Citations

Purpose To assess the consistency and quality of risk factor reporting for rotator cuff repair (RCR) retear and identify risk factors most frequently associated with retear. Methods A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) guidelines. Of the initial 3,158 studies, a total of 31 met the following inclusion criteria: (1) clinical studies regarding RCR failure, (2) arthroscopic procedures involving RCR, (3) reporting of clinical outcomes, (4) publication within the past 5 years, and (5) studies investigating preoperative risk factors for retear. After full‐text review, 18 risk factors were analyzed. Results The most consistently significant risk factors were acromiohumeral distance (80%), critical shoulder angle (67%), tear size (63%), anterior‐posterior dimension (60%), fatty infiltration (FI) (58%), and retraction size (56%). FI was analyzed using different methods among studies, with 63% finding significant results and 50% of all studies performing ordinal analysis. Tear size was inconsistently analyzed quantitatively or qualitatively, with 58% of studies finding significant results and 63% of all studies performing quantitative analysis. Risk factors consistently found to be nonsignificant included age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index. Conclusions Tear size, FI, and retraction size were found to be significant risk factors in most of the included studies evaluating rotator cuff retear. Risk factors less likely reported as predictive included repair technique, age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index. Risk factors that require further investigation include critical shoulder angle, acromiohumeral distance, and anterior‐posterior tear dimension. Level of Evidence Level III, systematic review of Level III‐IV studies.

Abstract In the standard approach to hip arthroscopy, access to the joint is achieved using fluoroscopic guidance to enter the central compartment of the hip using the Seldinger technique, penetrating the capsule with a needle and subsequently cannulating and obtaining direct visualization of the joint. In such a way, arthroscopists then proceed with accessory portal creation and capsulotomy, as desired, under direct intra‐articular visualization. In cases with severe pincer morphology or coxa profunda, it may not be possible to safely access the central compartment under fluoroscopic guidance due to significant lateral overcoverage of the femoral head. We present an outside‐in arthroscopic approach for accessing the hip joint in such patients, allowing for safe visualization, osseous pincer resection, and improved central compartment access while minimizing the risk to cartilage and labral tissue. Technique Video video See video under supplementary data.

Background: While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of MPFL reconstruction (MPFLR). An accurate understanding of the kinematic properties and functional behavior of current techniques used in MPFLR is imperative to restoring native biomechanics and improving outcomes. Purpose: To provide a comprehensive review of the biomechanical effects of variations in MPFLR, specifically to determine the effect of graft choice and reconstruction technique. Study Design: Systematic review. Methods: A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 32 studies met inclusion criteria: (1) using ≥8 human cadaveric specimens, (2) reporting on a component of MPFLR, and (3) having multiple comparison groups. Results: Gracilis, semitendinosus, and quadriceps grafts demonstrated an ultimate load to failure (N) of 206.2, 102.8, and 190.0 to 205.0 and stiffness (N/mm) of 20.4, 8.5, and 21.4 to 33.6, respectively. Single-bundle and double-bundle techniques produced an ultimate load to failure (N) of 171 and 213 and stiffness (N/mm) of 13.9 and 17.1, respectively. Anchors placed centrally and superomedially in the patella produced the smallest degree of length changes throughout range of motion in contrast to anchors placed more proximally. Sutures, suture anchors, and transosseous tunnels all produced similar ultimate load to failure, stiffness, and elongation data. Femoral tunnel malpositioning resulted in significant increases in contact pressures, patellar translation, tilt, and graft tightening or loosening. Low tension grafts (2 N) most closely restored the patellofemoral contact pressures, translation, and tilt. Graft fixation angles variably and inconsistently altered contact pressures, and patellar translation and tilt. Conclusion: Data demonstrated that placement of the MPFLR femoral tunnel at the Schöttle point is critical to success. Femoral tunnel diameter should be ≥2 mm greater than graft diameter to limit graft advancement and overtensioning. Graft fixation, regardless of graft choice or fixation angle, is optimally performed under minimal tension with patellar fixation at the medial and superomedial patella. However, lower fixation angles may reduce graft strain, and higher fixation angles may exacerbate anisometry and length changes if femoral tunnel placement is nonanatomic.

Case: A 20-year-old woman presented with a unipolar, 1.8 × 1.8-cm osteochondral defect of the left acetabulum. Osteochondral allograft transplantation was performed using a medial tibial plateau allograft resulting in excellent clinical outcomes across 4 different outcome scores and maintenance of the joint space at 4.3 years postoperatively. Conclusion: Although previous literature has demonstrated long-term clinical success of osteochondral allograft transplantation in knee, excellent clinical outcomes can also be obtained in the hip. Thus, osteochondral allograft transplantation may be a viable treatment option for adolescents and young adults with concomitant cartilage and subchondral bone hip defects.

