Makovicka, Justin L.

Background: It has been demonstrated that an athlete’s psychological readiness contributes to one’s ability to successfully return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction. However, the effect of graft choice on psychological readiness is not yet understood. Purpose/Hypothesis: The purpose of this study was to evaluate the association between graft choice and an athlete’s psychological readiness to RTS. It was hypothesized that similar ACL-Return to Sport after Injury (ACL-RSI) scores would be achieved among patients who underwent ACL reconstruction with quadriceps autograft (QA), hamstring tendon autograft (HA), and bone–patellar tendon–bone (BTB) autograft. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent primary ACL reconstruction at a single institution between January 2017 and December 2018 were placed into separate cohorts depending on graft type (HA, BTB, or QA; n = 30 patients in each group), and the ACL-RSI, International Knee Documentation Committee subjective form, and Lysholm scores were compared between the different graft cohorts at 6 months postoperatively, at RTS, and at 2 years postoperatively. Also, the rate of patients who achieved an ACL-RSI score of ≥65 (predictive of return to preinjury sport at 2 years postoperatively) was calculated, as was the RTS rate and time. Results: The QA group demonstrated significantly higher ACL-RSI scores than both the HA and BTB groups at 6 months postoperatively ( P < .0001) and RTS ( P = .011). The QA group also had a higher rate of achieving ≥65 on ACL-RSI than the other groups at 6 months postoperatively ( P = .002) and RTS ( P = .024). There was no significant difference in the RTS rate between the 3 groups, although the QA group demonstrated a significantly quicker return (QA, 8.1 months; BTB, 9.6 months; HA, 10.5 months; P < .001). Conclusion: Athletes undergoing primary ACL reconstruction with QA achieved a higher mean ACL-RSI score and more often achieved a score of ≥65 at the 6-month and RTS time points compared with the HA and BTB groups. QA may afford an advantage over other grafts in terms of improved psychological readiness to RTS.

Purpose To evaluate the effects of this graft preparation technique on histologic evidence of tenocyte mechanical damage. Methods A consecutive series of patients undergoing biceps tenodesis for shoulder pathology were evaluated. After suprapectoral tenodesis, 27 mm of the long head of the biceps was secured for compression into the patch. The remaining length of the residual tendon was longitudinally split, resulting in 2 equal lengths of remnant tendon from the same zone. One sample was sent to pathology with no preparation, and the other was prepared as a compressed biceps autograft patch according to the manufacturer’s recommendations. Both grafts were sent to pathology for evaluation of tenocyte morphology. Records were reviewed to determine if compression resulted in mechanical damage to the tenocytes at the time of biceps augmentation. Results Fifty‐five shoulder procedures and 110 samples were sent for pathology analysis. Forty‐two of the 55 (76%) specimens demonstrated morphologically normal tenocytes in both the compressed and noncompressed groups, and 7 (13%) cases showed evidence of tenocyte necrosis or mechanical damage in both groups. The difference in abnormal tenocyte morphology between the compressed and native groups was not statistically significant ( P = .625). Conclusions Autograft biceps compression into a point‐of‐care patch did not result in mechanical damage to tenocyte morphology at the time of insertion for augmentation of rotator cuff pathology. Clinical Relevance Free proximal biceps tendon compression can result in a patch that does not mechanically damage the tenocyte. The patch can be used as a biologic autograft to enhance shoulder rotator cuff repair, as well as subscapularis repair in the setting of shoulder arthroplasty.

Purpose To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow‐up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications. Results Eighteen athletes with minimum 2 years of follow‐up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years’ follow‐up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant ( P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively ( P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension. Conclusions For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient‐reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels. Level of Evidence Level IV, therapeutic case series.

Abstract Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra‐articular biceps pathology. In this report we describe an all‐arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation. Technique Video video See video under supplementary data.

AbstractIntroductionThe optimal alignment technique for total knee replacement (TKR) remains controversial. We previously reported six-month and two-year results of a randomized controlled trial comparing kinematically (KA) versus mechanically (MA) aligned TKR. In the present study, we report 12-year results from this trial.MethodsThe original cohort included 88 TKRs (44 KA using Shape Match patient-specific guides and 44 MA using conventional instrumentation), performed from 2008 to 2009. After IRB approval, the health record of the original 88 patients were queried. Revisions, re-operations, and complications were recorded. The non-deceased patients were contacted via phone. Reoperation and complications were documented via the patient's history. Further, a battery of patient-reported outcome measures (including patient satisfaction, WOMAC, Oxford, KOOS Jr, Forgotten Joint Score, and M-SANE) were obtained.ResultsOf the original 88 patients in the study, 15 patients had a least one reoperation (17%). Patella problems were the most common cause of reoperation accounting for 5/8 reoperations in the KA group versus 3/7 in the MA group. There was no statistically significant difference between the two alignment methods in terms of major and minor complications or reoperations. At the 12-year follow-up, 26 patients died leaving 62 patients for follow-up. Of these, 48 patients (77%) were successfully contacted. The kinematically aligned total knees self-reported better satisfaction (96% versus 82%), but no difference in other patient-reported outcome measures compared to mechanically aligned TKRs.ConclusionKA TKR demonstrates excellent mid to long-term results compared to MA TKR with similar reoperations, complications, and patient-reported outcome measures.

