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Background: Increased posterior tibial slope (PTS) and anterior tibial translation (ATT) result in a higher risk of anterior cruciate ligament reconstruction failure. Accurate measurement of PTS and ATT is essential to guide surgical planning in these patients. Full-length weightbearing lateral tibial radiographs yield the most accurate measurement of PTS and ATT compared with short-film tibial radiographs, computed tomography scans, and magnetic resonance imaging. Indications: We aim to demonstrate a validated, reproducible technique in a stepwise fashion to accurately measure PTS and ATT using full-length weightbearing lateral tibial radiographs. This presentation adds to the field by offering a precise measurement technique for surgical planning purposes. Technique Description: To precisely measure PTS using a full-length weightbearing lateral tibial radiograph, first, perpendicular lines are drawn 5 cm proximal to the ankle joint and 5 cm distal to the knee joint. A line is then extended proximally from the center of the perpendicular line near the ankle through the center of the perpendicular line near the knee, and then extended up to the tibial articular surface. Next, a line is drawn along the medial tibial plateau. The angle measured between these 2 lines is subtracted from 90° to yield the PTS. To precisely measure ATT, a line is drawn along the diaphysis of the tibia and approximated to the posterior aspect of the proximal tibia. Then, another parallel line is drawn and approximated to the posterior aspect of the distal femur. The distance between these lines is measured to yield anterior tibial translation. Results: We measured a PTS of 14.2° and an ATT of 12.6 mm using the technique described in this presentation. Discussion/Conclusion: This technique demonstrates an accurate and reproducible method to precisely measure PTS and ATT using full-length weightbearing lateral tibial radiographs. This technique yields greater accuracy in PTS and ATT than other imaging modalities. As a result, there is a direct benefit for surgical planning when using this technique. 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.

Background: The origin of arthrofibrosis of the knee is multifactorial; however, it is more commonly seen in patients with arthritis, prolonged immobility, or a history of trauma or surgery to the knee. Arthrofibrosis that results in a flexion contracture of the knee is commonly attributable to scarring and shortening of the posterior joint capsule as seen in the setting of operative intervention, such as anterior cruciate ligament reconstruction (ACLR). Indications: Arthroscopic posterior capsular releases of the knee are indicated in patients with recalcitrant arthrofibrosis who have (1) failed nonoperative management and (2) a flexion contracture of ≥10°. Technique Description: This arthroscopic technique utilizes posteromedial and posterolateral portals in addition to the standard anteromedial and anterolateral portals. A transpatellar tendon portal may also be used to create the posterolateral portal. Both a 30° and a 70° arthroscope are used to better visualize the posteromedial and posterolateral inferior and superior releases. In addition to releases of the capsule both inferiorly and posteriorly, the medial and lateral gastrocnemius tendons can be partially released from the femur to allow for a more adequate release. The 70° arthroscope is necessary to access the capsule posterior to the posterior cruciate ligament to ensure complete release. Results: This procedure is typically reserved for patients who have failed conservative management with extension splinting, physical therapy, and the use of corticosteroids. Persistent arthrofibrosis with flexion contracture can occur after ACLR, with an incidence as high as 38% in some series. The specific technique described in this video has documented patient-reported outcomes of achieving full extension in >90% of patients after an arthroscopic posterior capsular release at final follow-up. Discussion/Conclusion: Recalcitrant arthrofibrosis leading to a persisting extension deficit can be devastating for a patient, as it results in increased pain and stiffness, as well as a significant decrease in functionality. Performing a posterior capsular release in addition to the standard manipulation under anesthesia and lysis of adhesions/synovectomy will allow for greater knee range of motion, particularly greater knee extension. 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 The hip capsule is a dense, fibrous structure that plays a crucial role in providing hip stability. Its biomechanical function is tied to its complex anatomy, which includes the iliofemoral, pubofemoral, and ischiofemoral ligaments, along with the circumferential fibers of the zona orbicularis. Anatomic and biomechanical studies with advanced imaging and arthroscopic techniques have provided better understanding of the capsular morphology and its contribution to hip stability. Additionally, these studies provide insight into how capsulotomy and subsequent capsular management at the time of hip arthroscopy can potentially influence postoperative outcomes. Growing clinical evidence supports capsular preservation and repair at the time of primary hip arthroscopy and demonstrates the potential negative outcomes of capsular deficiency, such as pain, dysfunction, and instability. This review provides a comprehensive overview of the gross, arthroscopic, radiologic, and biomechanical anatomy of the hip capsule.

