Hevesi, Mario

Purpose To identify risk factors for medial meniscus posterior root tears (MMPRT) and arthroplasty‐free survival in postmenopausal women, while secondary objectives included analyzing menopause‐specific factors associated with MMPRT and defining risk factors for conversion to arthroplasty in patients with a confirmed MMPRT. Methods All patients at our institution with a diagnosed meniscal tear through December 2024 were identified. From this cohort, women with a menopausal diagnosis preceding their meniscal tear were matched one‐to‐one with men by age and body mass index. Imaging studies were reviewed to identify MMPRTs. Subsequent arthroplasty, Charlson Comorbidity Index, menopausal type (surgical or physiologic), hormone replacement therapy, bisphosphonate usage, and bone mineral density were recorded. Logistic and Cox regression were used to define risk factors for MMPRT and arthroplasty; survivorship was determined using Kaplan‐Meier analyses. Results The final cohort consisted of 1564 patients (n = 782 women) with a median age of 63 years, of which 244 patients (15.6%) had MMPRT. Age and female sex were associated with MMPRT. The presence of an MMPRT, female sex, body mass index, and Charlson Comorbidity Index were associated with arthroplasty. Among postmenopausal women, age at menopause, surgical menopause, hormone replacement therapy, and bone mineral density were associated with MMPRT. For patients with MMPRT, female sex was associated with arthroplasty. Ten‐year survivorship‐free from arthroplasty in patients with MMPRT was 53.5% for women and 78.4% for men ( P = .02). Conclusions Postmenopausal status, age, and hormone replacement therapy usage are risk factors for MMPRT. Compared with men, postmenopausal women with MMPRT exhibit reduced arthroplasty‐free survival, underscoring the need for targeted interventions. Level of Evidence Level III, retrospective comparative study.

Purpose To assess the reliability, predictability, and discriminative capacity of 3 anatomic measurements, tibial tubercle‐trochlear groove (TT‐TG), tibial tubercle‐posterior cruciate ligament, and patellar tendon‐lateral trochlear ridge (PT‐LTR), where PT‐LTR may offer a complementary approach to assessing recurrent patellofemoral instability (PFI) risk. Methods Patients diagnosed with PFI before primary patellofemoral stabilization surgery at a single institution between 2022 and 2024 were included. A control group without PFI was propensity matched 1:1 for age, sex, and laterality. Magnetic resonance images were evaluated to measure TT‐TG, tibial tubercle‐posterior cruciate ligament, and PT‐LTR. A priori power analysis determined the cohort size. Statistical analyses compared differences between the PFI and control groups with Student t‐tests, receiver operating characteristic analyses, and area under the curve with resultant sensitivity, specificity, and an optimal cutoff. Results Patients included 50 knees with PFI (28 women, 22 men; mean age 18 ± 5 years). The control group included 50 knees (27 women, 23 men; mean age 18 ± 4 years). Excellent inter‐ and intra‐rater reliability (intraclass correlation coefficient > 0.7) was shown for TT‐TG and PT‐LTR in the PFI and control groups. The distances for TT‐TG, tibial tubercle‐posterior cruciate ligament, and PT‐LTR were significant predictors ( P ≤ .025) of PFI. The average PT‐LTR distance difference for the PFI and control groups was 7.0 mm ( P < .001). PT‐LTR showed an area under the curve of 0.80 and, when ≥4.6 mm, was 66% sensitive and 92% specific for PFI. Conclusions The PT‐LTR distance is a reliable and discriminative metric for identifying PFI in both pediatric and adult populations. A PT‐LTR cutoff value of 4.6 mm showed diagnostic discrimination and substantially high specificity for recurrent PFI, indicating strong ability to identify patients with instability. Level of Evidence Level III, retrospective case control study.

