Levy, Bruce A.

Purpose To compare clinical and functional outcomes (including range of motion, clinical laxity, reoperation/revision rates, and patient‐reported outcome measures) of combined anterior cruciate ligament/posterior cruciate ligament reconstruction (ACLR/PCLR) with and without suture tape (ST) augmentation via a propensity‐matched cohort analysis. Methods A retrospective review was performed to identify all patients who underwent simultaneous primary ACLR/PCLR between 2001 and 2022. A 1:1 propensity match was performed using patient sex, Schenck classification grade, age ±8 years, and body mass index ±10 to produce 2 cohorts: ACLR/PCLR with and without (control) ST augmentation. Clinical outcomes (visual analog scale [VAS], range of motion, Tegner activity scale, Lysholm score, and International Knee Documentation Committee subjective score) were analyzed. Results The propensity match produced a final cohort of 50 ACLR/PCLR patients: 25 with ST augmentation and 25 nonaugmented controls. Most patients had a KD3M injury (12 in each cohort), and no significant differences were noted in concomitant neurovascular, meniscal, or chondral injuries between the groups. Forty patients (80%) completed follow‐up at a mean of 4.7 years for the ST cohort and 8.5 years for the control cohort ( P > .05). Postoperative ST versus control values for outcome measures including VAS at rest (0.9 vs 1.5; P = .71), VAS with use (3.0 vs 2.2; P = .24), International Knee Documentation Committee (75.7 vs 76.3; P = .37), Lysholm (81.8 vs 77.6; P = .91), and Tegner activity (4.8 vs 5.4; P = .37) scores showed no differences ( P > .05 for all). There were no differences in excessive postoperative clinical laxity between ST and control cohorts (ST n = 1 vs control n = 2, Lachman 2+, P = .140; ST n = 3 vs control n = 1, posterior drawer 2+, P = .122). The total number of patients who underwent reoperation was 7 of 25 (28%) for the ST cohort and 8 of 25 (32%) for the control cohort ( P = .76). Conclusions Concomitant ACLR/PCLR utilizing ST augmentation showed similarly satisfactory postoperative clinical outcomes at a minimum 2‐year follow‐up compared to a matched cohort without ST. The use of an independent ST did not limit motion or increase the incidence of complications or revision surgery. Level of Evidence Level III, retrospective comparative case series.

Abstract Anterior cruciate ligament reconstruction (ACLR) using bone–patellar tendon–bone autograft remains one of the most common autografts used, and there is significant evidence to support its title as the “gold standard.” There are nuances and technical challenges associated with every step of an ACLR, which always leave room for improvement. The purpose of this Technical Note is to provide reproducible, technical pearls where errors are commonly encountered during ACLR. In this article, we detail 10 technical pearls that surgeons should consider to enhance operative workflow and optimize success during ACLR with a bone–patellar tendon–bone autograft. Technique Video video See video under supplementary data.

Purpose To evaluate the differences in clinical outcomes and complication rates between open and arthroscopic iliopsoas (IP) tenotomy between 1998 and 2023 at our institution. Methods Patients who underwent arthroscopic iliopsoas fractional lengthening (IPFL) or open tenotomy for IP tendinitis following total hip arthroplasty (THA) between 1988 and 2023 were identified. Patients were excluded if they underwent revision IP tendon release, had additional concomitant procedures, or had less than a 24‐month postoperative follow‐up. Patient records were reviewed, and patient‐reported outcomes were collected via electronic survey. Results Fifty‐two patients (36 arthroscopic, 16 open) were followed for an average of 68.7 (24.0‐203.7) months. Overall surgery satisfaction was 7.9 (scale 0‐10) following arthroscopic IPFL and 6.0 following open tenotomy ( P = .178). Eighty‐six percent of patients reported improvement in their anterior groin pain following arthroscopic IPFL, compared to 45% following open tenotomy ( P = .065). In the arthroscopic cohort, 64% reported improved hip flexion strength, compared to 36% in the open cohort ( P = .158). Visual analog scale for pain at rest was lower following arthroscopic IPFL (1.1 ± 2.2 vs 3.3 ± 3.2, P = .0092), while pain with use did not differ between cohorts (3.1 ± 1.3 vs 2.6 ± 1.1, P = .786). There were no differences in postoperative Tegner (3.1 ± 1.3 vs 2.6 ± 1.1, P = .302), modified Harris Hip Score (77.0 ± 19.0 vs 69.2 ± 26.9, P = .073), or Single Assessment Numeric Evaluation (70.9 ± 28.7 vs 66.7 ± 31.8, P = .571) scores between arthroscopic and open cohorts. Revision THA rates did not differ following arthroscopic or open procedures (8.3% vs 25%, P = .104). Conclusions Patients have improved pain at rest following arthroscopic IPFL when compared to open tenotomy for IP tendinitis following THA. Overall complication and reoperation rates were low for both techniques. Level of Evidence Level III, retrospective cohort study.

