level of evidence, 4.Methods: The records of all patients undergoing MPFL repair for recurrent patellar dislocation at the Mayo Clinic from 2001 to 2006 were retrospectively reviewed. Twenty-seven patients (29 knees) with an average age of 19 years (range, 11-32 years) were included in this study. Clinical, functional, and radiographic outcomes were assessed at an average of 4 years after surgery (range, 2-7 years), using recurrent instability as the primary end point.Results: The success rate of MPFL repair for preventing recurrent dislocations was 72% (21 of 29 knees). Eight patients (28%) experienced a recurrent lateral patellar dislocation. Five of these patients required a reoperation, including two MPFL reconstructions, 1 tibial tubercle osteotomy with MPFL reconstruction, 1 tibial tubercle osteotomy with revision MPFL repair, and 1 revision MPFL repair. At final follow-up, the mean Lysholm and Kujala scores were 86 (range, 42-100) and 92 (range, 57-105), respectively. Postoperative radiographs revealed a mean patellofemoral congruence angle improvement of 27° (range, 5°-44°). The only statistically significant risk factor for failure was nonanatomical MPFL repair at the medial femoral condyle (P = .004).Conclusion: Isolated repair of the MPFL for recurrent patellar instability is associated with a relatively high failure rate, but remains a viable surgical option if surgical technique principles are followed. The clinical success of this operation depends on restoration of the anatomical origin of the MPFL and careful patient selection. [ABSTRACT FROM PUBLISHER]

BACKGROUND: When surgeons perform total hip arthroplasty for hips with a high dislocation related to developmental dysplasia of the hip, obtaining long-term stable implant fixation and optimizing patient function remain challenges. The purpose of this paper was to evaluate the results of cementless arthroplasty with a simultaneous subtrochanteric shortening osteotomy in a group of patients with Crowe type-IV developmental dysplasia of the hip. METHODS: In a retrospective study, we evaluated the results and complications of twenty-eight consecutive primary cementless total hip arthroplasties in twenty-four patients (twenty women and four men), all of whom had Crowe type-IV developmental dysplasia of the hip. The arthroplasty was performed in combination with a subtrochanteric shortening osteotomy and with placement of the acetabular component at the level of the anatomic hip center. The patients were evaluated at a mean of 4.8 years postoperatively. RESULTS: The mean Harris hip score increased from 43 points preoperatively to 89 points at the time of final follow-up (p < 0.01). Twelve (43%) of the twenty-eight hips had an early or late complication or a reoperation. Two (7%) of the twenty-eight subtrochanteric osteotomies were followed by nonunion. There was one instance of isolated loosening of the femoral stem. One acetabular component loosened, and one acetabular liner disengaged. Four hips dislocated postoperatively. All remaining components were well-fixed at the time of the last radiographic follow-up. No sciatic neurapraxic injuries were identified. CONCLUSIONS: Cementless total hip arthroplasty combined with a subtrochanteric femoral shortening osteotomy in patients with a high hip dislocation secondary to developmental dysplasia was associated with high rates of successful fixation of the implants and healing of the osteotomy site and a mean postoperative Harris hip score of 89 points. The complication rate, however, was substantially higher than that associated with primary total hip arthroplasty in patients with degenerative arthritis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the results of meniscal repair executed at the time of Anterior Cruciate Ligament (ACL) reconstruction in pediatric and adolescent patients. It states that clinical outcomes were assessed at a mean of 8 years postoperatively and a multivariate model was used for comparison with isolated meniscal tears. Moreover, complex tears have a higher rate of clinical success when repaired at the time of ACL reconstruction versus when repaired in isolation.