Abstract Meniscus surgery remains one of the most common orthopedic procedures worldwide. Successful meniscus repair requires A natomic reduction, B iologic preparation and augmentation, C ircumferential compression (ABCs), and an optimized rehabilitation protocol. Rehabilitation after surgery is critical for optimizing outcomes, yet the ideal approach remains controversial. A recent international European Union‐United States consensus task force developed recommendations for rehabilitation meniscal surgery. The group concluded that rehabilitation after meniscal repair and reconstruction should progress according to both time‐ and criterion‐based milestones. In practice, 2 rehabilitation pathways are utilized after meniscal repair: a standard protocol for biomechanically stable repairs that tolerate some weight‐bearing in full extension and a complex protocol for repairs requiring greater protection. Standard meniscal repairs (i.e., vertical longitudinal) are biomechanically stable and treated with moderate protection. During the first 4 weeks, patients are restricted to 0° to 90° of knee range of motion, partial weight‐bearing with crutches, and full knee extension during ambulation. Between weeks 4 and 8, patients progress to weight‐bearing as tolerated while avoiding loaded knee flexion beyond 90° until week 16, with emphasis on gait normalization and strengthening. From weeks 8 to 16, aerobic conditioning and strengthening continue. Pending surgeon clearance, return to running begins at week 12, plyometric exercises at week 14, and return to sport at 4 to 8 months. Complex meniscal repairs (e.g., radial or root tears) require a protective rehabilitation approach. During weeks 0 to 6, range of motion is restricted to 0° to 90° with toe‐touch weight‐bearing and full knee extension during ambulation. Range of motion and weight‐bearing progress from weeks 6 to 12, while loaded flexion beyond 90° remains restricted until week 16. Between weeks 12 and 18, aerobic conditioning and strengthening continue. Pending surgeon clearance, running begins at week 14, plyometrics at week 16, and return to sport typically occurs at 6 to 9 months.

Purpose To evaluate implantation rates, time to implantation, and predictors of implantation following matrix‐induced autologous chondrocyte implantation (MACI) biopsy for knee chondral defects. Methods Patients undergoing MACI biopsy or implantation for symptomatic knee chondral defects from 2017 to 2024 at a single institution were reviewed. At a minimum 1‐year follow‐up, the decision to proceed with implantation, recurrent symptoms, complications, and reoperations were assessed. Kaplan‐Meier analysis estimated time to implantation, and multivariable logistic regression identified predictors of MACI implantation. Results A total of 208 knees in 202 patients (mean age 28.0 ± 10.9 years, range 11‐59) underwent MACI biopsy for 243 chondral defects (patella [38%], femoral condyle [34%], and trochlea [26%]). At a mean follow‐up of 4.3 years (range 1.0‐8.3), 64 knees (31%) proceeded to second‐stage MACI implantation. Among 144 knees not implanted, 87 (60%) reported symptom improvement, and 26 (18%) had persistent symptoms. The remaining 22% did not undergo implantation due to another cartilage procedure, insurance denial, or pending scheduling. Patients who underwent biopsy at the home institution had a shorter time from biopsy to implantation compared with those biopsied at outside institutions (6.1 vs 13.1 months, P = .001). Median time to implantation was 9.4 months (95% confidence level: 7.2‐12.2) for home biopsies. Lower body mass index was associated with progression to implantation after adjusting for covariates (odds ratios 0.92, P = .019). Patients implanted within 4 months had larger chondral defects (4.0 vs 3.0 cm 2 , P = .045). At a mean 4.1‐year follow‐up, 6 patients (8%) experienced postoperative complications, including 3 (4%) who required revision chondroplasty. Conclusions MACI biopsy for knee chondral defects resulted in approximately one‐third of patients proceeding to MACI implantation, at a median of 9.4 months after biopsy. Lower body mass index was associated with higher likelihood of progression to implantation, larger chondral defects with earlier implantation, and among patients who did not proceed to implantation, approximately 60% reported symptom improvement following concomitant chondroplasty at the time of biopsy. Level of Evidence Level IV, retrospective case series.

