Brinkman, Joseph C.

Purpose To evaluate the effectiveness of adding lateral extra‐articular tenodesis (LET) to primary anterior cruciate ligament reconstruction (ACLR) in competitive female soccer athletes with greater preoperative generalized ligamentous laxity. Methods A retrospective review of female high school and collegiate soccer players who underwent primary ACLR from 2013 to 2021, with a minimum of 2 years of follow‐up, was conducted. Participants were divided into 2 groups: those who received ACLR alone and those who received ACLR with LET. Generalized ligamentous laxity was defined as a Beighton score ≥4 and was not considered an indication for LET. Anterior cruciate ligament (ACL) autografts included the quadriceps, bone−patellar tendon−bone, and hamstrings in both groups. Patient demographics and physical examination findings, including pivot shift results, were collected. Positive pivot‐shift refers to a grade ≥2. Patient outcomes included graft failure (defined as ACL retear), International Knee Documentation Committee score, Lysholm score, return to sport, and complications. Independent t tests, χ 2 tests, and Mann‐Whitney U tests were conducted to compare outcomes between the 2 groups. Minimally clinical important difference was calculated from preoperative to final follow‐up. Results A total of 133 female soccer players who underwent ACLR met inclusion criteria, including 43 patients that received an ACLR + LET and 90 patients who underwent isolated ACLR. Average follow‐up was 39.0 and 36.1 months in the LET group and the control group, respectively. Patients who underwent LET had a greater generalized ligamentous laxity rate (48.8% vs 18.9%; P < .001) and greater median Beighton score (3.0 vs 1.0; P < .001) than those without LET. There was a similar rate of graft failure in patients who underwent LET compared with the control group (4.7% vs 3.0%; P = .658). On the basis of minimally clinical important difference thresholds, there were no clinically relevant differences in International Knee Documentation Committee or Lysholm scores noted between the 2 groups. Return‐to‐sport rates also were comparable between the LET and control cohorts (90.7% vs 85.6%; P = .807). Conclusions The addition of LET during ACLR in female soccer players with preoperative generalized ligamentous laxity yields graft retear and return‐to‐sport rates comparable with those of athletes without ligamentous laxity. Level of Evidence Level III, retrospective comparative study.

Objective The aim of the study was to assess the interrater reliability between seven individuals assessing quadriceps femoris cross-sectional area, echo intensity, and corrected echo intensity. Design A retrospective subanalysis of data collected in a randomized controlled clinical trial (IRB 19-008473. NCT ID NCT04302558). Patients aged 13–50 yrs with an anterior cruciate ligament tear requiring surgical reconstruction were assessed for cross-sectional area of the rectus femoris, vastus intermedius, vastus lateralis, vastus medialis, and vastus medialis obliquis, and echo intensity of the rectus femoris. Musculoskeletal ultrasound imaging of the quadriceps was performed by one physical therapist, and quantitative assessments were performed by four physicians and three physical therapists. Results Physicians and physical therapists had good reliability for cross-sectional area of the rectus femoris (median interclass correlation 0.86 doctor of medicine (MD) and 0.84 physical therapist), cross-sectional area of the vastus medialis obliquis (0.82 and 0.82), and echo intensity mean (0.92 and 0.92). Rectus femoris cross-sectional area had the smallest coefficient of variation (26.512.7%), whereas subcutaneous fat had the largest coefficient of variation (93.3% left, 86.4% middle, 86.1% right). Conclusions These findings demonstrate reliability between physicians and physical therapists in interpretation of ultrasound images of the quadriceps. The inconsistency demonstrates the need for a consistent training across disciplines to ensure accurate image interpretation.

Background: Young female patients undergoing hip arthroscopy have an increased prevalence of baseline capsular laxity of the hip joint. This laxity, along with superimposed postoperative iatrogenic capsular deficiency secondary to an unrepaired capsule, could potentially lead to worse outcomes after arthroscopic treatment of femoroacetabular impingement (FAI) in this population. Purpose: To compare outcomes and revision rates for young female patients undergoing hip arthroscopy for FAI and labral tear with capsular closure (CC group) versus capsular nonclosure (CNC group). Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of prospectively collected data of patients who underwent index hip arthroscopy using interportal capsulotomies by a single surgeon between January 2014 and February 2020 was performed. Female patients aged 12 to 21 years who underwent hip arthroscopy with cam or pincer osteoplasty and labral repair with a 2-year minimum follow-up were included. The Beighton score was assessed. The Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Hip Outcome Score–Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at 3 months, 1 year, and 2 years postoperatively. Data were analyzed using the Mann-Whitney U test and Fisher exact test. Results: A total of 23 hips (20 patients) were included in the CC group and 17 hips (16 patients) were included in the CNC group. The groups were not different regarding characteristics and preoperative patient-reported outcome scores. At all follow-up intervals postoperatively, the CC group scored significantly higher HOS-ADL and HOS-SSS. Fifteen of 17 (88.2%) patients in the CC group returned to sports versus 8 of 14 (57.1%) in the CNC group ( P = .03). Four (17.4%) hips in the CC group had revision surgery compared with 9 (52.9%) hips in the CNC group (odds ratio, 5.1; 95% CI, 1.2-22.5; P = .02). Conclusion: Young female patients treated with CC while undergoing arthroscopic FAI had improved outcomes, fewer revisions, and a higher return-to-sports rate than those treated without CC.