Abstract Arthrofibrosis of the knee is a difficult‐to‐manage complication after meniscoligamentous knee injuries, traumatic injuries with articular extension, and surgeries to treat these conditions. Treatment protocols for the management of postoperative arthrofibrosis exhaust nonoperative therapies before proceeding to the operating room for lysis of adhesions (LOA). Although LOA restores range of motion in most cases, a recurrence of arthrofibrosis is possible when postoperative therapy protocols are not strictly followed. Limited treatment options exist in the setting of recalcitrant arthrofibrosis. Revision arthroscopic LOA may be performed in this scenario. This revision procedure places neurovascular anatomy in the posterior compartment at risk. Performing a posterior capsule release in the arthroscopic management of recalcitrant arthrofibrosis is challenging but important to optimize recovery of range of motion. This Technical Note and accompanying video present a stepwise approach to LOA that demonstrates a safe method for performing an arthroscopic posterior capsule release in these challenging cases. Technique Video video See video under supplementary data.

Abstract The ability of the knee to resist valgus stress is largely a result of the integrity of the superficial medial collateral ligament (MCL) and neighboring supporting structures (i.e., deep MCL, semimembranosus, and posterior oblique ligament). The MCL is known to have a robust healing capacity; consequently, the decision to proceed with operative versus nonoperative management of even grade III MCL tears is controversial. When it comes to operative management of these injuries, the decision to proceed with repair or reconstruction is nuanced because the chronicity and location of the MCL tear (i.e., proximal, midsubstance, or distal) largely determine which technique is appropriate. In distal MCL avulsions, including the so‐called Stener lesion, with good tissue quality, direct MCL repair has shown excellent mid‐term outcomes. Consequently, there is a growing need to understand different techniques to address MCL incompetence. In this article, we present a method for primary MCL repair using a washer post–suture post construct. Technique Video video See video under supplementary data.

Abstract Background: Iliopsoas (IP) tendinitis is a recognized complication following total hip arthroplasty (THA) and isolated iliopsoas fractional lengthening (IPFL) has been able to provide symptom relief. IPFL has traditionally been done openly; however, the arthroscopic IPFL has recently been described as an alternative, offering the potential for lower surgical site morbidity and a more favorable post-operative recovery. Purpose: To compare clinical and patient reported outcomes following open and arthroscopic IPFL. We hypothesize that patients undergoing arthroscopic IPFL will have improved pain, function, and satisfaction with lower post-operative complication rates when compared to patients undergoing open IPFL. Methods: Patients with symptomatic IP tendinitis following THA who underwent IPFL from 1988-2023 were reviewed. Inclusion criteria included 2 years follow-up and no concomitant procedures. Patient records were evaluated for surgery type, radiographic anterior acetabular component overhang, reoperations, and need for revision THA. Surveys were used to report overall surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, mHHS, SANE score, Tegner activity scale, and VAS for pain. Results: Fifty-two patients (16 males and 36 females, age: 63.9 ± 11.7 years, BMI: 28.8 ± 5.4 kg/m2) were followed for a mean of 68.7 (24.0 – 203.7) months postoperatively. Overall surgery satisfaction was 7.9 (arthroscopic) and 6.0 (open) (p = 0.178). 86% of patients treated arthroscopically reported feeling “slightly” or “much better” and 86% also reported improvement in their anterior groin pain, compared to 55% and 45% respectively treated openly. In the arthroscopic cohort, 64% reported that their hip flexion strength was “slightly ” or “much better”, compared to 36% treated openly. Average VAS pain score was 1.7 ± 2.7 at rest (arthroscopic: 1.1 ± 2.2, open: 3.3 ± 3.2, p = 0.0092) and 3.0 ± 1.3 (arthroscopic: 3.1 ± 1.3, open: 2.6 ± 1.1) with use. Mean postoperative Tegner score was 3.0 ± 1.3 (arthroscopic: 3.1 ± 1.3, open: 2.6 ± 1.1) compared to 2.3 ± 1.2 preoperatively (arthroscopic: 2.3 ± 1.3, open: 2.1 ± 1.1) (p = 0.0018). Mean post-operative mHHS and SANE score was 74.9 ± 21.6 (arthroscopic: 77.0 ± 19.0, open: 69.2 ± 26.9) and 69.7± 29.7 (arthroscopic: 70.9 ± 28.7, open: 66.7 ± 31.8) respectively. Conclusion: The results indicate that arthroscopic IPFL trends towards significantly improved pain, function, and satisfaction scores when compared to patients undergoing open IPFL, and should be considered when appropriate over an open IPFL given the less invasive nature of an arthroscopic procedure.