Background: When surgeons perform total hip arthroplasty for hips with a high dislocation related to developmental dysplasia of the hip, obtaining long-term stable implant fixation and optimizing patient function remain challenges. The purpose of this paper was to evaluate the results of cementless arthroplasty with a simultaneous subtrochanteric shortening osteotomy in a group of patients with Crowe type-IV developmental dysplasia of the hip. Methods: In a retrospective study, we evaluated the results and complications of twenty-eight consecutive primary cementless total hip arthroplasties in twenty-four patients (twenty women and four men), all of whom had Crowe type-IV developmental dysplasia of the hip. The arthroplasty was performed in combination with a subtrochanteric shortening osteotomy and with placement of the acetabular component at the level of the anatomic hip center. The patients were evaluated at a mean of 4.8 years postoperatively. Results: The mean Harris hip score increased from 43 points preoperatively to 89 points at the time of final follow-up (p < 0.01). Twelve (43%) of the twenty-eight hips had an early or late complication or a reoperation. Two (7%) of the twenty-eight subtrochanteric osteotomies were followed by nonunion. There was one instance of isolated loosening of the femoral stem. One acetabular component loosened, and one acetabular liner disengaged. Four hips dislocated postoperatively. All remaining components were well-fixed at the time of the last radiographic follow-up. No sciatic neurapraxic injuries were identified. Conclusions: Cementless total hip arthroplasty combined with a subtrochanteric femoral shortening osteotomy in patients with a high hip dislocation secondary to developmental dysplasia was associated with high rates of successful fixation of the implants and healing of the osteotomy site and a mean postoperative Harris hip score of 89 points. The complication rate, however, was substantially higher than that associated with primary total hip arthroplasty in patients with degenerative arthritis. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Isolated meniscal tears in the skeletally immature patient are infrequent but well-recognized injuries. Although few studies have evaluated the pediatric and adolescent population, arthroscopic surgical repair remains the standard of care for patients in this age group with unstable meniscal tears. Purpose: To review our results of arthroscopic repair of isolated meniscal tears in pediatric and adolescent patients to further define future management of these injuries. Study Design: Case series; Level of evidence, 4. Methods: The records of all patients 18 years old or younger who underwent isolated meniscal repair between 1990 and 2005 were retrospectively reviewed. Forty-four patients (6 girls, 38 boys) with an average age of 15.8 years (range, 9.9-18.7 years) were included in this study, for a total of 45 isolated meniscal tears. Clinical examinations were performed, International Knee Documentation Committee forms were administered, and Tegner scores were determined at an average of 5.8 years (range, 2.5 months-13.8 years) postoperative follow-up. Three patients were lost to follow-up. Results: The clinical success rate of arthroscopic meniscal repair was 80% for simple tears, 68% for displaced bucket-handle tears, and 13% for complex tears. Seventeen menisci (38% overall) failed initial repair at a mean of 17 months (range, 3-61 months) postoperatively and underwent repeat arthroscopic surgery (15 partial meniscectomies, 2 rerepair). The average Tegner and International Knee Documentation Committee scores were 8 (range, 5-9) and 89.4 (range, 79-99), respectively, at the time of final follow-up. Risk factors for failure included complex tears and rim width greater than 3 mm. Conclusion: Clinically successful repair of an isolated meniscal tear in patients 18 years or younger was variable depending on tear type, with complex tears and rim width 3 mm or greater being negative prognostic factors. [ABSTRACT FROM AUTHOR]

Purpose: The management of paragangliomas is controversial. Observation, surgery, external-beam radiotherapy (EBRT), and stereotactic radiosurgery (SRS) may, alone or in combination, be appropriate, depending on the size and extent of the tumor, previous treatment, and patient age, general health, and neurologic condition. Few data exist regarding long-term tumor control and late effects after EBRT or SRS. Methods and Materials: We performed a retrospective review of all patients treated with EBRT or SRS for paraganglioma at our institution between 1967 and 1994. The endpoints of the study were tumor control and late complications. Results: The 33 patients in this study had a median follow-up of 13 years (range, 4 months to 36 years). The 10-year tumor control rate was 92% (95% confidence interval, 75–98%). At the last follow-up visit, no patient had developed a radiation-induced malignancy. Conclusion: External-beam RT and SRS are safe and effective for enlarging and/or symptomatic paragangliomas. The risk of developing a delayed radiation-induced malignancy after EBRT or SRS is low. This risk must be weighed against the significant immediate and permanent risk of cranial nerve deficits if the tumor is untreated or is surgically resected. This risk must also be weighed against the immediate but low risk of surgical mortality. [Copyright &y& Elsevier]

Purpose Methods Results Conclusion Level of Evidence The demographic and radiological risk factors of subchondral insufficiency fractures of the knee (SIFK) continue to be a subject of debate. The purpose of this study was to associate patient‐specific factors with SIFK in a large cohort of patients.Inclusion criteria consisted of patients with SIFK as verified on magnetic resonance imaging (MRI). All radiographs and MRIs were reviewed to assess characteristics such as meniscus tear presence and type, subchondral oedema presence and location, location of SIFK, mechanical limb alignment, osteoarthritis as assessed by Kellgren–Lawrence grade and ligamentous injury. A total of 253 patients (253 knees) were included, with 171 being female. The average body mass index (BMI) was 32.1 ± 7.0 kg/m2.SIFK was more common in patients with medial meniscus tears (77.1%, 195/253) rather than tears of the lateral meniscus (14.6%, 37/253) (p < 0.001). Medial meniscus root and radial tears of the posterior horn were present in 71.1% (180/253) of patients. Ninety‐one percent (164/180) of medial meniscus posterior root and radial tears had an extrusion ≥3.0 mm. Eighty‐one percent (119/147) of patients with SIFK on the medial femoral condyle and 86.8% (105/121) of patients with SIFK on the medial tibial plateau had a medial meniscus tear. Varus knees had a significantly increased rate of SIFK on the medial femoral condyle in comparison to valgus knees (p = 0.016).In this large cohort of patients with SIFK, there was a high association with medial meniscus root and radial tears of the posterior horn, meniscus extrusion ≥3.0 mm as well as higher age, female gender and higher BMI. Additionally, there was a particularly strong association of medial compartment SIFK with medial meniscus tears. As SIFK is frequently undiagnosed, identifying patient‐specific demographic and radiological risk factors will help achieve a prompt diagnosis.Level IV. [ABSTRACT FROM AUTHOR]