Background: Persistent mildly abnormal knee kinematics after anterior cruciate ligament (ACL) reconstruction (ACLR) is an ongoing clinical problem. Purpose: To compare the clinical outcomes of revision ACLR (rACLR), rACLR and lateral extra-articular tenodesis (LET), or isolated LET in patients with a grade ≥2 pivot shift after ACLR with an intact or partially torn graft and a new, symptomatic medial meniscal tear. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all patients with a new, symptomatic medial meniscal tear diagnosed after a primary ACLR was performed. Patients were included if they demonstrated a grade ≥2 pivot shift on physical examination with an intact or partially torn ACL graft. Exclusion criteria included complete graft rupture. The senior author’s management evolved in a practice change design from rACLR to rACLR with LET, to isolated LET over the study period. The primary outcomes were the International Knee Documentation Committee (IKDC), Lysholm, and Tegner patient-reported outcomes (PROs) at 2 years postoperatively. Results: A total of 47 patients, with 16 in the rACLR group, 12 in the rACLR and LET group, and 19 in the isolated LET group were included. Baseline characteristics between groups were similar. At 2 years, the rACLR group IKDC score was 86.1 ± 6.6 and was lower than the rACLR and LET group (91.9 ± 4.4; P = .009; 95% CI, –10.4 to −1.2) and the isolated LET group scores (91.7 ± 3.0; P = .004; 95% CI, –9.7 to −1.6). The Lysholm score was lower in the rACLR group (85.8 ± 6.3) when compared with the rACLR and LET group (91.8 ± 4.6; P = .03; 95% CI, –11.8 to −0.39). There was no difference in any Tegner scores at 2 years ( P = .09). Conclusion: In patients with grade ≥2 pivot shift after an ACLR with an intact or partially torn graft and a new, symptomatic medial meniscal tear, the addition of an LET with or without rACLR led to improved PROs compared with an isolated rACLR. An isolated LET in this patient population should be considered an acceptable treatment option.

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 compare the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using hamstring autograft (HA) plus lateral extra‐articular tenodesis (LET), isolated all‐soft tissue quadriceps autograft (QA), and isolated HA. Methods A retrospective review was performed comparing high‐risk patients undergoing ACL reconstruction with isolated HA, isolated QA, or HA + LET from August 2013 to January 2023. High‐risk patients, as determined by high‐grade pivot shift or generalized ligament laxity, with at least a 2‐year follow‐up, were included. Lysholm and International Knee Documentation Committee scores were compared at 3, 6, 12, and 24 months postoperatively. Retear rate, postoperative pivot‐shift grade, return to sport, and complications were recorded. Results In total, 159 patients (56 HA, 47 HA + LET, and 56 QA) were included. At 6 months postoperatively, the HA International Knee Documentation Committee score was significantly lower than that of the HA + LET and QA groups ( P < .0001). Similarly, the Lysholm score was significantly lower in the HA cohort at 6 months, 1 year, and 2 years postoperatively ( P < .0001‐.02). There was no difference in the rate of achieving the minimally important clinical difference between the cohorts for either of these outcome scores. The retear rate was significantly higher in the HA group (17.9%) compared to the HA + LET (4.3%) and QA (1.8%) cohorts ( P = .01). The rate of postoperative pivot shift of grade 2 or more was also higher in the isolated HA group ( P = .04). Conclusions The use of an all‐soft tissue QA or HA + LET for ACL reconstruction resulted in a lower retear rate and postoperative pivot‐shift grade compared to an isolated HA graft in high‐risk patients at 2 years postoperatively. There was no difference in the rate of achieving the minimal clinically important difference between the cohorts. The QA and HA + LET reconstruction options may improve stability and decrease the failure rate compared with HA reconstruction alone. Level of Evidence Level III, retrospective cohort study.

