Citations

Objectives: While uncommon, acute traumatic patellar dislocations can lead to recurrent symptoms of patellar instability in 15% to 45% of patients. Patellar stability is an interplay of bony and soft tissue restraints as well as anatomic factors, however, a mainstay of treatment remains reconstruction of the medial patellofemoral ligament (MPFL). Instability events can lead to intra-articular derangements of the knee, both in the acute and chronic patellar instability setting. These findings may not always be appropriately identified on magnetic resonance imaging (MRI). The incidence of these “surprise” injuries have not been previously reported. The purpose of this study is to determine the rates of coexisting intra-articular pathology in patients with patellar instability requiring MPFL reconstruction and elucidate any discordance between preoperative MRI findings and diagnostic arthroscopy findings. Methods: All patients undergoing MPFL reconstruction at a single institution between 2010 and 2023 were identified and preoperative MRI reports, defined as the most recent MRI report to the date of surgery with no interval traumatic events, were queried. Records without full MRI reports as read by a radiologist or cases in which a diagnostic arthroscopy was not conducted were excluded. MRI findings were discordant from arthroscopic findings if a lesion identified on diagnostic arthroscopy was not present in the full MRI report. Procedures that were undertaken because of these missed pathologies on MRI were recorded. Results: A total of 640 patients were identified during the study period, and 507 complete records were ultimately included. Preoperative MRI identified patellar osteochondral lesions or cartilage fissures in 333 patients (66%), loose bodies in 119 patients (24%), lateral femoral condyle osteochondral lesions or fissures in 97 patients (19%) and meniscus tears in 47 patients (9%). Among these patients, 172 (34%) had a diagnosis at the time of arthroscopy which was not identified on the preoperative MRI. These arthroscopic findings resulted in 75 loose body removals, 74 patellar shaving chondroplasties, 16 partial meniscectomies, 3 microfractures, 3 osteochondral lesion open reduction internal fixation, and 2 meniscal repairs which would have been missed without diagnostic arthroscopy due to discordant MRI findings. Conclusions: Over one-third of patients at a single institution who underwent diagnostic arthroscopy in the setting of patellar instability surgery had pathology identified which required surgical intervention that was not reported on a preoperative MRI. A comparison of MRI and diagnostic arthroscopy has been extensively reported on for other knee pathologies including ACL tear and lateral meniscal tear; however, there has been no similar investigation of the reliability of MRI for identification of concomitant pathology in the setting of patellar instability to date. The findings of this study highlight the importance of diagnostic arthroscopy in the treatment of patellar instability, the frequency with which this altered treatment, and the high preponderance of discordant MRI findings.

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.

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]