➤: Mesenchymal stromal cells (MSCs) are a subset of progenitor cells that help to promote tissue healing and regeneration through the secretion of various cytokines and growth factors. Although technically pluripotent, MSCs in vivo rarely repair damaged tissue through direct differentiation and engraftment.➤: Augmentation of traditional marrow stimulation techniques with MSCs has been theorized to improve repair tissue quality and defect fill. Clinical trials evaluating this technique are limited but have shown modest improvements compared with isolated marrow stimulation.➤: Various scaffolds also have been utilized in combination with MSCs to treat focal chondral defects. Although the techniques described are heterogeneous, many have shown promising early clinical outcomes.➤: Newer techniques involving 3-dimensional bioprinted scaffolds seeded with MSCs allow for the recreation of complex architecture, more closely resembling articular cartilage. These techniques are evolving and have not yet been studied in human clinical trials. [ABSTRACT FROM AUTHOR]

Background: Hip arthroscopy is rapidly advancing, with positive published outcomes at short- and midterm follow-up; however, available long-term data remain limited. Purpose: To evaluate outcomes of primary hip arthroscopy at a minimum 10-year follow-up at 2 academic centers by describing patient-reported outcomes and determining reoperation and total hip arthroplasty (THA) rates. Study Design: Case series; Level of evidence, 4. Methods: Patients with primary hip arthroscopy performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative patient-reported outcomes—including the visual analog scale, Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Specific subscales, modified Harris Hip Score, Nonarthritic Hip Score, 12-item International Hip Outcome Tool, surgery satisfaction, and reoperations. Results: A total of 294 patients undergoing primary hip arthroscopy (age, 40 ± 14 years; 66% women; body mass index, 27 ± 6) were followed for 12 ± 3 years (range, 10-24 years) postoperatively. Labral debridement and repair were performed in 41% and 59% of patients, respectively. Of all patients who underwent interportal capsulotomy, 2% were extended to a T-capsulotomy, and 11% underwent capsular repair. At final follow-up, patients reported a mean visual analog scale at rest of 2 ± 2 and with use of 3 ± 3, a 12-item International Hip Outcome Tool of 68 ± 27, a Nonarthritic Hip Score of 81 ± 18, a modified Harris Hip Score of 79 ± 17, and a Hip Outcome Score Activities of Daily Living of 82 ± 19 and Sport Specific subscale of 74 ± 25. The mean surgical satisfaction was 8.4 ± 2.4 on a 10-point scale, with 10 representing the highest level of satisfaction. In total, 96 hips (33%) underwent reoperation—including 65 hips (22%) converting to THA. THA risk factors included older age, higher body mass index, lower lateral center-edge angle, larger alpha angle, higher preoperative Tönnis grade, as well as labral debridement and capsular nonrepair (P ≤.039). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared with 31% for patients undergoing combined labral debridement and capsular nonrepair (P =.006). Labral repair trended toward increased 10-year THA-free survival (84% vs 77%; P =.085), while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%; P =.033). Conclusion: At a minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high satisfaction and acceptable outcome scores. In total, 33% of patients underwent reoperation—including 22% who underwent THA. Conversion to THA was associated with patient factors including older age, higher Tönnis grade, and potentially modifiable surgical factors such as labral debridement and capsular nonrepair. [ABSTRACT FROM AUTHOR]