Purpose To evaluate return‐to‐sport (RTS) rates and patient‐reported outcome measures (PROMs) following hip arthroscopic labral repair for femoroacetabular impingement in active basketball players with a minimum of 2‐year follow‐up. Methods All patients who were active basketball players and underwent hip arthroscopy with labral repair for femoroacetabular impingement from 2009 to 2022 were identified. Patients were evaluated for postoperative RTS and revision surgery at a minimum 2‐year follow‐up. RTS was defined as resuming basketball participation, at any level. Modified Harris Hip Score (mHHS), Hip Outcome Score‐Activities of Daily Living (HOS‐ADL) and Sport (HOS‐Sport), and surgery satisfaction were also collected. Results Sixty‐seven hips in 54 athletes (29 male, 25 female) with a mean age of 22.2 years (range 13‐39 years) were included. Eighty‐six (86%) were recreational or high school basketball players. There was significant improvement in all PROMs from baseline to a minimum 2‐year follow‐up (all P < .001). After excluding for athletes who did not RTS for nonmedical reasons, 78% of athletes returned to basketball following hip arthroscopy. Including patients who cited nonmedical reasons for not returning, the overall RTS rate was 65%. Athletes who RTS had significantly higher mHHS ( P = .012), HOS‐ADL ( P = .006), and HOS‐Sport ( P = .002), as well as lower visual analog scale pain (2.2 vs 3.4, P = .037) than those who did not RTS. Calculated minimal clinically important difference values were 8.3 for mHHS, 7.2 for HOS‐ADL, and 13.4 for HOS‐Sport. Anchor‐based patient acceptable symptom state calculations yielded thresholds of 83.5 for mHHS, 92.6 for HOS‐ADL, and 79.2 for HOS‐Sport—with 70%, 63%, and 67% of patients achieving these thresholds, respectively. Conclusions Basketball players who undergo hip arthroscopic labral repair for femoroacetabular impingement show significant improvements in PROMs with 78% RTS rate at a minimum 2‐year follow‐up. Although many athletes discontinued basketball for reasons unrelated to the hip, 18% cited hip issues. Basketball players who successfully return to basketball report higher PROMs than nonreturners, and cohort‐specific minimal clinically important difference analysis indicates that most athletes achieve clinically meaningful improvements. Level of Evidence Level IV, therapeutic retrospective case series.

Purpose To investigate outcomes among patients undergoing total hip arthroplasty after hip arthroscopy (HA‐THA) compared with a matched cohort undergoing primary THA without prior arthroscopy (Only‐THA). Methods Patients who underwent THA after primary hip arthroscopic labral repair from 2009 to 2022 at a single institution were identified. Cases were propensity‐matched 1:4 to primary THA controls by age at THA, sex, body mass index (BMI), surgical approach, and year of surgery. At minimum 2‐year follow‐up, patient‐reported outcomes (PROs)—Forgotten Joint Score (FJS), modified Harris Hip Score (mHHS), and Hip Disability and Osteoarthritis Outcome Score Pain (HOOS‐Pain)—were analyzed. Results Sixty‐two hips (age: 47.5 ± 9.3 years, BMI: 29.7 ± 6.2 kg/m 2 ) were matched to 248 Only‐THA hips (age: 47.9 ± 10 years, BMI: 29.5 ± 5.8 kg/m 2 ). Although both HA‐THA and Only‐THA patients showed significant ( P < .001) postoperative improvements in PROs, HA‐THA patients reported significantly lower postoperative FJS, mHHS, HOOS‐Pain, and inferior Visual Analog Scale pain scores ( P < .001) compared with Only‐THA controls. A cohort‐specific minimal clinical important difference for mHHS was calculated as 9.6 points, with 75.7% of HA‐THA and 87.5% Only‐THA patients achieving this threshold ( P = . 077). At mean 6.6 ± 3.3 years follow‐up, HA‐THA patients with preoperative Tönnis grades 1 reported significantly decreased FJS, mHHS, and HOOS‐Pain compared with HA‐THA patients with preoperative Tönnis grade 2‐3 ( P ≤ .05). HA‐THA patients with Tönnis grade 1 also exhibited worse PROs ( P < .001) compared with Only‐THA controls. Although there were no differences in complication rates between HA‐THA and Only‐THA patients (8% vs. 5%, P = .49), all‐cause reoperation was greater amongst HA‐THA (10% vs. 2%, P = .01). Conclusions Patients undergoing THA after prior hip arthroscopy showed modestly inferior subjective outcomes at mid‐term follow up compared with an age‐matched cohort without prior arthroscopy. Although both groups showed meaningful improvement, a smaller proportion of HA‐THA patients achieved the cohort‐specific MCID for mHHS compared with Only‐THA controls. Level of Evidence Level III, retrospective cohort study.

