Tagliero, Adam

AbstractPurposePart two of this consensus aimed to provide recommendations for the prevention of meniscus injuries, non‐operative treatment of acute tears and degenerative lesions, return to sports and patient‐reported outcome measures.MethodsThis consensus followed the European Society of Knee Surgery, Sports Traumatology and Arthroscopy (ESSKA) formal consensus methodology. For this combined ESSKA—American Orthopedic Society for Sports Medicine (AOSSM)—American Academy of Sports Physical Therapy (AASPT) initiative, 67 experts from 14 countries, including orthopedic surgeons and physiotherapists, were involved. The 26 Steering Group members established guiding questions, screened the existing evidence, and proposed statements, and provided Grades of recommendations. The 41 Rating Group members assessed the statements according to a Likert scale (1–9). Final documents were assessed by an international peer review group for geographical adaptability.ResultsLow to moderate scientific level of evidence was available, so that grades of recommendations were low (three Grade A ratings, four Grade B, three Grade C and 13 Grade D), underlining the relevance of this consensus. One strong and 17 relative agreements with overall median of 8 (8–9) and a mean of 7.92 ± 0.37 were achieved for 23 statements on 18 questions. Prevention of meniscus injuries is possible with general knee injury reduction programmes and through avoidance of certain activities. Non‐operative treatment including physical therapy is the first line approach for degenerative meniscus lesions and may be an option for some acute tears. Return to sports after meniscus tear surgery should be both criterion‐based and time‐based. Patient reported outcomes in combination with performance‐based measures are recommended to evaluate the rehabilitation process.ConclusionThis international EU–US consensus established recommendations for prevention strategies, describes rehabilitation of non‐operated patients and of patients after partial meniscectomy, meniscus repair and meniscus reconstruction, and establishes return to sport criteria. These updated and structured recommendations may be applied by surgeons and physiotherapists.Level of EvidenceLevel I, consensus.

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 There are multiple underlying etiologies of patellar instability including both osseous and soft‐tissue factors. Obligate flexion dislocation consists of lateral dislocation of the patella, occurring each time the knee flexes. This generally results from a predominantly lateral contracture of the extensor mechanism and can be technically challenging to manage. Quadricepsplasty can be of particular clinical utility for obligate flexion dislocation and constitutes a realignment of the proximal soft‐tissue attachments of the patella. The described technique features isolation of the 4 muscles of the quadriceps and subsequent stepwise lengthening of the vastus lateralis, advancement of the vastus medialis obliquus, and Z‐lengthening of the rectus femoris and vastus intermedius. This technique can be used in isolation or in combination with other procedures, such as medial patellofemoral ligament reconstruction, to surgically address patellofemoral maltracking. Technique Video video See video under supplementary data.

Background: While patients may report painful or prominent hardware after tibial tubercle osteotomy (TTO), little is known about the frequency, associated factors, and outcomes after removal of symptomatic hardware. Purpose/Hypothesis: The purpose was to investigate the incidence of hardware removal after TTO due to pain or complications, factors associated with hardware removal, and postoperative outcomes after removal. It was hypothesized that clinical outcomes would be similar between patients who underwent TTO without hardware removal and those who underwent TTOs and subsequently hardware removal. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis was performed on patients who underwent TTO at a single institution from 2000 to 2023. Age at the time of the index surgery, sex, race, body mass index, number and size of screws, tibial tubercle–trochlear groove distance, and reason for hardware removal were collected retrospectively. Knee radiographs were reviewed for measurement of soft tissue–hardware distance. Patients were contacted via email to capture final patient-reported outcome measures (PROMs). A univariate logistic regression model was used to determine factors associated with hardware removal. Results: A total of 152 patients representing 171 knees were included. Of the overall cohort, 38 knees (22.2%) in 32 patients underwent TTO with subsequent hardware removal. The most common reason for hardware removal was anterior knee pain (79%). Compared with patients aged 11 to 20 years, patients aged 21 to 30 years demonstrated higher odds of undergoing hardware removal (OR, 3.67; 95% CI, 1.51-9.44; P = .009). Compared with a soft tissue–hardware distance of 0 to 4.9 mm, a distance of 10.0 to 14.9 mm demonstrated lower odds of hardware removal (OR, 0.24; 95% CI, 0.07-0.84; P = .027). Visual analog scale scores (0-10 scale) improved by a mean of 3.6 points after hardware removal ( P = .003). In patients undergoing hardware removal for pain, no difference in final PROMs was found compared with patients who underwent TTO without hardware removal. Conclusion: Hardware removal in patients undergoing TTO was mainly attributed to hardware-related pain/irritation. On average, pain scores improved after hardware removal. There was no difference in final PROMs between patients who had their hardware removed due to pain (eg, without any clinically relevant concomitant pathology) and patients who did not require hardware removal. Size and number of screws were not associated with a subsequent hardware removal procedure. The thickness of the soft tissue envelope overlying implanted hardware was inconsistently associated with lower odds of hardware removal.