Background: Osteochondral allograft transplantation (OCAT) is an accepted knee joint–preserving treatment strategy for focal osteochondral lesions that is often conducted in combination with meniscal allograft transplantation (MAT). Despite its frequent and simultaneous utilization, there remains a lack in the literature reporting on outcomes and failure rates after concomitant procedures. Purpose: To determine (1) the midterm clinical success rate after OCAT+MAT in comparison with a matched-pair cohort undergoing isolated OCAT, (2) whether patient-specific and procedural variables influence the risk of failure, and (3) patient-reported outcome measures over time. Study Design: Cohort study; Level of evidence, 3. Methods: A single-center matched-pair cohort study was conducted investigating outcomes in patients who underwent OCAT of the medial or lateral femoral condyle with and without MAT between 2004 and 2020. Patients were matched 1:1 by age (±5 years), sex (male or female), body mass index (±5), and grouped Kellgren and Lawrence grade (grades 0-1 or 2-4). The minimum follow-up time was 2 years. Radiographic variables (International Cartilage Regeneration & Joint Preservation Society [ICRS] grade and Kellgren and Lawrence grade) were assessed preoperatively and at follow-up. Subjective patient-reported outcome measures (Lysholm score, Knee injury and Osteoarthritis Outcome Score [KOOS] including subscores, International Knee Documentation Committee [IKDC] score, and visual analog scale score) were collected preoperatively and at follow-up. Clinical failure was defined as revision surgery for graft failure or conversion to total knee arthroplasty. Patient-reported, clinical, and radiographic outcomes were compared between groups. Results: In total, 66 patients (33 treated with isolated OCAT, 33 treated with OCAT+MAT; 57.6% male) with a mean age of 26.3 years (range, 18-62 years) were followed for a mean of 5.6 years (minimum, 2 years; range, 24-218 months). The 2 cohorts showed no difference in Kellgren and Lawrence grade postoperatively (P =.59). There was a significantly higher ICRS grade detected at follow-up in the OCAT+MAT group (2.81 ± 1.10) compared with the OCAT group (2.04 ± 0.96) (P <.05). There were no statistically significant differences between the groups regarding reoperation rate (OCAT: n = 6; OCAT+MAT: n = 13; P =.116), time to reoperation (OCAT: 46.67 ± 47.27 months vs OCAT+MAT: 28.08 ± 30.16 months; P =.061), and failure rate (OCAT: n = 4 [12.1%] vs OCAT+MAT: n = 5 [15.2%]; P =.66). In the OCAT+MAT group, an increase of tibial slope by 1° conferred a 1.65-fold increase in the hazard for failure over decreased slope (hazard ratio, 1.65; 95% CI, 1.10-2.50; P <.05). The overall survival rate was 86% at a mean follow-up of 5.6 years. Patient-reported outcome scores were significantly improved at the final follow-up compared with preoperative status. No significant differences were seen between groups with respect to subjective IKDC, Lysholm, Tegner, and KOOS results, except for the KOOS Symptoms subscale score, which was significantly higher in the OCAT+MAT group than in the OCAT group (mean difference, 14.6; P <.05) and did exceed the minimal clinically important difference threshold of 10.7. Conclusion: Midterm results after isolated OCAT and OCAT+MAT show high rates of healing and sustainable subjective improvement of knee function and quality of life. However, it should be noted that the difference in reoperation rate and time to reoperation between the groups is arguably clinically important and that lack of statistical significance may be because of low power. These results imply that isolated OCAT is an efficient joint-preserving treatment that can be combined with MAT in well-selected patients with meniscal insufficiency without negative influence on global clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective: To identify preoperative MRI findings in patients with arthroscopically confirmed hypermobile lateral meniscus utilizing a standard MRI knee protocol, with comparison to normal control and lateral meniscal tear groups. Subjects and methods: All patients with arthroscopically confirmed hypermobile lateral meniscus diagnosed at our institution were retrospectively identified. The following structures were evaluated on preoperative knee MRIs: superior and inferior popliteomeniscal fascicles, lateral meniscus and meniscocapsular junction, popliteal hiatus, and soft tissue edema around the popliteal hiatus. The same MRI features were evaluated in the normal control and lateral meniscal tear groups. Results: Study, normal control, and lateral meniscal tear patients (18 each) were included. In the study group, 94.4% had superior popliteomeniscal fascicle abnormality, 89.0% had inferior popliteomeniscal fascicle abnormality, and 72.2% had lateral meniscal abnormality. Incidence of these abnormalities was significantly higher than in the normal control group. Meniscal abnormalities in the study group all involved the posterior horn meniscocapsular junction, 12/13 of which had vertical signal abnormality at the junction and 1/13 with anterior subluxation of the entire posterior horn. Popliteus hiatus measurements were largest in the lateral meniscal tear group. Conclusion: In patients with hypermobile lateral meniscus, the combination of popliteomeniscal fascicle abnormality and vertical signal abnormality at the meniscocapsular junction was seen in the majority of patients. Popliteomeniscal fascicle signal abnormality without identifiable lateral meniscal injury was the next most common imaging appearance. Radiologists may provide valuable information by suggesting the diagnosis of hypermobile lateral meniscus in such cases. [ABSTRACT FROM AUTHOR]