Through a Delphi process, all 33 panelists reached consensus on topics relating to MRI reporting of knee meniscus lesions, demonstrating that interdisciplinary and multi-institutional standardization is possible.

Background: Posterior medial meniscus root tears (PMMRTs) are frequently observed injuries that alter tibiofemoral biomechanics, yet the long-term outcomes are poorly described. Purpose: To perform a systematic review and meta-analysis of the current literature on long-term clinical and radiographic outcomes of operatively managed PMMRTs. Study Design: Meta-analysis and systematic review; Level of evidence, 4. Methods: A systematic review was performed with the inclusion criteria of English-language studies, diagnosis of PMMRT on magnetic resonance imaging, and minimum 5-year radiographic or patient-reported outcome (PRO) metrics. Data analysis included management strategy, surgical technique, meniscal extrusion, medial joint space, PROs, and radiographic measurements. Failure was defined as conversion to arthroplasty, subsequent partial medial meniscectomy (PMM) and/or proximal tibial osteotomy, or clinical failure on PROs. Continuous outcome variables were analyzed with a random effects meta-analysis of mean differences. Chi-square meta-analysis was also used to analyze categorical variables. Results: Twelve studies were identified with >5-year follow-up after PMMRT (mean ± SD, 84.1 ± 11.0 months). Five studies performed PMM, 6 performed medial meniscus root repair (MMR), and 1 utilized either meniscectomy or repair. There were 797 total patients (female, n = 667; 83.7%), with mean ages ranging from 47.2 to 65. Both interventions showed significant PRO improvements after surgery: PMM (pre- vs postoperative Lysholm, 56.1 vs 68.2; P < .01) and MMR (Lysholm, 52.1 vs 83.1; International Knee Documentation Committee [IKDC], 40.0 vs 72.8; P < .01). MMR had significantly lower Kellgren-Lawrence grades (PMM vs MMR, 2.4 vs 1.8; P < .01) and superior IKDC scores (46.5 vs 72.8; P < .01) as compared with PMM. Additionally, PMM had a significantly higher failure rate (23% vs 5.3%) and conversion to knee arthroplasty (20.5% vs 3.5%) as compared with MMR, with odds ratios of 9.8 and 10.2, respectively. Conclusion: This systematic review and meta-analysis of studies with >5-year minimum follow-up found that PMM was associated with a 10-fold increase in clinical failure and conversion to knee arthroplasty relative to MMR in observational studies. In addition, MMR demonstrated superior Kellgren-Lawrence grades and IKDC scores as compared with PMM. The findings of the current analysis suggest that MMR is associated with superior outcomes as compared with PMM at mid- to long-term follow-up.

Abstract Anterior and posterior cruciate ligament (ACL and PCL) reconstruction poses the risk of residual anterior or posterior tibial translation, respectively. As a result, patients may have residual knee instability and laxity, which can contribute to poor outcomes and graft failure. Ultimately, minimizing anterior and posterior tibial translation through proper ACL and PCL graft tensioning has the potential to improve clinical and functional outcomes in the setting of ACL and PCL reconstruction surgery. This technique aims to show a reproducible method for “setting” anterior and posterior tibial translation in the setting of ACL and PCL reconstructions.