Abstract Purpose The demographic and radiological risk factors of subchondral insufficiency fractures of the knee (SIFK) continue to be a subject of debate. The purpose of this study was to associate patient‐specific factors with SIFK in a large cohort of patients. Methods Inclusion criteria consisted of patients with SIFK as verified on magnetic resonance imaging (MRI). All radiographs and MRIs were reviewed to assess characteristics such as meniscus tear presence and type, subchondral oedema presence and location, location of SIFK, mechanical limb alignment, osteoarthritis as assessed by Kellgren–Lawrence grade and ligamentous injury. A total of 253 patients (253 knees) were included, with 171 being female. The average body mass index (BMI) was 32.1 ± 7.0 kg/m 2 . Results SIFK was more common in patients with medial meniscus tears (77.1%, 195/253) rather than tears of the lateral meniscus (14.6%, 37/253) ( p < 0.001). Medial meniscus root and radial tears of the posterior horn were present in 71.1% (180/253) of patients. Ninety‐one percent (164/180) of medial meniscus posterior root and radial tears had an extrusion ≥3.0 mm. Eighty‐one percent (119/147) of patients with SIFK on the medial femoral condyle and 86.8% (105/121) of patients with SIFK on the medial tibial plateau had a medial meniscus tear. Varus knees had a significantly increased rate of SIFK on the medial femoral condyle in comparison to valgus knees ( p = 0.016). Conclusion In this large cohort of patients with SIFK, there was a high association with medial meniscus root and radial tears of the posterior horn, meniscus extrusion ≥3.0 mm as well as higher age, female gender and higher BMI. Additionally, there was a particularly strong association of medial compartment SIFK with medial meniscus tears. As SIFK is frequently undiagnosed, identifying patient‐specific demographic and radiological risk factors will help achieve a prompt diagnosis. Level of Evidence Level IV.

Background: Patients with isolated anterior cruciate ligament (ACL) reconstruction have demonstrated an increased risk of ACL graft failure and lower patient-reported outcome (PRO) scores when increased posterior tibial slope (PTS) is present. However, there is a paucity of literature evaluating the effect of PTS on outcomes after combined bicruciate multiligamentous knee reconstruction. Purpose: To determine whether differences exist for graft failure rates or PRO scores based on PTS after combined bicruciate multiligamentous knee reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent combined ACL and posterior cruciate ligament (PCL) reconstruction between 2000 and 2020 at our institution were identified. Exclusion criteria were age <18 years, knee dislocation grade 5 injuries, concomitant osteotomy procedures, and <2 years of clinical follow-up. Demographic and outcomes data were collected from our prospectively gathered multiligamentous knee injury database. Lysholm and International Knee Documentation Committee (IKDC) scores were analyzed in relation to PTS. Outcomes were compared for patients with a PTS above and below the mean for the total cohort, PTS >12° versus <12°, positive versus negative Lachman test at follow-up, and positive versus negative posterior drawer test at follow-up. Results: A total of 98 knees in 98 patients were included in the study, with a mean clinical follow-up of 5.1 years (median, 4.6 years; range, 2-16 years). The mean PTS was 8.7° (range, 0.4°-16.9°). Linear regression analysis showed no significant correlation between PTS and IKDC or Lysholm scores. Patients with a PTS above the mean of 8.7° trended toward lower IKDC ( P = .08) and Lysholm ( P = .06) scores. Four patients experienced ACL graft failure and 5 patients experienced PCL graft failure. There were no differences in graft failure rates or PRO scores for patients with a PTS >12°. Patients with a positive Lachman test trended toward higher PTS (9.6° vs 8.5°, P = .15). Conclusion: In this series of bicruciate multiligamentous knee reconstructions at midterm follow-up, no differences in graft failures, complications, reoperations, revisions, or PRO scores based on PTS were identified. Patients with a positive Lachman test were found to have a slightly higher PTS, although this did not reach statistical significance.

Abstract Acetabular labral tears are commonly diagnosed in patients with hip or groin pain, most of which occur anterosuperiorly. In some cases, operative intervention in the form of arthroscopic labral repair may be necessary to restore labral function. Posterolateral tears can be technically challenging when using traditional modified anterior portal and anterolateral (AL) portal access owing to a suboptimal drill trajectory. In this article, we describe the establishment of a posterolateral (PL) portal 1 to 2 cm posterior to the tip of the greater trochanter, mirroring the distal‐to‐proximal trajectory of the AL portal and entering the capsulotomy at the 10‐o'clock position. This method highlights that the PL portal is used for drilling and anchor placement, whereas the remaining work is performed through the AL portal. This avoids the use of any shavers or burrs in the PL portal near important neurovascular structures, including the sciatic nerve. Addressing posterolateral labral tears in the 9‐ to 11‐o'clock position using a PL portal can enhance labral fixation, thereby mitigating the risk of suboptimal repairs that can negatively impact postoperative outcomes. Technique Video video See video under supplementary data.