Background: Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability and a paucity of data evaluating the results of shoulder instability surgery (SIS). Purpose: To assess reoperation rates, patient-reported outcomes, and return to wrestling (RTW) after SIS in a cohort of competitive wrestlers. Study Design: Case series; Level of evidence, 3. Methods: All competitive wrestlers with a history of shoulder instability and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of shoulder instability (anterior shoulder instability [ASI], posterior shoulder instability [PSI], and traumatic multidirectional shoulder instability [TMDI]) were analyzed. Exclusions included revision SIS and <2 years of follow-up. Athletes were contacted for determination of complications, RTW, and Western Ontario Shoulder Instability Index scores. Results: Ultimately, 104 wrestlers were included with a mean age at initial instability of 16.9 years (range, 12.0-22.7 years), mean age at surgery of 18.9 years (range, 14.0-29.0 years), and a mean follow-up of 5.2 years (range, 2.0-22.0 years). A total of 58 (55.8%) wrestlers were evaluated after a single shoulder instability event, while 46 (44.2%) sustained multiple events before evaluation. ASI was the most common direction (n = 79; 76.0%), followed by PSI (n = 14; 13.5%) and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), with open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) performed less frequently. RTW occurred in 57.3% of wrestlers at a mean of 9.8 months. Recurrent instability was the most common complication, occurring in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.4%) wrestlers. Across the entire cohort, survivorship rates free from recurrent instability and revision surgery were 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Preoperative recurrent instability was an independent risk factor for postoperative recurrent instability (hazard ratio, 3.8; 95% CI, 1.33-11.03; P =.012). Conclusion: Competitive wrestlers with multiple dislocations before initial clinical evaluation were 3.8 times more likely to experience postoperative recurrent instability. Patients should be counseled that despite SIS, only 57.3% returned to wrestling after surgery. [ABSTRACT FROM AUTHOR]

Background: Meniscal allograft transplantation (MAT) is an accepted and effective treatment option in the context of unsalvageable menisci, particularly in young and active patients. It has been shown to reduce pain and improve knee function in previously symptomatic patients. However, there is still limited knowledge about the long-term survival rates of allografts, the durability of clinical results, and the influence of patient-specific parameters, such as leg alignment, tibial slope, and preoperative International Cartilage Regeneration & Joint Preservation Society (ICRS) grade. Purpose: To determine (1) the long-term clinical success rate after MAT with bony fixation in a large, single-center cohort of consecutive patients, and (2) if patient-specific and procedural variables influence the clinical, anatomic, and subjective outcomes and risk of failure. Study Design: Case-control study; Level of evidence, 3. Methods: Data on 185 consecutive knees undergoing MAT in a single institution were prospectively collected and screened for inclusion in this study. The minimum follow-up time was 2 years. Radiographic variables (ICRS grade and Kellgren-Lawrence grade) were assessed preoperatively and at follow-up. Subjective patient-reported outcome measures (PROMs) (Lysholm score, Knee injury and Osteoarthritis Outcome Score [KOOS] including subscores, International Knee Documentation Committee [IKDC] score, and visual analog scale [VAS] score) were collected preoperatively and at follow-up. Clinical failure was defined as revision surgery due to graft failure or conversion to total knee arthroplasty. Anatomic failure was considered a tear covering >20% of the allograft, any peripheral tear, and unstable peripheral fixation leading to dislocation of the graft. Subjective failure was defined as Lysholm score ≤65. Preoperative tibial slope and leg alignment were assessed. Survival analyses were performed using the Kaplan-Meier estimate. Univariate and multivariate analyses were performed to determine risk factors for clinical and anatomic failure. Results: A total of 157 knees met inclusion criteria. After a mean follow-up time of 7 ± 3.5 years, 127 (80.9%) knees were free of clinical, anatomic, and subjective failure. Fourteen (8.9%) knees experienced clinical failure, 26 (16.6%) knees were identified as having experienced anatomic failure, and 13 (8.3%) patients experienced subjective failure with a reported Lysholm score of ≤65 at a mean follow-up of 7 years. Concurrent osteochondral allograft transplantation was identified as a predictor of both clinical (hazard ratio [HR], 4.55; 95% CI, 1.46-14.17; P =.009) and anatomic (HR, 3.05; 95% CI, 1.34-6.92; P =.008) failure. Cartilage damage of ICRS grade 3 or 4 of the index compartment conveyed an increased risk for clinical (HR, 3.41; 95% CI, 1.05-11.01; P =.04) and anatomic (HR, 3.04; 95% CI, 1.31-7.11; P =.01) failure. High-grade cartilage damage preoperatively (HR, 10.67; 95% CI, 1.037-109.768; P =.046), patient age >25 years (HR, 5.44; 95% CI, 0.120-246.070; P =.384), and a body mass index >30 (HR, 2.24; 95% CI, 0.748-6.705; P =.149) were associated with subjective failure. PROMs including KOOS and IKDC were significantly improved at final follow-up compared with preoperative scores across all measurements (P <.005). Conclusion: MAT showed good to excellent clinical results at a mean follow-up of 7 years. Low ICRS lesion grade was associated with a higher clinical and anatomic survival rate. Patients with concurrent OCA transplantation are at a higher risk of clinical and anatomic failure, but still report significantly improved PROMs. These results suggest that MAT has a lasting beneficial effect both in isolation and in complex cases with ≥1 concurrent procedures. [ABSTRACT FROM AUTHOR]