Background: Rupture of the pectoralis major is most commonly seen with eccentric contraction mechanisms, and surgical options in the setting of acute tear include direct repair, endocortical buttons, suture anchors, and transosseous tunnel fixation. This technique video will detail repair using a unicortical endobutton fixation construct. Indications: Surgical repair is indicated for acute, complete pectoralis major tears; incomplete tears involving rupture of the sternal head with intact clavicular head; and tears in the young, active, high-demand demographic. Delay in diagnosis increases the risk of tendon retraction and fatty atrophy. Recent literature has shown that acute repair is superior to chronic repair in functional outcome, pain relief, and overall cosmesis. Technique Description: A beach-chair position and a deltopectoral approach are used to identify and mobilize the torn and retracted sternal head of the pectoralis major. A No. 2 SutureTape is then passed through the disrupted sternal head in a Krackow fashion to allow for a 6-strand repair. Two of the suture strands are then shuttled through the endocortical button. A drill is used to create a corticectomy for endobutton placement, which is secured into place by sequentially tightening each limb. Two additional endobuttons are placed in a similar fashion to complete the construct. Results: Outcomes studies regarding patients with pectoralis major tendon ruptures who underwent endocortical button fixation reveal that 83% of patients had good or excellent outcomes in a recent systematic review. Another study showed no significant difference in functional outcomes, return to activity, or complication rate with endocortical button fixation compared with other mechanisms of fixation. Discussion/Conclusion: Unicortical endobutton fixation can provide another fixation strategy for acute pectoralis major tears in young, active high-demand individuals. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Abstract Radial meniscal tears can be challenging to address and require advanced arthroscopic techniques for satisfactory repair. When radial tears occur in older patients, the surgeon often encounters suboptimal tissue integrity that presents its own challenges. Incorporating ripstop sutures in tie‐grip repair constructs for radial tears has been documented in the literature with favorable biomechanical properties. This Technical Note and accompanying video present a reproducible method for incorporating tie‐grip and mobile ripstop stitches to fortify traditional meniscal repair configurations for radial tears. This technique augments the biomechanical strength of repair and may prove useful in poor tissue quality and areas of small focal deficiency, especially in scenarios with repairable but degenerative meniscal tissue. This is particularly relevant considering many repairs fail due to pull‐through of sutures within the meniscal tissue. Technique Video video See video under supplementary data.

Background: Snapping biceps femoris syndrome (SFS) represents a rare clinical entity in which the biceps femoris subluxates over the fibular head in deep flexion. Two primary pathophysiologies have been described including a prominent or abnormal fibular head morphology. Others have implicated an anomalous biceps femoris insertion. The diagnosis is made clinically, with operative and nonoperative intervention strategies available for treatment. Indications: SFS often results in audible snapping and associated pain at the lateral fibular head. When recalcitrant to nonoperative management, surgical intervention can lead to resolution of symptoms. We present the case of a college-aged male who has bilateral symptoms, worse on the right, which have resulted in significant activity modification and daily discomfort recalcitrant to anti-inflammatory medication and physical therapy. Technique Description: The patient was placed supine on the operating room table with an ipsilateral bump under the hip to assist in exposure of the lateral aspect of the knee. Examination under anesthesia (EUA) confirmed the snapping biceps femoris. A lateral approach to the knee and a common peroneal neurolysis was performed. The biceps femoris insertional anatomy was examined for anomalous tendon insertion or insertional tearing. The prominent fibular head was exposed and resected, with careful attention not to disrupt the lateral collateral ligament or popliteofibular ligament insertion sites. The biceps femoris was then repaired to the prepared bony bed of the fibula with one double-loaded suture anchor. Repeat EUA confirmed complete resolution of snapping even with maximal internal rotation of the tibia; this was carefully examined again with the tourniquet deflated to ensure its compressive effect was not partially responsible for the resolution. Results: Published data pertaining to SFS is limited to case reports and small case series. With appropriate indications, surgical intervention yields promising results with a high percentage of patients returning to prior level of activity or prior participation level in sport. Discussion/Conclusion: SFS can be diagnosed with a careful clinical assessment. When recalcitrant to nonoperative management, it is effectively treated with surgical intervention to restore normal fibular anatomy, and prevent recurrent instability and persistent pain. The presented technique allows for appropriate management of these rare injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anterior cruciate ligament (ACL) injuries to soccer players present unique challenges in sports medicine, given the sport’s global prevalence and intricate injury dynamics. These injuries, especially in the youth and female demographic, have become a substantial concern in sports medicine. This review explores the epidemiology, mechanism of injury, diagnostic procedures, treatment modalities, and rehabilitation strategies related to ACL tears within the soccer community. Progress in diagnostics, treatments, and rehabilitation underscores the importance of evidence-based approaches. As soccer continues its ascent in popularity, addressing the specific risks and nuances of ACL injuries in this context remains of paramount significance.

Abstract Unstable osteochondritis dissecans lesions of the medial femoral condyle have classically been treated with open reduction and fixation under direct visualization through an open arthrotomy. Given the value of avoiding open arthrotomies, we present an arthroscopic approach for lesion elevation, debridement, and fixation. The lesion is first elevated using an arthroscopic elevator, leaving a laterally based osseous hinge. Once elevated, fibrous debris is debrided from the base of the lesion. Subsequently, the fragment is reduced, and percutaneous transpatellar instrumentation is used for fixation. The use of this technique allows for excellent mobilization, debridement, and fixation of the osteochondritis dissecans lesion while minimizing violation of periarticular soft tissues. Technique Video video See video under supplementary data.

Abstract A broad range of shoulder pathologies are treated with shoulder arthroscopy due to its minimally invasive nature. Mastering the fundamentals is critical for high‐quality care; this includes patient positioning. Surgeons must consider the advantages and disadvantages of the 2 most prominent patient positions: lateral decubitus and beach chair. The beach‐chair position offers an intuitive anatomic view with the advantage of shoulder maneuverability. Understanding the associated pitfalls related to patient hemodynamics; head, neck, and shoulder positioning; and protection of bony prominences can guide the operative care team to obtaining a safe position for the patient. The purpose of this Technical Note and video is to present and demonstrate a reproducible and teachable method for safely positioning a patient in the beach‐chair position for shoulder arthroscopy, as well as to describe the associated advantages and disadvantages. Technique Video video See video under supplementary data.