Background: Dancers are at risk of femoroacetabular impingement (FAI) owing to supraphysiologic range of motion and associated demands placed on their hips. There remains a paucity of literature on midterm outcomes in dancers who undergo primary arthroscopy and labral repair for FAI. Purpose: To determine the rate of return to dance and patient-reported outcome measures in competitive dancers after hip arthroscopy with labral repair for FAI with minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: This study included dancers with FAI undergoing primary hip arthroscopy with labral repair from 2010 to 2022. Patient-reported outcome measures were collected at 2-year minimum follow-up: modified Harris Hip Score (overall, activities of daily living, gait, pain), Hip Outcome Score (activities of daily living, sports-specific subscale), Tegner Activity Scale, visual analog scale for pain, and surgery satisfaction. Patients were evaluated for preoperative radiographic measurements, postoperative return to sport, and revision surgery. Return to dance was evaluated. Results: Thirty-seven dancers were followed for a mean 7.4 years (range, 3.2-12.2) postoperatively (36 female and 1 male; mean ± SD age, 21 ± 7 years; mean body mass index, 23.3 ± 4.5). All outcome scores significantly improved postoperatively as compared with preoperatively ( P ≤ .037). Twenty dancers (71%) returned to dance. Of those who returned to dance, 17 (85%) returned to sport at the same or higher level as compared with the preoperative level. At final follow-up, 45% of dancers who initially returned to dance continued to dance. Of the dancers who no longer participated in dance at final follow-up, 7 (65%) quit dancing for nonhip-related reasons. Mean surgery satisfaction (0-10) at final follow-up was 7.1. Four patients (10%) underwent revision hip arthroscopy with revision labral repair. Conclusion: Hip arthroscopy with labral repair in dancers results in sustained improvements in function and pain at minimum 2-year follow-up. Most dancers return to their prior levels of dance, and nearly half remain active several years later. Notably, discontinuation of dance was often unrelated to hip symptoms, underscoring the importance of counseling patients on clinical and lifestyle factors influencing return to sport.

Purpose To prospectively investigate subjective anterior groin pain, patient‐reported outcome measures, complications, reoperation rates, and hip flexion strength after arthroscopic iliopsoas fractional lengthening. Methods From 2023 to 2025, patients with persistent groin pain after total hip arthroplasty refractory to conservative management undergoing arthroscopic iliopsoas fractional lengthening were prospectively identified at 2 tertiary referral centers. Pre‐ and postoperative outcomes at a minimum 6‐month follow‐up including the Visual Analog Scale, Tegner activity scale, Single Assessment Numeric Evaluation, and subjective anterior groin pain and hip flexion strength were analyzed. Results Fifty‐nine hips in 56 patients were included (age: 64.9 ± 9.8 years, 59% women, body mass index: 30.0 ± 5.8 kg/m 2 ) and followed for 10.0 ± 6.9 months postoperatively (range: 4‐25 months). Patients experienced significant ( P < .001) postoperative improvements in the Visual Analog Scale at rest (1.4 ± 2.2 vs 2.8 ± 2.1), Visual Analog Scale with use (3.0 ± 2.9 vs 7.8 ± 1.8), Tegner activity scale (2.8 ± 1.2 vs 2.0 ± 1.0), and Single Assessment Numeric Evaluation score (73.8 ± 22.5 vs 47.7 ± 22.2). Postoperative surgical satisfaction was 8.0 ± 2.7 (scale: 0‐10). Nearly 90% of patients reported feeling much or slightly better regarding their anterior groin pain postoperatively at 2‐week (91%), 6‐week (88%), 3‐month (91%), and final follow‐up (92%). Regarding hip flexion strength, ≥66% reported feeling much or slightly better at 2‐week (73%), 6‐week (95%), 3‐month (89%), and final follow‐up (66%). Three hips (6%) underwent reoperation at the final follow‐up (1 acetabular screw removal with open revision release, 1 revision total hip arthroplasty for loosening, and 1 two‐stage exchange for nonacute periprosthetic joint infection). Conclusions Nearly 90% of patients who underwent arthroscopic iliopsoas fractional lengthening after primary total hip arthroplasty reported improved anterior groin pain, whereas two‐thirds reported increased subjective hip flexion strength throughout the follow‐up. Of note, clinically meaningful improvement in pain at rest was achieved by 50% of patients based on cohort‐specific minimal clinically important difference criteria. Level of Evidence Level IV, retrospective therapeutic case series.

The total number of total hip arthroplasties performed each year is expected to increase significantly over the coming decades. As a result, an increasing number of young patients are undergoing total hip arthroplasty while similarly, a growing subset of active elderly patients desire to return to sports or high-impact activity after surgery. Patients are typically provided restrictions and activities to avoid following surgery. For these patients, there is no clear consensus or guidelines regarding whether they should limit their activity level postoperatively and in particular, if returning to high-impact exercise increases their risk of complications and subsequent revision surgery. This article will discuss the most common complications after total hip arthroplasty and whether patients who return to sports or a high-impact activity after surgery may be more predisposed to these complications in comparison to their more sedentary peers.

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.