Citations

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 determine clinical and radiographic outcomes of medial collateral ligament (MCL) pie‐crusting during isolated medial meniscal root repair. Methods A retrospective review was conducted between August 2013 and December 2019 in patients undergoing isolated medial meniscal root repair. Outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, re‐tears, MCL laxity, and conversion to total knee arthroplasty (TKA), were compared between pie crust (PC) and non‐pie crust (NPC) cohorts. Other assessments included subjective instability or stiffness, infection, and intra‐operative chondromalacia. Additionally, radiographic outcomes were compared to determine progression of medial compartment arthrosis. Results Final analysis included 97 knees, 45 in the PC, and 52 in the NPC group. IKDC and Lysholm scores were similar between both groups preoperatively and 3 months postoperatively. However, at the 6,12, and 24‐month follow up, the PC group had a significantly higher measured IKDC and Lysholm scores than the NPC group. PASS percentages for the IKDC score were significantly higher in the PC group at 6 months, 1 year, and 2 years (96.2%; P = .02) follow‐up compared to the NPC group. MCID percentages for the IKDC score were also significantly higher at the 1‐ and 2‐year (100%; P = .05) follow‐up in the PC group compared to the NPC group. There was also a significantly higher rate of recurrent medial meniscal root tears in the NPC group (4 [8.9%]) compared to the PC group (0 [ P = .03]). No MCL laxity was observed at 6 months follow‐up. Conclusions MCL pie‐crusting during isolated medial meniscal root repair can be used as an alternative surgical technique, as it leads to improved clinical and patient outcomes compared to patients who do not undergo MCL pie‐crusting in the short term. Additionally, those that underwent MCL pie‐crusting had a lower incidence of recurrent tears, and no patients experienced MCL laxity at 6 months. Level of Evidence Level III, retrospective cohort/comparative study.

ABSTRACT Snapping proximal hamstring is an uncommon phenomenon, with few case reports documenting surgical treatment. The purpose of this study is to report snapping resolution, minimum 2-year post-operative patient-reported outcome (PRO), satisfaction scores and complications from patients who underwent surgical release of the conjoint tendon from the sacrotuberous ligament with reattachment to the ischial tuberosity. Prospectively collected data from two institutional databases were retrospectively reviewed for patients who underwent hamstring repair for partial- or full-thickness tears. Patients were included if they demonstrated ‘snapping proximal hamstrings’ on preoperative physical examination, including ultrasound confirmation, and repair subsequently performed. Patients were excluded if they had reconstruction of the proximal hamstring tendon or claimed worker’s compensation. With a total of 20 patients (15 females and 5 males), successful resolution of snapping was reported in 100% of the cohort. For patients with pre- and post-surgical lower-extremity functional scores (LEFS), post-surgical LEFS were significantly higher than pre-surgical LEFS (pre-surgical: 17.0 ± 4.0, post-surgical: 73.6 ± 3.3, P &lt; 0.001). Average post-operative PROs were as follows: International Hip Outcome Tool-12, 92.3 ± 8.3; modified Harris Hip Score, 93.2 ± 7.8; Non-arthritic Hip Score, 92.5 ± 6.8; Hip Outcome Score-Sports Specific Subscale, 94.4 ± 6.7; LEFS, 73.9 ± 3.4; and median visual analog scale of 0 with an interquartile range of 0-1. Patient satisfaction was ‘very satisfied’ in 19 (95%) patients and ‘satisfied’ in 1 (5%) patient. At a minimum 2-year follow-up, patients who underwent surgical treatment for chronic snapping of the proximal hamstrings demonstrated complete resolution of painful posterior snapping, reported high PROs and satisfaction, and had no reported post-operative complications.

Purpose To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow‐up (6 weeks) and 1‐year (or most recent) follow‐up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow‐up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow‐up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow‐up ( P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow‐up. Conclusions In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow‐up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence Level III, case–control study.

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.