Background: Historically, symptomatic hip labral lesions were treated with arthroscopic debridement. Hip labral repair has become the standard treatment for labral pathology; however, to date, there are limited long-term studies regarding the outcomes of isolated labral debridement. Purpose: To (1) evaluate the long-term patient-reported outcomes of isolated labral debridement, (2) report reoperation and arthroplasty rates, and (3) identify risk factors contributing to reoperation or poor clinical outcomes. Study Design: Case series; Level of evidence, 4 Methods: A retrospective review of a prospectively generated cohort of 59 hips in 57 patients from 1996 to 2010 who underwent hip arthroscopy with labral debridement was performed. Only patients with Tönnis grade <3 were included. Additionally, given the time period analyzed, resection of cam morphology was not performed, and the interportal capsulotomy was not repaired. The pre- and postoperative modified Harris Hip Score; Hip Outcome Score (HOS)-Activities of Daily Living and -Sports scores; and reoperation, conversion to total hip arthroplasty, and risk factors were analyzed. Results: In total, 48 hips in 47 patients (14 men, 33 women; mean age, 48.0 ± 12.9 years) met inclusion criteria and were followed for a mean of 17 ± 3 years (range, 13-27 years). The mean preoperative Tönnis grade was 1.3 ± 0.6 (range, 0-2), the mean chondral acetabular International Cartilage Regeneration & Joint Preservation Society (ICRS) grade was 1.7 ± 1.6 (range, 0-4), the mean chondral femoral ICRS grade was 0.9 ± 1.4, and the mean acetabular labral articular cartilage grade was 2.5 ± 1.2 (range, 0-4). At the final follow-up, mean the modified Harris Hip Score, HOS-Activities of Daily Living score, and HOS-Sports score were 82.2 ± 16.6, 81.9 ± 20.5, and 82.2 ± 20.5, respectively. Nineteen hips underwent subsequent reoperation at a mean of 5.5 ± 6.2 years (range, 0.5-21.2 years) postoperatively, including 16 hips (33% overall) being converted to total hip arthroplasty. Higher acetabular ICRS chondral grades at the time of surgery were observed in patients who went on to subsequent surgery compared with those who did not (2.3 ± 1.6 vs 1.1 ± 1.5; P =.02). In reoperation-free hips, Tönnis grade demonstrated a trend of increasing over time (1.4 preoperatively vs 1.7 at radiographic follow-up; P =.08). At the final follow-up, 19 hips (40%) had undergone reoperation, and 5 additional hips (10%) were rated as "abnormal" or "severely abnormal" in function, resulting in an overall clinical failure rate of 50%. Conclusion: Isolated labral debridement was found to result in high rates of failure and reoperation, with a third of patients being converted to arthroplasty and half of patients meeting criteria for reoperation or clinical failure. Of note, for patients remaining reoperation-free, satisfactory outcome scores were observed. [ABSTRACT FROM AUTHOR]

A letter to the editor in response to the article "Is Subchondral Acetabular Edema or Cystic Change on MRI a Contraindication for Hip Arthroscopy in Patients With FAI?," that was published in a previous issue of the journal is presented.