Background: Acetabular overcoverage (pincer morphology) has been suggested to be both a source of pain and dysfunction and potentially protective against osteoarthritic change. Purpose: To compare the minimum 5-year clinical outcomes of patients undergoing primary hip arthroscopic labral repair with a lateral center edge angle (LCEA) of ≥40° as compared with nondysplastic controls with an LCEA of 25° to 40°. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed to identify all patients who underwent primary hip arthroscopic labral repair between 2009 and 2019 at a single academic institution. Patients with an LCEA of ≥40° (pincer) were propensity-matched to nondysplastic controls with an LCEA of 25° to 40° on a 1-to-2 basis by sex, age, body mass index, and surgery year. Patient-reported outcome measures (PROMs)—including visual analog scale, Tegner activity score, modified Harris Hip Score, International Hip Outcome Tool (iHOT-12), and Hip Outcome Score were analyzed—as were reoperations and conversions to total hip arthroplasty (THA). Results: A total of 55 patients with pincer morphology (preoperative LCEA: 41.9°± 2.1°) were matched to 110 nondysplastic controls (LCEA: 31.2°± 4.1°), resulting in a total of 165 hips in 163 patients (67% women, mean age: 37.7 ± 9 years). Pincer patients were corrected to a mean postoperative LCEA of 38.7°± 4.1º ( P < .001), with 22 pincer patients having residual overcoverage; namely, a postoperative LCEA ≥40° (range, 40°-45.8°). There were no differences between cohorts regarding intraoperative characteristics—including femoral and acetabular Outerbridge grade—as well as capsulotomy type and the presence of capsular repair ( P ≥ .210). At a mean 8-year follow-up (range, 5.1-13.2), there was no difference in any postoperative PROMs between pincers and controls ( P ≥ .215) and no difference in PROMs between patients with residual overcoverage and pincer patients with a postoperatively normalized LCEA ( P ≥ .291). At final follow-up, 4 patients in the pincer cohort (7%) and 21 controls (19%) converted to THA ( P = .046). Conclusion: Patients with lateral acetabular overcoverage demonstrated similar and satisfactory postoperative PROMs at a minimum 5-year follow-up compared with propensity-matched nondysplastic controls, regardless of whether the LCEA was corrected to <40°. Of note, nondysplastic controls demonstrated a higher rate of conversion to THA, suggesting a potentially chondroprotective role for acetabular overcoverage.

Background: Despite the growing clinical relevance of obesity in the context of multiligament knee injuries, there remains a paucity of data evaluating patient-reported outcomes in this population. Purpose: To compare clinical and functional outcomes, including postoperative patient-reported outcome measures (PROMs) and complication/revision rates, of multiligament knee reconstruction (MLKR) in individuals with a body mass index (BMI) >30 kg/m 2 versus <30 kg/m 2 at a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was performed to identify all patients who underwent MLKR between 2001 and 2022 at a single institution. Patients with a BMI >30 kg/m 2 were propensity-matched to patients with a BMI <30 kg/m 2 on a 1:1 basis by age, sex, laterality, and Schenck classification (knee dislocation). Medical records were reviewed for patient characteristics, time to surgery, year of surgery, number and type of ligament interventions, graft choice, single versus staged reconstruction, and concomitant injuries. Postoperative clinical examination findings and PROMs for each cohort, including visual analog scale score, Tegner activity scale score, Lysholm score, and International Knee Documentation Committee (IKDC) subjective score, were analyzed and compared. Postoperative complication and revision rates were evaluated and compared. Results: Of 158 patients, 79 patients with a BMI <30 kg/m 2 (mean age, 31.0 ± 11.5 years; mean BMI, 25.8 ± 3.0 kg/m 2 ) were matched to 79 patients with a BMI >30 kg/m 2 (mean age, 32.8 ± 9.5 years; mean BMI, 37.1 ± 5.8 kg/m 2 ). There were no significant differences between cohorts regarding age, sex, laterality, and Schenck classification ( P ≥ .100); however, patients in the BMI >30 kg/m 2 group had greater numbers of posterior cruciate ligament reconstruction. The mean follow-up was 7.5 ± 4.8 years for the BMI <30 kg/m 2 cohort and 7.2 ± 4.8 years for the BMI >30 kg/m 2 cohort ( P = .229). Patients with a lower BMI (<30 kg/m 2 ) had significantly better postoperative mean IKDC (79.3 ± 18.7 vs 67.9 ± 21.2; P = .004), Lysholm (85.1 ± 17.1 vs 75.7 ± 21.0; P = .007), and Tegner (5.1 ± 2.0 vs 4.4 ± 1.7; P = .041) scores. The BMI >30 kg/m 2 group also had significantly more postoperative complications ( P = .028). However, there was no significant difference between the 2 cohorts in terms of reoperation rate or conversion to total knee arthroplasty ( P ≥ .189). Conclusion: Patients who undergo MLKR and have a BMI >30 kg/m 2 demonstrate significantly decreased postoperative PROMs when compared to patients with a BMI <30 kg/m 2 . Increasing BMI significantly increased the incidence of complication rates after MLKR.