Tagliero, Adam J.

Cartilage injuries can present in a diverse setting of anatomic locations, with varying severity, and can impact athletes of all ages and competition levels. Moreover, the timing of when an injury presents introduces an additional dimension to treatment decision-making. Frequently, the level of competition, in conjunction with career trajectory and short-term and long-term athlete goals, will dictate whether a temporary or definitive treatment strategy is ideal. Although indicating the correct therapeutic regimen may prove challenging, understanding the athlete-specific considerations can be essential to meeting the goals of the athlete and other stakeholders involved in the athlete’s career. The purpose of this review is to comprehensively present the deliberations a treating physician must consider in managing cartilage injuries within a spectrum of athletic levels ranging from youth to professional levels, with a secondary focus on the presentation of temporizing treatment strategies and associated outcomes.

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.

Abstract Shoulder arthroscopy is a popular modality for the treatment of shoulder pathology. Since its advent in the 1970s, significant advancements have been made in both technology and technique. Shoulder arthroscopy is performed in either the beach‐chair or lateral decubitus positions, and each position has its unique benefits and considerations. Beach‐chair positioning, initially described in the 1980s, has become the preferred method of positioning for most arthroscopic procedures. In this work, we describe the history of beach‐chair positioning for shoulder arthroscopy. We outline a reproducible and teachable method for consistent and comprehensive diagnostic arthroscopy in the beach‐chair position. Pearls, pitfalls, advantages, and disadvantages of diagnostic arthroscopy in this position are discussed. When properly executed, diagnostic arthroscopy in the beach‐chair position can effectively identify and characterize intra‐articular shoulder pathologies. Technique Video video See video under supplementary data.

Purpose To describe the clinical and radiographic features associated with isolated hypermobile lateral meniscus (HLM), and report patient outcomes following surgically repaired isolated HLM. Methods All patients diagnosed with HLM from 2000 to 2020 at a single academic institution were identified and reviewed. Patients were excluded if they had concomitant ligament injury or lacked 2‐year follow‐up. Preoperative and postoperative visual analog scale (VAS) pain scores were determined from clinical notes. Statistical analysis was performed in JMP, and statistical significance was determined with use of a paired t ‐test. Results Eighteen knees in 17 patients met inclusion criteria. Mean patient age was 24.1 (range: 6‐61) years. Mean follow‐up was 73 months (25‐151 months). All 18 knees reported pain at presentation; 94% (17/18) had mechanical symptoms. All 18 knees had preoperative MRIs, but only 1 (5.6%) knee was correctly diagnosed by a musculoskeletal trained radiologist. Most repairs were performed with an all‐inside technique (61%, 11/18). VAS score improved significantly from 7.2 ± 2.9 preoperatively to 0.7 ± 1.9 postoperatively, with average improvement of VAS score of 6.5 ( P < .001). Only one (5.6%) knee required revision meniscal surgery. Conclusions Hypermobile lateral meniscus patients commonly see multiple providers, fail to have their HLM diagnosed on MRI, and undergo various treatments prior to a successful diagnosis. Localized lateral joint line pain, mechanical symptoms, and absence of distinct meniscus tear on MRI are the most frequent clinical presentations. Surgery with meniscus repair is a reliable solution to improve pain and mechanical symptoms. Level of Evidence Level IV, therapeutic case series.

Background: There is a paucity of research on the management of partial-thickness tears of the distal bicep tendon, and even less is known about the long-term outcomes of this condition. Purpose: To identify patients with partial-thickness distal bicep tendon tears and determine (1) patient characteristics and treatment strategies, (2) long-term outcomes, and (3) any identifiable risk factors for progression to surgery or complete tear. Study Design: Case-control study; Level of evidence, 3. Methods: A fellowship-trained musculoskeletal radiologist identified patients diagnosed with a partial-thickness distal bicep tendon tear on magnetic resonance imaging between 1996 and 2016. Medical records were reviewed to confirm the diagnosis and record study details. Multivariate logistic regression models were created using baseline characteristics, injury details, and physical examination findings to predict operative intervention. Results: In total, 111 patients met inclusion criteria (54 treated operatively, 57 treated nonoperatively), with 53% of tears in the nondominant arm and a mean follow-up time after surgery of 9.7 ± 6.5 years. Only 5% of patients progressed to full-thickness tears during the study period, at a mean of 35 months after the initial diagnosis. Patients who were nonoperatively treated were less likely to miss time from work (12% vs 61%; P < .001) and missed fewer days (30 vs 97 days; P < .016) than those treated surgically. Multivariate regression analyses demonstrated increased risk of progression to surgery with older age at initial consult (unit odds ratio [OR], 1.1), tenderness to palpation (OR, 7.5), and supination weakness (OR, 24.8). Supination weakness at initial consult was a statistically significant predictor for surgical intervention (OR, 24.8; P = .001). Conclusion: Clinical outcomes were favorable for patients regardless of treatment strategy. Approximately 50% of patients were treated surgically; patients with supination weakness were 24 times more likely to undergo surgery than those without. Progression to full-thickness tear was a relatively uncommon reason for surgical intervention, with only 5% of patients progressing to full-thickness tears during the study period and the majority occurring within 3 months of initial diagnosis.