Background: The Latarjet and other bony augmentation procedures are commonly used to treat anterior shoulder instability in the setting of significant glenoid bone loss. Although several fixation strategies have been reported, the biomechanical strength of these techniques remains poorly understood. Purpose: To perform a systematic review of the biomechanical strength of glenoid bony augmentation procedures for anterior shoulder instability. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of the Medline, Embase, Web of Science, and Cochrane Library databases was performed to identify biomechanical studies evaluating various fixation strategies for coracoid and other bone transfer procedures for anterior shoulder instability. Biomechanical results included load to failure with both compression and traction forces, stiffness, and cyclic displacement. The quality of included articles was assessed based on the Quality Appraisal for Cadaveric Studies (QUACS) scale. Results: A total of 21 biomechanical studies comprising 486 specimens were included. The number of screws used and the addition of washers were found to significantly increase rigidity and load to failure. The comparison of fixation techniques demonstrated mixed results in load to failure between screw and alternative constructs including suture buttons and suture anchors. However, studies that tested graft displacement consistently found more graft displacement in buttons compared with screws. The median and mean of the QUACS scale were both 12, with a range of 10-13. Conclusion: Biomechanical studies consistently demonstrated that when glenoid bone grafts were fixed with screws, the number of screws and use of washers significantly increased construct rigidity and load to failure. Different metal screw materials and sizes did not consistently demonstrate a significant difference in biomechanical strength. There are mixed results when comparing suture buttons to screw fixation. The evaluated studies revealed that all double metal screw constructs and the majority of suture button and anchor constructs were able to withstand the glenohumeral load reflective of activities of daily living using a 150-N threshold.

Purpose To compare Medicaid and Medicare rates for the 20 most commonly billed orthopaedic sports medicine procedures. Methods Medicaid reimbursement rates were obtained from state‐specific fee schedules. Medicare rates were collected from the Centers for Medicare & Medicaid Services Physician Fee Schedule, along with relative value units for each procedure. State rates were compared using averages and dollar differences. Reimbursement rates were adjusted for cost of living using the Medicare Wage Index. Variability between states and between procedures was assessed using coefficients of variation. Results Mean Medicaid reimbursement was lower than that of Medicare for 19 of the 20 procedures. In total, Medicaid reimbursed surgeons 14.9% less when data were unadjusted and 26.0% less when data were adjusted for cost of living. Variation in Medicare rates between states was constant, with a coefficient of variation of 0.06. For Medicaid, the coefficients of variation ranged from 0.27 to 0.70 for unadjusted data and from 0.35 to 0.69 for adjusted data. Conclusions On average, Medicaid reimburses orthopaedic sports medicine specialists less than does Medicare, with substantial variability between states. Adjustment for cost of living increases the percentage difference and the variability between states’ Medicaid reimbursement rates. Level of Evidence Level IV, economic analysis.

Purpose To characterize the relationship between testosterone replacement therapy (TRT) and anterior cruciate ligament (ACL) injuries. Methods A retrospective cohort study using a large insurance database was conducted. Patients who were prescribed TRT for at least 3 months were matched with controls who were not prescribed TRT. Rates of ACL tears were compared between the cohorts. Multiple subgroups were created based on age (<25, 25‐35, 36‐45, 46‐55, 56‐65, and 65+ years). Multivariable logistic regressions were performed to determine the association of TRT with ACL tears while accounting for demographic variables and comorbidities. Results After matching, there were 160,839 patients in both the TRT cohort and the control cohort. The incidence of ACL injuries was 17.8 per 10,000 person‐years (95% confidence interval [CI]: 16.4‐19.2) for patients who were prescribed TRT and 4.9 per 10,000 person‐years (95% CI: 4.1‐5.7) for controls ( P < .001). Within 2 years of filling a testosterone prescription for at least 3 months, 572 (0.35%) patients experienced an ACL injury compared to only 157 (0.10%) controls during the same follow‐up period (odds ratio: 2.77; 95% CI: 2.26‐3.42, P < .001). When stratified by age, all groups except the <25 years of age group demonstrated a significantly higher rate of ACL tears (odds ratio 3.91‐12.3, P < .001‐.009). When separated by sex, males on TRT were 3.13 (95% CI: 2.50‐3.93, P < .001) times more likely while females on TRT were 1.94 (95% CI: 1.13‐3.41, P = .018) times more likely to experience an ACL injury compared to controls. Conclusions This study found that patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2‐year follow‐up period. Level of Evidence Level III, retrospective comparative study.

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.