Background: Revision anterior cruciate ligament (ACL) reconstruction is being performed at an increasing rate. Previous literature has suggested that autograft ACL reconstruction is a better option than allograft in revision surgery, although the optimal autograft choice remains unknown. The all–soft tissue quadriceps tendon (ASTQT) autograft has been found to be an effective option for primary ACL reconstruction. However, few studies have evaluated ASTQT autograft in revision ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to evaluate the ASTQT autograft in revision ACL reconstruction in athletes compared with bone–patellar tendon–bone (BTB) autograft. We hypothesized that the ASTQT autograft would lead to similar return to play, time to return to play, retear rate, and patient-reported outcomes compared with BTB autograft. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was performed on all athletes undergoing revision ACL reconstruction between August 2013 and December 2019 at a single institution. Patients participating in high school or college athletics undergoing first-time revision with either ASTQT or BTB autograft with ≥2 years of follow-up were included. Demographic variables, complications, return to sports, and outcome scores including the International Knee Documentation Committee (IKDC) and Lysholm were collected and compared between the 2 cohorts. Results: A total of 58 revision ACL reconstructions were included, with 32 in the ASTQT cohort and 26 in the BTB cohort. Return to sports at the same level occurred in 62.5% of the ASTQT group and 53.8% of the BTB group. The ASTQT group returned to sports significantly faster than the BTB group (8.9 vs 10.3 months; P = .020). There was no difference in retear rates (3.1%, ASTQT; 7.7%, BTB) or other complications between the 2 groups. The IKDC scores were significantly higher at the 6- and 12-month follow-up for the ASTQT autograft group compared with the BTB group (6 months: ASTQT, 71.3; BTB, 61.7, P = .001; 12 months: ASTQT, 82.7; BTB, 78.6; P = .021). Lysholm scores were also greater in the ASTQT cohort at these time points (6 months: ASTQT, 75.1; BTB, 63.6; P < .001; 12 months: ASTQT, 82.0; BTB, 74.5; P < .001). However, IKDC and Lysholm scores were similar between both groups at final follow-up (IKDC: ASTQT, 82.9; BTB, 81.7; P = .344; Lysholm: ASTQT, 83.0; BTB, 81.0; P = .104) There was no significant clinical difference in the absolute difference in scores or rate of achieving clinical thresholds between the 2 cohorts. Conclusion: ASTQT autograft for revision ACL in athletes has similar outcomes compared with BTB autograft. However, the ASTQT may possibly afford quicker return to sports and better early improvements in patient-reported outcomes that normalize by 1 year. The soft tissue quadriceps autograft should be considered a viable graft option in revision ACL reconstruction in athletes.

Purpose To determine structural knee injury rates and to identify risk factors and the number of games missed associated with these injuries in National Basketball Association (NBA) players from the 2015 to 2020 seasons. Methods Publicly available player records of active NBA players between the 2015 and 2020 seasons (excluding the shortened 2019 season) were reviewed to identify players with a knee injury associated with missing one or more games. Player demographics, anthropometric measurements, statistics, injury characteristics, and history of other lower‐extremity injuries were recorded. We sought factors associated with having a structural knee injury in bivariate analysis and multivariable logistic regression. Negative binomial regression was conducted to evaluate factors associated with the total number of games missed. Results Two hundred twelve players (of 1,011, 21%) sustained a structural knee injury. Accounting for potential confounders, having a structural knee injury was associated with more minutes per game played (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0‐1.2; P = .002), a greater usage rate (OR 1.1; 95% CI 1.0‐1.2; P = .004), and a lower player efficiency rating (OR 0.94; 95% CI 0.89‐1.0; P = .041). A greater number of missed games was associated with more minutes per game (regression coefficient [RC] 0.065; 0.028‐0.10; P = .001), fewer points per game (RC –0.078; –0.14 to –0.017; P = .013), and greater usage rate (RC 0.032; 0.0040‐0.060; P = .025). Conclusions Structural knee injuries occurred in 21% of players in this study with an overall rate of 5.42 injuries per 1,000 game exposures. Significant risk factors associated with injury were minutes per game, usage rate, and true shooting percentage. Player efficiency was significantly associated with a decreased risk of injury. Increased minutes per game and usage rate were significantly associated with a longer duration of game loss. Level of Evidence Level IV, case series.