The multiple ligament knee injury involving the medial collateral ligament, anterior cruciate ligament, and posterior cruciate ligament is typically the result of a high-energy trauma or knee dislocation event. Optimal treatment strategies are debated, specifically in regard to timing of surgery, reconstruction/repair techniques, and postoperative protocols. This review details the stepwise treatment of these complex patients from diagnosis to postoperative rehabilitation and summarizes the current literature. [ABSTRACT FROM AUTHOR]

Meniscal injuries have posed a challenging problem for many years, especially considering that historically the meniscus was considered to be a structure with no important role in the knee joint. This led to earlier treatments aiming at the removal of the entire structure in a procedure known as a meniscectomy. However, with the current understanding of the function and roles of the meniscus, meniscectomy has been identified to accelerate joint degradation significantly and is no longer a preferred treatment option in meniscal tears. Current therapies are now focused to regenerate, repair, or replace the injured meniscus to restore its native function. Repairs have improved in technique and materials over time, with various implant devices being utilized and developed. More recently, strategies have applied stem cells, tissue engineering, and their combination to potentiate healing to achieve superior quality repair tissue and retard the joint degeneration associated with an injured or inadequately functioning meniscus. Accordingly, the purpose of this current review is to summarize the current available pre-clinical and clinical literature using stem cells and tissue engineering for meniscal repair and regeneration. [ABSTRACT FROM AUTHOR]

Approximately one-third of skeletally mature patients with primary patellar dislocation will experience recurrent patellar instability over time. Because of the multifactorial combination of features contributing to overall stability of the patellofemoral joint, first-time patella dislocation presents a challenge to the treating physician. A detailed patient history, focused physical examination, and appropriate diagnostic imaging are essential for identifying risk factors for recurrent instability. Individual risk factors include young patient age, patella alta, trochlear dysplasia, and lateralization of the tibial tubercle. In combination these factors may pose even greater risk, and recently published predictive scoring models offer clinicians objective criteria to identify patients most at risk for recurrence. In patients at low risk of recurrence, nonoperative management can be effective, with "a la carte" surgical treatments gaining popularity in those with a higher than acceptable risk of re-dislocation. [ABSTRACT FROM AUTHOR]

Athletes have traditionally been subdivided into risk classifications for ACL injury relative to the biomechanical traits they display during landing. This investigation aimed to discern whether these separate risk classifications elicit strain differences on the ACL and MCL during landing. It was hypothesized that the higher risk simulation profiles would exhibit greater ACL strain and that the ACL would exhibit greater strain than the MCL under all conditions. The mechanical impact simulator was used to simulate landing on a cohort of 46 cadaveric specimens. The simulator applied external joint loads to the knee prior to impulse delivery. These loads were organized into a series of profiles derived from in vivo motion capture previously performed on a cohort of 44 athletes and represented various risk classifications. Strain gauges were implanted on the ACL and MCL and simulations performed until a structural failure was elicited. Differences were assessed with Kruskal-Wallis tests. The highest-risk profiles tended to exhibit greater peak ACL strain and change in ACL strain than the baseline- and moderate-risk profiles. Specimens that failed during lower-risk simulations expressed greater strain at these loads than specimens that completed higher-risk simulations. The ACL recorded greater strain than the MCL throughout all simulation profiles. This behavior justifies why neuromuscular interventions have greater impact on higher-risk athletes and supports the continued screening and targeted training of those athletes that express greater injury risk. The loading disparity between ACL and MCL justifies their limited concomitant injury rate. • Simulation of higher-risk landing mechanics lead to greater ACL strain response. • Specimens that failed during lower-risk simulations expressed greater ACL strain. • The ACL expressed greater strain than the medial collateral ligament throughout testing. • This work justifies prevention screening as training is more effective in high-risk athletes. [ABSTRACT FROM AUTHOR]