Objectives: Distal biceps tendon tears, although rare, significantly impair patient’s elbow mobility and function. There is a paucity of contemporary literature reporting long term outcomes of distal biceps (DB) injuries. Therefore, the authors sought to identify magnetic resonance imaging (MRI) confirmed distal bicep tears and report on (1) patient demographics and injury characteristics of all patients with distal bicep pathology, (2) outcomes of all patients with non-operatively managed DB pathology, and (3) outcomes of all patients with operatively managed DB pathology. Methods: Patients with an MRI-confirmed distal biceps rupture from 1996 to 2016 were identified through an institutional image database. Patients from the initial search were then cross-referenced with the [REDACTED] 1 to ensure record availability. Patients were included if they had complete medical records and ≥5 years of clinical follow-up. Patients with inflammatory arthritis and enthesitis, polytrauma, or incidental findings without clinical assessment were excluded. Medical records were reviewed to confirm the diagnosis of distal biceps tears and obtain further subject details. Results: A total of 158 patients (22 female, 136 male) with a mean age 51.5 years (44.8-61.2) were identified and included. Baseline patient demographics including BMI, smoking status, dominant-handedness, laborer occupation, and gender were gathered (Table 1). Patients had a mean clinical follow-up of almost 14 years (Table 1, range 8.4 -17.8). Outcomes of the 52 non-operative and 106 operatively managed patients, included severe complications, functional outcomes, and health-related productivity loss are reported in Table 2. There were 7 re-operations (4%), 5 re-ruptures (3%), and overall 35% of the operatively treated cohort experienced a complication. Conclusions: Patients with distal bicep pathology tended to be a male laborer in their 50s without clinically significantly associated risk factors. The majority of patients regained full ROM, and 83% were able to return to work without modifications, irregardless of operative or non-operative management. At long term follow up, patients treated operatively were more likely to report missing time from work and averaged more days missed than their non-operatively treated counterparts. Additionally, operative patients had no statistically significant gains functional outcomes, and were subject to potential post-operative complications. Surgeon bias may play a role in deciding treatment for distal biceps tears. As such, careful patient selection for surgical intervention for distal biceps pathology should be employed; surgeons should consider restricting surgical intervention to patients who have significant clinical symptoms or fail non-operative management. [Table: see text][Table: see text]

Objectives: Distal biceps tendon tears, although rare, significantly impair patient’s elbow mobility and function. There is a paucity of literature reporting outcomes of partial thickness tears to inform management strategies. Therefore, the authors sought to identify magnetic resonance imaging (MRI) confirmed partial thickness distal biceps tears and report on (1) demographics and treatment strategies, (2) outcomes and complications, and (3) any identifiable risk factors for progression to surgery or full thickness tear. Methods: Patients who experienced a partial thickness distal biceps tear confirmed on MRI from 1996 to 2016 were identified by a musculoskeletal radiologist through an institutional image database. Patients were included if they had complete medical records and at least one visit of clinical follow-up. Patients with inflammatory arthritis and enthesitis, polytrauma, or incidental findings without clinical assessment were excluded. Medical records were reviewed to confirm the diagnosis and obtain study details. Multivariate logistic regression models were created using baseline characteristics, injury details and physical exam findings in order to predict operative intervention. Results: Overall, 111 patients (22F, 89M, age: 53.6 years ± 13) were identified and included. Baseline injury characteristics and patient demographics including weakness in elbow flexion, forearm supination, and patient reported sensation at time of injury were all found to be statistically different between treatment groups (Table 1). Patients were followed to a mean of 10 years of clinical follow up. Within the cohort, 57 patients were treated non-operatively, while 54 were treated operatively. Patients who received surgical intervention were more likely to report missing time from work and greater loss of productivity due to missed time (Table 2); however, almost 90% of patients returned to work without restrictions, regardless of treatment modality (88% vs 88%, Table 2). For surgical patients, there were 5 re-operations (9%), 3 re-ruptures (6%), and overall, 31% of the operatively treated cohort experienced a complication. Results of the final multivariate logistic regression model are included in Table 3; final model variables included age at initial consult, tenderness to palpation tendon insertion on exam, and supination weakness. Of these, supination weakness at initial consult was found to be a statistically significant predictor for surgical intervention (p=.001, OR=24.8). Conclusions: Operative patients tended to be male with more profound supination weakness; these patients tended to report increased loss of productivity due to time missed after treatment. At 10 year clinical follow up 31% experienced some complication and 9% underwent a re-operation. However, patients demonstrated uniform ability to return to work without modification and no statistical differences in functional outcomes, regardless of treatment modality. Patients who suffer from a partial distal biceps tear should be counseled that operative management represents a balance of returning function with potential complications and increased loss of productivity. [Table: see text][Table: see text][Table: see text]