Objectives: Despite attaining satisfactory knee function following anterior cruciate ligament (ACL) reconstruction, many athletes are unable to return to their pre-injury level of play. ACL tears are known to take a significant psychological toll on the injured athlete and an athlete’s “psychological readiness” may play a large role in their ability to return to sport. The Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale is the only questionnaire to specifically assess the psychological readiness to return to sport after ACL reconstruction. Several factors have been identified to affect an athlete’s psychological readiness to return to sport including age and sex. However, the effect of graft choice on psychological readiness to return to sport have not been studied. The purpose of this study was to evaluate the effect of graft choice on the athlete’s psychological readiness to return to sport. We hypothesized that patients undergoing ACL reconstruction with quadriceps autograft (QA) would reach higher ACL-RSI scores earlier than patients using hamstring autograft (HA) and bone-patellar tendon- bone (BTB) autografts. Methods: The study was a prospective, non-randomized study involving high-level athletes undergoing primary ACL reconstruction with or without meniscal surgery. The participants were involved in varsity high-school, college or professional sports. Each athlete was placed in a group depending on if an all- soft-tissue quadriceps autograft (QA Group), bone-patellar tendon-bone autograft (BTB Group) or hamstring autograft (HA Group) was used for their reconstruction. Graft choice was made by the athlete after the benefits and risks of each graft were discussed in detail. Over the study period, thirty consecutive athletes in each group undergoing primary ACL reconstruction with each specific graft were entered into the study. Athletes undergoing concomitant surgery other than meniscal surgery were excluded from the study. The athletes were asked to fill out the ACL-RSI scale 6-months following surgery, at the time of release to full sport and 2-years following surgery. Current literature shows an ACL-RSI score of 65 or higher as being the score that best predicts return to sport. In addition to comparing the ACL-RSI raw scores between groups, we also compared the percentage of patients reaching an ACL-RSI score of 65 (A-R 65) between the graft types. In addition, patient reported outcomes (PROs) including the International Knee Documentation Committee (IKDC) and Lysholm surveys were completed at the same time points as the ACL-RSI scores. Clinical outcomes included return to sport (RTS), RTS at the same or higher level, time to RTS and graft re-tear. All patients underwent the same rehabilitation protocol regardless of the graft used. RTS was allowed based on appropriate progression through the rehab program, quadriceps strength 90% that of the non-operated leg and triple-hop test 90% the non-operative leg. Return to sport was defined as participation in an official game within the chosen sport of the athlete. Results: The demographics between the three groups was homogenous with the overall average age of the group being 19.1 years. The study included 43.3% high school, 50% college and 6.7% professional athletes with no difference between the groups. The HA group had an ACL-RSI score of 49.2 at 6- months, 59.2 at RTP and 61.7 at the 2-year follow up. The BTB group had scores of 48.1, 64.7 and 63.1 at 6-month, RTP and 2-years postoperatively. The QA group had significantly higher scores than both the HA and BTB groups at the 6-month time period (65.3), and RTP time point (70.6) and similar scores compared to the other two groups at the 2-year follow up (72.7). The HA and BTB groups had similar ACL-RSI raw scores throughout the study. The QA group had a higher percentage of patients reaching the A-R 65 level (53.3%) compared to the HA group (23.3%) and the BTB group (13.3%) at the 6-month postoperative time point. At the RTS time point, the QA group again had a significantly higher rate of patients reaching the A-R 65 level (65.4%) than the other two groups (33.3% HA and 36% BTB group). At the 2-year time point, there was no difference between the three groups with regards to reaching the A- R 65 level. The percentage of athletes reaching the A-R 65 level was not different between the HA and BTB groups at any time point. The IKDC and Lysholm scores were similar between the three groups at all time points. The overall RTP for the study was 82.2% and RTP at the same or higher level was 62.2%. There was no significant difference in return to play between the three groups (HA group 77%, BTB group 83.3% and QA group 87%). Likewise, RTP at the same or higher level was similar between the groups at 57%, 63% and 67% for the HA, BTB and QA groups respectively. There was a significant difference between the QA group and the HA and BTB groups with respect to time to RTS. The average time to RTS for the QA group was 8.1 months compared to 10.5 months for the HA group and 9.6 months for the BTB group. All three groups showed a significant intragroup difference in the ACL-RSI score at all time points between the cohort of patients in each group who were able to return to sport at the same or higher level and those who could not. Clinically, graft re-tears occurred in 17% of the HA group, 10% of the BTB group and 0% of the QA group (p=.02). Conclusions: The QA lead to a higher ACL-RSI score and higher percentages of athletes reaching the A-R 65 level at the 6-month and RTS time points compared to both the hamstring and BTB groups. This fact may explain why the quad group was able to return to sport in significantly less time than the other two groups. The higher ACL-RSI score may be an indication of an athlete’s confidence in their reconstructed knee. This confidence after surgery may allow the athlete to break through the psychological barriers that can make return to sport difficult.