Purpose: Identifying predictive factors for all-cause reoperation after anterior cruciate ligament reconstruction could inform clinical decision making and improve risk mitigation. The primary purposes of this study are to (1) determine the incidence of all-cause reoperation after anterior cruciate ligament reconstruction, (2) identify predictors of reoperation after anterior cruciate ligament reconstruction using machine learning methodology, and (3) compare the predictive capacity of the machine learning methods to that of traditional logistic regression. Methods: A longitudinal geographical database was utilized to identify patients with a diagnosis of new anterior cruciate ligament injury. Eight machine learning models were appraised on their ability to predict all-cause reoperation after anterior cruciate ligament reconstruction. Model performance was evaluated via area under the receiver operating characteristics curve. To explore modeling interpretability and radiomic feature influence on the predictions, we utilized a game-theory-based method through SHapley Additive exPlanations. Results: A total of 1400 patients underwent anterior cruciate ligament reconstruction with a mean postoperative follow-up of 9 years. Two-hundred and eighteen (16%) patients experienced a reoperation after anterior cruciate ligament reconstruction, of which 6% of these were revision ACL reconstruction. SHapley Additive exPlanations plots identified the following risk factors as predictive for all-cause reoperation: diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. XGBoost was the best-performing model (area under the receiver operating characteristics curve of 0.77) and outperformed logistic regression in this regard. Conclusions: All-cause reoperation after anterior cruciate ligament reconstruction occurred at a rate of 16%. Machine learning models outperformed traditional statistics and identified diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair as predictive risk factors for reoperation. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. These models will allow surgeons to tabulate individualized risk for future reoperation for patients undergoing anterior cruciate ligament reconstruction. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Background: Arthrofibrosis (AF) after anterior cruciate ligament reconstruction (ACLR) remains a challenge. There is a paucity of data on arthroscopic interventions for AF after ACLR. Purpose: To (1) describe the patient, injury, and surgical characteristics and patient-reported outcomes (PROs) of those requiring an arthroscopic intervention for loss of motion after ACLR and (2) compare outcomes between patients undergoing an early intervention (within 3 months) versus those undergoing a late intervention (after 3 months). Study Design: Case series; Level of evidence, 4. Methods: Patients with a history of ACLR and a subsequent operative procedure for postoperative AF at a single institution between 2000 and 2018 were retrospectively identified. Arthroscopic interventions included lysis of adhesions, capsular release with or without manipulation under anesthesia, and excision of cyclops lesions. Patients were excluded if they had a knee dislocation or multiple-ligament injury, a periarticular fracture, or less than 2-year follow-up from the arthroscopic intervention. PROs including the Tegner activity score, visual analog scale pain score, and International Knee Documentation Committee score as well as knee range of motion (ROM) were recorded. Results: A total of 40 patients were included with a mean age of 27.2 years (range, 11.0-63.8 years) at surgery and a mean follow-up of 10.0 years (range, 2.9-20.7 years). The mean preoperative flexion and extension were 102° (range, 40°-150°) and 8° (range, 0°-25°), respectively. The mean postoperative flexion and extension were 131° (range, 110° to 150°) and 0° (range, –10° to 5°), respectively. After the arthroscopic intervention, the mean ROM improved from 94° (range, 40°-140°) preoperatively to 131° (range, 107°-152°) at final follow-up (P <.001), and the visual analog scale pain score improved from 3.0 preoperatively to 1.2 postoperatively (P =.001). Overall, 13 patients (32.5%) underwent an intervention within 3 months and 27 (67.5%) after 3 months. The early intervention group had a higher postoperative International Knee Documentation Committee score compared with the late intervention group (86.8 vs 71.7, respectively; P =.035). Conclusion: An arthroscopic intervention for AF after ACLR successfully improved knee ROM and pain. Patients who underwent either early or late surgery obtained satisfactory motion and function, although improved PROs were observed when the intervention occurred within 3 months of the primary procedure. [ABSTRACT FROM AUTHOR]

Objective: The feasibility of low-dose photon-counting detector (PCD) CT to measure alpha and acetabular version angles of femoroacetabular impingement (FAI). Material and methods: FAI patients undergoing an energy-integrating detector (EID) CT underwent an IRB-approved prospective ultra-high-resolution (UHR) PCD-CT between 5/2021 and 12/2021. PCD-CT was dose-matched to the EID-CT or acquired at 50% dose. Simulated 50% dose EID-CT images were generated. Two radiologists evaluated randomized EID-CT and PCD-CT images and measured alpha and acetabular version angles on axial image slices. Image quality (noise, artifacts, and visualization of cortex) and confidence in non-FAI pathology were rated on a 4-point scale (3 = adequate). Preference tests of standard dose PCD-CT, 50% dose PCD-CT, and 50% dose EID-CT relative to standard dose EID-CT were performed using Wilcoxon Rank test. Results: 20 patients underwent standard dose EID-CT (~ CTDIvol, 4.5 mGy); 10 patients, standard dose PCD-CT (4.0 mGy); 10 patients, 50% PCD-CT (2.6 mGy). Standard dose EID-CT images were scored as adequate for diagnostic task in all categories (range 2.8–3.0). Standard dose PCD-CT images scored higher than the reference in all categories (range 3.5–4, p < 0.0033). Half-dose PCD-CT images also scored higher for noise and cortex visualization (p < 0.0033) and equivalent for artifacts and visualization of non-FAI pathology. Finally, simulated 50% EID-CT images scored lower in all categories (range 1.8–2.4, p < 0.0033). Conclusions: Dose-matched PCD-CT is superior to EID-CT for alpha angle and acetabular version measurement in the work up of FAI. UHR-PCD-CT enables 50% radiation dose reduction compared to EID while remaining adequate for the imaging task. [ABSTRACT FROM AUTHOR]