Background: Lateral meniscal oblique radial tears (LMORTs) are the most common type of lateral meniscal tears and occur concomitantly with anterior cruciate ligament (ACL) tears in up to 12% of cases. Four types of LMORTs have been classified in the literature based on proximity to the meniscal root and extent of the tear. Type 1 and 2 LMORTs represent partial and complete posterior root tears less than 10 mm from the root insertion. Type 3 and 4 LMORTs are partial and complete posterior radial meniscus tears greater than 10 mm from the root insertion. Indications: Type 3 and 4 LMORTs can and should be addressed with an all-inside side-to-side repair at the time of ACL reconstruction. LMORTs that are not repaired at the time of ACL reconstruction can contribute to persistent instability and meniscal extrusion. Technique Description: Diagnostic arthroscopy is performed to evaluate the posterior aspects of both the medial and lateral meniscus. The medial leaflet is commonly flipped into the notch and scarred to ACL remnant. After identifying and isolating the medial leaflet, an arthroscopic suture passer is used to pass a suture from inferior to superior through the medial leaflet. A second suture is passed from inferior to superior through the lateral leaflet. This is used to shuttle the suture pass through the medial leaflet to the bottom of the meniscus, where it can be tied in a horizontal mattress fashion. The sutures are tied down with aide of an arthroscopic knot pusher. A second set of sutures is passed and used to shuttle a second suture that would be tied posterior to the first suture, again in a horizontal mattress fashion. This allows reduction of the fragments in apposition across the tear. Postoperatively, patients are allowed range of motion from 0° to 90° and to toe touch weightbearing for the first 4 weeks. Patients are advanced to weightbearing as tolerated at 5 weeks. Typical return to sport ranges from 6 to 9 months postoperatively. Results: Results have been published for 2-year outcomes of type 3 and 4 LMORT repairs and have demonstrated persistent improved patient-reported outcomes as well as healing rates that are greater than 80% and in some series approach nearly 100%. Discussion/Conclusion: Arthroscopic all-inside side-to-side surgical repair is a durable and reliable treatment option for patients presenting for ACL reconstruction with concomitant type 3 or 4 LMORT. 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.

Purpose To investigate the feasibility and accuracy of 3‐dimensional (3D) iPhone scans using commercially available applications compared with computed tomography (CT) for mapping chondral surface topography of the knee. Methods Ten cadaveric dysplastic trochleae, 16 patellae, and 24 distal femoral condyles (DFCs) underwent CT scans and 3D scans using 3 separate optical scanning applications on an iPhone X. The 3D surface models were compared by measuring surface‐to‐surface least distance distribution of overlapped models using a validated 3D‐3D registration volume merge method. The absolute least mean square distances for the iPhone‐generated models from each scanning application were calculated in comparison to CT models using a point‐to‐surface distance algorithm allowing regional “inside/outside” measurement of the absolute distance between models. Results Only 1 of the 3 scanning applications created models usable for quantitative analysis. Overall, there was a median absolute least mean square distance between the usable model and CT‐generated models of 0.18 mm. The trochlea group had a significantly lower median absolute least mean square distance compared with the DFC group (0.14 mm [interquartile range, 0.13‐0.17] vs 0.19 mm [0.17‐0.25], P = .002). iPhone models were smaller compared with CT models (negative signed distances) for all trochleae, 83% of DFCs, and 69% of patellae. Conclusions In this study, we found minimal differences between a 3D iPhone scanning application and conventional CT scanning when analyzing surface topography. Clinical Relevance Emerging 3D iPhone scanning technology can create accurate, inexpensive, real‐time 3D models of the intended target. Surface topography evaluation may be useful in graft selection during surgical procedures such as osteochondral allograft transplantation.

Purpose To report the clinical outcomes and reoperation rates of arthroscopic and endoscopic iliopsoas release at short‐term follow‐up after ipsilateral total hip arthroplasty (THA) at 2 separate medical institutions and to evaluate whether demographic and radiographic parameters are associated with postoperative patient‐reported outcomes (PROs). Methods Patients with iliopsoas tendinitis in the setting of prior THA who underwent arthroscopic iliopsoas fractional lengthening from 1988 to 2023 at 2 academic institutions were reviewed. Patients were included if they had 12 months of follow‐up and underwent evaluation of preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score, Single Assessment Numeric Evaluation score, Tegner activity scale score, visual analog scale (VAS) score, and revision hip arthroplasty. Results Sixty hips in 58 patients (19 male and 39 female patients) were followed up for a mean of 39.3 months (range, 12.0‐105.9 months) postoperatively. Of the patients, 77% reported feeling “much better” or “slightly better,” 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. The surgery satisfaction rating was 7.2 ± 3.3 (scale of 0 to 10). The mean postoperative modified Harris Hip Score, VAS score for pain at rest, VAS score for pain with use, and Single Assessment Numeric Evaluation score were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9, respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and did not significantly correlate with postoperative PROs ( P ≥ .45). The Tegner score improved from 2.5 ± 1.7 preoperatively to 2.9 ± 1.4 postoperatively ( P = .0253). Three patients underwent revision arthroplasty at a mean of 25.3 months (range, 11.6‐40.4 months) postoperatively, with an acetabular component revision rate of 3.3%. Conclusions Satisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening after THA. There was no statistically significant relation between anterior acetabular component overhang and final PROs. Level of Evidence Level IV, therapeutic case series.