Objectives: ACL reconstruction using hamstring autograft (HA) has been found to have a high re-tear rate in high risk patients including those with a Pivot shift of 2 or higher and those with generalized ligamentous laxity (GLL). Because of this, the use of lateral extra-articular tenodesis (LET) has gained traction in the sports community. Several studies have shown lower ACL graft re-tears with the addition of LET and is felt by many to be necessary when using a HA in high risk patients. However, no study has compared hamstring autograft + LET versus other graft types. The purpose of our study was to compare the surgical outcomes of HA+LET vs an all-soft-tissue quadriceps autograft (QA) without LET. We hypothesized that a QA would lead to similar graft re-tear and rotational instability rates as HA+LET. Methods: This retrospective study compared high risk patients including those with a Pivot shift of 2 or more and GLL undergoing ACL reconstruction with either a HA, HA+LET and QA. In this study, GLL was defined as patients with a Beighton score of 4 or more. Patients were included in the study if they were undergoing a primary ACL reconstruction with either hamstring autograft (HA group), hamstring autograft with extra-articular tenodesis (HA+LET group) or all-soft-tissue quadriceps autograft (QA group) and no other procedures other than meniscal work. All surgeries were performed by the senior surgeon and followed the same rehabilitation protocol after surgery regardless of what type of graft was used during the surgery. Graft choice was dependent on the when during the study the procedure was performed. Early in the study period, HA were used on most patients regardless of whether they were high risk or not. Later, HA+LET was performed due to emerging studies showing higher failure rates in high risk patients undergoing HA alone compared to those undergoing HA+LET. Finally, the senior author transitioned to using QA for most cases. Patient reported outcomes (PROs) were obtained on each patient preoperatively, 3,6,12 and 24-months after surgery. The PROs used in this study included the International Knee Documentation Committee (IKDC) and Lysholm scores. Clinical failure was defined by a patient who had a graft re-tear or those with a residual pivot shift of 2 or more after surgery. Pivot shift was tested for at the 6,12 and 24-month follow up. Other complications associated with the procedure were documented. Results: A total of 166 high risk patients underwent ACL reconstruction over the 7 year study period. There were 63 patients in the HA group, 47 in the HA+LET and 56 in the QA group. The demographics between the three groups was similar with an overall age of the patients in the study being 17.8 years. The mean Beighton score was 3.2 for the group with 24% of the population having GLL. The overall rate of Grade 2 or higher pivot was 82%. There was no difference between the groups with regards to percentage GLL or 2+pivot shift. All three groups had a higher percentage of women than men (HA group 66%; HA+LET group 62% and QA group 56%), but there was no significant difference between the groups. The QA group had a significantly larger graft diameter (9.6mm) compared to the HA group (7.9mm) and the HA+LET group (8.1mm) (p<.001). The number of meniscal repair and partial meniscectomy was similar between all three groups with 21.1% of the population undergoing meniscectomy and 48% of the entire population undergoing meniscal repair. The study was made up of 68.4% athletes for the HA group, 62.4% for the HA+LET and 72.6% for the QA group (p=.32). A significant increase in both IKDC and Lysholm scores were seen at every timepoint compared to preoperative levels. There was no difference between the three groups at any time point for either the IKDC and Lysholm scores. The preoperative IKDC score for the HA group increased from 51.7 to 90.3 at the 2-year follow-up. The HA+LET IKDC scores increased from 53.1 preoperatively to 88.4 at the 2-year follow-up. The QA group had IKDC scores of 49.8 pre op and 90.6 at 2 years. The Lysholm scores increased from 53 to 91.9, 54.8 to 89.4 and 51.9 to 92.6 preoperatively to the 2-year follow-up for the HA, HA+LET and QA groups respectively. The graft re-tear rate of the HA group was significantly higher than the HA+LET and QA groups (14.3%, 2.1% and 1.8% respectively). Residual pivot shift of 2 or more was found in 36.5% of the HA group, 14.9% in the HA+LET group and 19.6% in the QA group. The residual pivot shift in the HA group was significantly higher than the HA+LET and QA groups, but no difference was identified between the HA+LET and QA groups. Return to sport (RTS) was similar between the three groups with 80% of athletes returning to sport with HA grafts, 81% with HA+LET and 86% with QA grafts. The use of a QA in this high-risk population lead to a significantly faster RTS (8.6 months) compared to the HA and HA+LET groups; however, the addition of a LET did not lead to a shorter time to return to sport (10.7 months for the HA group and 11.7 months for the HA+LET group). There was no difference between the three groups for contralateral ACL tears, arthrofibrosis or infection. Conclusions: The use of an all-soft-tissue QA or the addition of an LET to a HA both lead to significant decreases in graft re-tear rate and residual pivot shifts of 2 or greater compared to a HA graft alone in high risk patients undergoing primary ACL reconstruction. However, the use of QA and LET do not improve the patient reported outcome scores at 2-year follow up compared to HA alone. RTS was significantly faster with QA compared to the HA and HA+LET; however, the addition of an LET to a HA did not increase the rate to which an athlete was able to return to play. In conclusion, high risk patients including those with GLL and pivot shifts greater than 2 should undergo ACL reconstruction with either a quadriceps autograft or have a LET added to a hamstring autograft.