Abstract Purpose: 1) To report the clinical outcomes and reoperation rates of arthro- and endo-scopic iliopsoas release at short-term follow-up following ipsilateral total hip arthroplasty from two separate medical institutions, and 2) to evaluate whether demographic and radiographic parameters are associated with postoperative patient reported outcomes. Methods: Patients with iliopsoas tendinitis in the setting of prior THA that underwent arthroscopic iliopsoas fractional lengthening from 1988 – 2023 were reviewed at two academic institutions. Patients were included if they had minimum 12-month follow-up and were evaluated for preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score (mHHS), Single Assessment Numeric Evaluation (SANE) score, Tegner activity scale, visual analog scale (VAS), and revision hip arthroplasty. Results: Sixty hips in 58 patients (19 males, 39 females) were followed for a mean of 39.3 (12.0-105.9) months postoperatively. 77% of patients reported feeling “much” or “slightly better”, 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. Surgery satisfaction was 7.2 ± 3.3 (scale of 0 to 10). Mean postoperative mHHS, VAS pain at rest, VAS pain with use, and SANE scores were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9 respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and didn’t significantly correlate with postoperative PROs (p ≥ 0.45). Tegner score improved to 2.9 ± 1.4 from 2.5 ± 1.7 preoperatively (p = 0.0253). Three patients underwent revision arthroplasty at a mean of 25.3 (11.6 – 40.4) months postoperatively, with an acetabular component revision rate of 3.3%. Conclusions: Satisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening following THA. There was no statistically significant relationship between anterior acetabular component overhang and final PROs. Level of Evidence: IV; Retrospective Case Series

Abstract Purpose Developing large‐scale, standardized radiographic registries for anterior cruciate ligament (ACL) injuries with artificial intelligence (AI) tools can enhance personalized orthopaedics. We propose deploying Artificial Intelligence for Knee Imaging Registration and Analysis (AKIRA), a trio of deep learning (DL) algorithms, to automatically classify and annotate radiographs. We hypothesize that algorithms can efficiently organize radiographs based on laterality, projection, identify implants and classify osteoarthritis (OA) grade. Methods A collection of 20,836 knee radiographs from all time points of treatment (mean orthopaedic follow‐up 70.7 months; interquartile range [IQR]: 6.8–172 months) were aggregated from 1628 ACL‐injured patients (median age 26 years [IQR: 19–42], 57% male). Three DL algorithms (EfficientNet, YOLO [You Only Look Once] and Residual Network) were employed. Radiograph laterality and projection (anterior‐posterior [AP], lateral, sunrise, posterior‐anterior, hip–knee–ankle and Camp‐Coventry intercondylar [notch]) were labelled by a DL model. Manually provided labels of metal fixation implants were used to develop a DL object detection algorithm. The degree of OA, both as measured by specific Kellgren–Lawrence (KL) grades, as well as based on a binarized label of OA (defined as KL Grade ≥2), on standing AP radiographs were classified using a DL algorithm. Individual model performances were evaluated on a subset of images prior to the deployment of AKIRA to registry construction using all ACL radiographs. Results The classification algorithms showed excellent performance in classifying radiographic laterality (F1 score: 0.962–0.975) and projection (F1 score: 0.941–1.0). The object detection algorithm achieved high precision–recall (area under the precision‐recall curve: 0.695–0.992) for identifying various metal fixations. The KL classifier reached concordances of 0.39–0.40, improving to 0.81–0.82 for binary OA labels. Sequential deployment of AKIRA following internal validation processed and labelled all 20,836 images with the appropriate views, implants, and the presence of OA within 88 min. Conclusion AKIRA effectively automated the classification and object detection in a large radiograph cohort of ACL injuries, creating an AI‐enabled radiographic registry with comprehensive details on laterality, projection, implants and OA. Study Design Cross‐sectional study. Level of Evidence Level IV.