Background: Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia. Methods: Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures. Results: Ten distinct nonoperatively managed humerus fractures—3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)—were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management. Conclusions: Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.

Background: Patellofemoral instability is due to a combination of bony and soft tissue factors. While recurrent patellar dislocations are rare, evaluation and treatment of these conditions require addressing patellar height and lateralization of the tibial tubercle (TT), restraint to lateral patellar subluxation, and trochlear dysplasia. Other factors to consider are coronal limb-length alignment outside of the physiologic 5 to 8° of valgus, which may significantly alter the Q angle and contribute to lateral instability. Other ligaments around the patella contribute to soft-tissue restraint, including the medial and lateral patellotibial ligaments, patellomeniscal ligaments, and the medial quadriceps tendon femoral ligament. Patellar tilt is assessed with and without quadriceps contraction to further evaluate the patella’s relationship to the trochlear groove. The Caton-Deschamps Index, as well as patellar trochlear index (PTI), are used to measure patellar height for patella alta or baja. Technique Description: The technique is to surgically manage a patient in neutral mechanical alignment on standing limb radiographs, with moderate-to-severe DeJour type B trochlear dysplasia and a trochlear sulcus angle of around 145°, patella alta with a Caton-Deschamps Index of 1.6 and PTI of 0.22, a TT to trochlear groove (TT-TG) distance of 8 mm, and a deficient medial patellofemoral ligament (MPFL). The MPFL reconstruction is done first, with harvesting of the ipsilateral quadriceps tendon and maintenance of its distal attachment on the superior patellar pole. The quadriceps tendon graft is folded medially upon its distal attachment and fixed in this position with suture anchors. Tibial tubercle osteotomy is accomplished by spacing drill holes 2 mm apart, medially and laterally, on the TT and connecting the drill holes with an osteotome and reciprocating saw. A distalized location to secure the TT is selected and superficial bone is excised. A medial parapatellar arthrotomy is performed, and bur attachments are used to drill into the subchondral bone beneath the femoral articular surface to create a V-shaped flap of trochlear cartilage. An arthroscope is inserted under the trochlear flap during this process to visualize the appropriate depth. The trochlear flap is then secured with screws passed over guide pins to secure the flap to the desired location. Cannulated screws and washers are then used to secure the TT to its distalized and/or medialized position, with fluoroscopic verification of screw depth and location. The arthrotomy is then closed with the knee at 45°. The quadriceps graft is passed through a subretinacular channel and secured with suture anchors, adjacent to the adductor tubercle, to complete the MPFL reconstruction. Before closure, appropriate tracking and translation of the patella is verified. Results: Sulcus-deepening trochleoplasty, with or without MPFL reconstruction, has been reported to obtain satisfactory outcomes at 2 years, with close to 85% return to sport and 100% return to work, with improvements in International Knee Documentation Committee (IKDC) scores from 50.8 to 79.1 in some studies. MPFL reconstruction with tibial tubercle osteotomy (TTO) has yielded a 94.5% patient satisfaction rate in the literature. Discussion/Conclusion: In patients with recurrent patellar instability and DeJour types B-D trochlear dysplasia, MPFL reconstruction with TTO and sulcus-deepening trochleoplasty provides excellent subjective outcomes and restores patellar tracking with elimination of recurrent subluxation.

Background Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia. Methods Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union. Results There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries. Conclusions Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.