Purpose To evaluate the superior to inferior glenoid height as a reliable reference in best‐fit circle creation for glenoid anatomy. Methods The morphology of the native glenoid was evaluated using magnetic resonance imaging (MRI) in patients without shoulder instability. Using T1 sagittal MRI images, 2 reviewers independently estimated glenoid size using the two‐thirds technique and the “best‐fit circle” technique at 2 different times. A Student t ‐test was used to determine significant difference between the two methodologies. Inter‐ and intra‐rater reliability were calculated using interclass and intraclass coefficients. Results This study included 112 patients. Using the results of glenoid height and “best‐fit circle” diameter, the diameter of the “best‐fit circle” was found to intersect the glenoid line at 67.8% of the glenoid height on average. We found no significant difference between the 2 measures of glenoid diameter (27.6 vs 27.9, P = .456). The interclass and intraclass coefficients for the two‐third method were 0.85 and 0.88, respectively. The interclass and intraclass coefficients for the perfect circle methods were 0.84 and 0.73, respectively. Conclusions We determined that the diameter of a circle placed on the inferior glenoid using the “best‐fit circle” technique corresponds to 67.8% of the glenoid height. Additionally, we found that constructing a perfect circle using a diameter equal to two‐thirds the height of the glenoid may improve intraclass reliability. Level of Evidence Level IV, retrospective cohort study.

Background: The development of Achilles tendon treatment modalities has been rapid, and it is increasingly difficult for clinicians to stay up to date with the most influential studies in this field. In order to fully understand the current state of the literature regarding Achilles tendon injury, it is invaluable to be familiar with the foundational articles and studies upon which the field is built. Purpose: To objectively determine the 50 most frequently cited studies in Achilles tendon pathology and to conduct a bibliometric analysis. Study Design: Cross-sectional study. Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics of Achilles tendon research. The 50 most cited articles were selected for analysis from an initial 17,244 identified articles. The information extracted for each article included author name, publication year, country of origin, journal name, study type, and level of evidence. Results: For these 50 studies, the total number of citations was calculated to be 13,159, with a mean of 263.2 citations per paper. The most cited article collected 657 citations. The publication dates of the 50 studies included in this analysis spanned 41 years (1972-2013). The largest number of articles were published by Swedish authors (n = 14); however, many other countries were represented, including Canada and Finland (n = 6 articles each). The most prevalent study designs were cohort studies (n = 13) with level 4 evidence studies being the most common (n = 14). Conclusion: Among the 50 most influential articles in Achilles tendon pathology, the study designs most commonly used were cohort studies and review articles. Sweden was the country of origin for the most studies included on this list, which reflects this country’s interest and commitment to researching Achilles tendon injuries and treatments.

Purpose To compare the 5‐year clinical and functional outcomes of the soft‐tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft. Methods A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft‐tissue QT or double‐tendon HT autograft with at least 5 years of follow‐up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications. Results A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2‐years’ postoperatively. At 5 years’ postoperatively, the QT group demonstrated significantly greater IKDC ( P = .018) and Lysholm ( P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years’ postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications. Conclusions Although the QT autograft demonstrated increased patient‐reported outcome scores when compared with the HT at 5 years’ postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years’ postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid‐term follow‐up. Level of Evidence III, retrospective comparison study.