Background: Bucket-handle meniscal tears (BHMTs) are a common subtype of meniscal tears that represent a clinical challenge. Arthroscopic inside-out repair has been considered the gold standard in treatment; however, an all-inside approach has gained widespread popularity, with limited long-term evidence. Purpose/Hypothesis: The purpose of this study was to (1) compare long-term clinical outcomes and rates of failure after surgical repair of BHMTs using the all-inside versus inside-out technique, and 2) identify risk factors for failure at long-term follow-up. It was hypothesized that clinical outcomes and rates of failure would be similar between the 2 techniques. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who had undergone surgical repair of BHMTs between 2003 and 2013 at a single institution were identified. Patient-reported outcome measures (PROMs) were assessed preoperatively and at the latest follow-up using the Tegner scale, International Knee Documentation Committee questionnaire, and visual analog scale pain at rest and with activity. A univariate Cox proportional hazards model was used to identify predictors for repair failure, defined as revision meniscal surgery and/or documented meniscal retear. Results: In total, 63 patients were included (37 with inside-out repair, 26 with all-inside repair). At a mean follow-up of 11.2 years, the survival rate for BHMT repair was 63% overall, 70% for all-inside repairs, and 60% for inside-out repairs ( P = .37). The mean time to failure was 2.6 years for all-inside repairs and 2.5 years for inside-out repairs ( P = .98). PROM scores were not significantly different between the 2 repair groups ( P > .22). Univariate Cox proportional hazards model for failure demonstrated that increasing age at surgery was associated with lower failure rates (hazard ratio, 0.91 change per 1-year increase in age; 95% CI, 0.84-0.98) and medial meniscus repair was associated with higher failure rates (hazard ratio, 3.12; 95% CI, 1.14-8.77). Conclusion: Long-term follow-up of BHMT repair demonstrated satisfactory clinical outcomes and failure rates. In appropriately selected patients, the all-inside technique did not compromise outcome as compared with the inside-out repair techniques. For both methods, older age was associated with lower failure rates and medial meniscus repair was associated with increased failure.

Background: As machine learning becomes increasingly utilized in orthopaedic clinical research, the application of machine learning methodology to cohort data from the Multicenter ACL Revision Study (MARS) presents a valuable opportunity to translate data into patient-specific insights. Purpose: To apply novel machine learning methodology to MARS cohort data to determine a predictive model of revision anterior cruciate ligament reconstruction (rACLR) graft failure and features most predictive of failure. Study Design: Cohort study; Level of evidence, 3. Methods: The authors prospectively recruited patients undergoing rACLR from the MARS cohort and obtained preoperative radiographs, surgeon-reported intraoperative findings, and 2- and 6-year follow-up data on patient-reported outcomes, additional surgeries, and graft failure. Machine learning models including logistic regression (LR), XGBoost, gradient boosting (GB), random forest (RF), and a validated ensemble algorithm (AutoPrognosis) were built to predict graft failure by 6 years postoperatively. Validated performance metrics and feature importance measures were used to evaluate model performance. Results: The cohort included 960 patients who completed 6-year follow-up, with 5.7% (n = 55) experiencing graft failure. AutoPrognosis demonstrated the highest discriminative power (model area under the receiver operating characteristic curve: AutoPrognosis, 0.703; RF, 0.618; GB, 0.660; XGBoost, 0.680; LR, 0.592), with well-calibrated scores (model Brier score: AutoPrognosis, 0.053; RF, 0.054; GB, 0.057; XGBoost, 0.058; LR, 0.111). The most important features for AutoPrognosis model performance were prior compromised femoral and tibial tunnels (placement and size) and allograft graft type used in current rACLR. Conclusion: The present study demonstrated the ability of the novel AutoPrognosis machine learning model to best predict the risk of graft failure in patients undergoing rACLR at 6 years postoperatively with moderate predictive ability. Femoral and tibial tunnel size and position in prior ACLR and allograft use in current rACLR were all risk factors for rACLR failure in the context of the AutoPrognosis model. This study describes a unique model that can be externally validated with larger data sets and contribute toward the creation of a robust rACLR bedside risk calculator in future studies. Registration: NCT00625885 (ClinicalTrials.gov identifier).