Objectives: ACL reconstruction is one of the most common knee procedures performed annually in the United States. Athletes participating in cutting and pivoting sports are at high risk for ACL injury. In the general population, most graft choices including allograft, bone-patellar tendon-bone (BTB) autograft, hamstring autograft and quadriceps autograft have all been shown to excellent results following reconstruction. However, in the high-level cutting and pivoting athlete, the optimal graft for reconstruction remains controversial. Most consider BTB autograft to be the gold standard for such athletes. However, BTB autografts have drawbacks including anterior knee pain, difficulty kneeling and possible patellar fracture and patellar tendon rupture. Quadriceps autograft has increased in popularity since it offers a thicker graft with more favorable tensile properties compared to BTB and hamstring autografts. The quadriceps autograft has nearly twice the cross sectional area, higher load to failure and greater stiffness than the BTB autograft. Studies have shown equivalent outcomes when directly comparing BTB autograft vs. soft tissue quadriceps autograft in the general population. No studies have directly compared these two grafts in athletes participating in cutting and pivoting sports. We hypothesized that the quadriceps autograft would lead to similar patient outcomes, re-tear rates, return to sport and complications as BTB autografts in the cutting and pivoting athlete. Methods: A retrospective review of cutting and pivoting athletes with ACL tears treated with BTB autograft or soft tissue quadriceps autograft with at least 2 years of follow up was performed. Only athletes participating in cutting and pivoting sports were included in the study. Four sports were considered to be cutting and pivoting including soccer, football, lacrosse and basketball. The decision on which graft to use was based on the athlete’s choice after discussing the pros and cons of each graft. Exclusion criteria included those athletes with recurrent ACL tears, multiligamentous injuries, previous meniscal surgery and those requiring osteotomies. International Knee Documentation Committee Subjective Knee Evaluation (IKDC) and Lysholm knee scoring scale were used to evaluate patient reported outcomes. Through chart review, ability to return to sport, time to return to sport and complications were identified. The postoperative rehabilitation protocol for both grafts was identical. Results: There were 32 athletes in the soft tissue quadriceps autograft group and 36 in the BTB autograft group. The average age was 18.6 years for the quad group and 19.7 years for the BTB autograft group (p=0.63). Females made up 62.5% of the quadriceps group and 44.4% of the BTB group (p=0.14). The quad group was made up of 56.3% high school and 43.7% college athletes compared to 61.1% high school and 38.9% college athletes in the BTB autograft group (p=0.53). Soccer was the most common sport with 16 in the quad group and 14 in the BTB group. The rest of the quad group included 8 football players, 4 lacrosse and 4 basketball players. The remaining BTB group consisted of 12 football players, 8 lacrosse and 2 basketball players. Meniscal surgery was performed in combination with the ACL reconstruction in 17 (53.1%) of the quad group and 22 (61.1%) of the BTB autograft group (p=0.37). Average graft size was 9.5mm for the quad autograft group and 10 for the BTB autograft group. The 2-year IKDC score was 93.6 for the quad group and 95.1 for the BTB group (p=0.45). The 2 year Lysholm scores were 95.7 and 96.1 for the quad and BTB groups respectively. Return to play at the same or higher level was 90.6% in the quad group and 86.1% in the BTB autograft group (p=0.82). Time to return was also similar between the groups with 7.1 months for the quad group and 7.6 months for the BTB autograft group. There was 1 re-tear which required revision in the BTB group and no re-tears in the quad group (p=0.34). Arthrofibrosis requiring MUA and lysis of adhesions occurred in 2 quad autografts and 4 BTB autografts (p=0.49). One contralateral ACL rupture occurred in the quad autograft group and 4 in the BTB autograft group (p=0.21). Conclusions: The optimal ACL graft in high level athletes participating in cutting and pivoting sports remains in question. In our comparison of quadriceps autograft compared to BTB autograft in this athletic population, no difference in patient reported outcomes, return to sport or re-tear rates was identified. Based on these findings, quadriceps autograft is as effective as BTB autografts in cutting and pivoting athletes and should be part of the graft choice discussion with the athlete.

Background: Although there is some evidence that cannabinoid (CBD) products may provide a therapeutic effect for musculoskeletal pain, little is known about the usage patterns or their prevalence of use in orthopaedic sports medicine patients. Purpose: To report the prevalence and perceived self-efficacy of CBD products in patients evaluated in an orthopaedic sports medicine clinic. Study Design: Descriptive epidemiology study. Level of evidence, 2. Methods: The study population consisted of new patients who visited an orthopaedic surgery sports medicine clinic at a large academic center for consultation with a surgeon between August 2020 and March 2021. All patients were asked to complete a survey that assessed perceived pain and effectiveness of CBD products and other nonsurgical treatment modalities using the Single Assessment Numeric Evaluation score (range, 0-100) and the Numeric Pain Rating Scale (NRS). Descriptive factors were collected via chart review. Descriptive statistics were used to characterize the data. Results: Overall, 823 patients completed the survey (45.4% female; mean age, 51 years [range, 18-87 years]; mean body mass index, 28.9 [range, 17.2-58.4]). Body areas involved included 285 shoulders, 44 elbows, 76 hips, 276 knees, 58 ankles, and 77 other. Of these patients, 19% (152/823) endorsed the use of CBD products before their initial evaluation. The mean NRS for pain was significantly different between non-CBD users and CBD users (5.6 vs 6.1; P = .029). CBD users were significantly more likely to have tried other nonoperative modalities compared with nonusers, including nonsteroidal anti-inflammatory drugs (79.6% vs 69.8%; P = .032), bracing (44.7% vs 34.6%; P = .024), steroid injections (38.8% vs 21.6%; P < .001), and physical therapy (54% vs 36.1%; P < .001). In addition, 30.9% of CBD utilizers reported marijuana use compared with 2.8% of non-CBD users ( P < .001) for management of their pain. Conclusion: In the current study, 19% of patients had used CBD products to manage joint-related issues. Sports medicine providers should be aware of this high incidence of usage and the potential interactions CBD products may have with other treatment modalities. Further studies are needed to assess the effectiveness of CBD as a therapeutic agent and the specific interactions it has with other drugs and other forms of treatment.