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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 < 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 compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first‐time anterior shoulder dislocation after the age of 50 years. Methods An established geographic medical record system was used to identify patients who experienced a first‐time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi‐square tests and survivorship curves were generated using Kaplan‐Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment. Results 179 patients were included with a mean follow‐up of 11 years. 14% ( n = 26) underwent early surgery within 3 months and 86% ( n = 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full‐thickness rotator cuff tears (82% vs 55%; P = .01), labral tears (24% vs 8.0%; P = .01), and humeral head fracture (23% vs 8.5%; P = .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate‐severe pain (19% vs 17%; P = .78) and frozen shoulder (8 vs 9%, respectively; P = .87) at final follow‐up. Although nerve palsy (19% vs 8%; P = .08) and progression to osteoarthritis (20% vs 14%; P = .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P = .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent ( n = 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01). Conclusions Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow‐up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery. Level of Evidence Level III, retrospective cohort study.

Background: Patellar instability has the highest incidence in adolescents aged between 14 and 18 years. The unique relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis in skeletally immature patients warrants precisely positioned MPFL graft insertion. A paucity of data are available evaluating the results of MPFL reconstruction using allograft tendon before skeletal maturity. Purposes: (1) To assess the results of MPFL reconstruction using allograft tendon in skeletally immature patients by analyzing redislocation and reoperation rates, radiological outcomes, and patient-reported outcomes and (2) to determine whether epidemiological, intraoperative, or radiographic factors influence recurrent instability and clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: Prospectively collected data were retrospectively analyzed for 69 skeletally immature patients who experienced a first-time or recurrent lateral patellar dislocation and were treated with anatomic MPFL reconstruction. Inclusion criteria were MPFL reconstruction using allograft and the availability of preoperative magnetic resonance imaging scans in the presence of open or partially open physes. Patients with <2 years of follow-up and patients with previous surgeries on the same knee were excluded from the study. Preoperative radiographic imaging was reviewed and analyzed. Trochlear dysplasia, tibial tubercle–trochlear groove distance, and patellar height were evaluated. Descriptive data, concomitant injuries, surgical procedure details, complications, and postoperative history were assessed via review of medical records and patient charts. Validated patient-reported and surgeon-measured outcomes were collected pre- and postoperatively, including Kujala score, Lysholm score, and Tegner activity score. Return-to-sports rate was assessed. The influence of epidemiological, intraoperative, and radiographic parameters on the redislocation rates and clinical outcomes was assessed using a multiple linear regression model. Results: A total of 79 physeal-sparing MPFL reconstructions (69 patients) met the inclusion criteria. The mean age of the patient cohort was 14.7 ± 1.8 years (range, 8.5-16.9 years). Within the mean follow-up time of 37.9 ± 12.1 months (range, 24-85 months after surgery, there were 12 patients with clinical failures resulting in reoperation. Eleven patients experienced a redislocation of the patella, and 1 patient sustained a transverse noncontact patellar fracture 6 months after index surgery that required operative fixation. No injuries to the distal femoral physes were clinically observed. At the final follow-up, patients had a mean Lysholm score (1-100) of 96.5 ± 6.7, a mean Kujala score (1-100) of 96.5 ± 7.4, and a mean Tegner Activity Scale score (1-10) of 4.9 ± 1.3. Patellar height and trochlear dysplasia did not influence redislocation or clinical scores. In total, 57 of the 63 patients (90.5%) who were engaged in sports before injury returned to the same or higher level of competition. In a subgroup analysis of patients who underwent isolated MPFL reconstruction (n = 44) without concomitant procedures, 9 patients (20.5%) experienced failure and had a redislocation. A univariate analysis of hazards for failure based on patient-specific variables was carried out. A body mass index ≥30 conveyed a hazard ratio of 2.51 (95% CI, 0.63-10.1; P = .19), and the tibial tubercle-trochlear groove distance by increments of 1 mm was associated with a hazard ratio of 2.02 (95% CI, 0.51-8.11; P = .32). Conclusion: Physeal-sparing anatomic reconstruction of the MPFL using an allograft tendon in skeletally immature patients was a safe and effective treatment for patellar instability, regardless of patellar height and trochlear dysplasia. Failure rates decreased when the MPFL reconstruction was performed concomitantly with a tibial tubercle osteotomy.

Background: Osteochondritis dissecans (OCD) is a disorder originating in the subchondral bone, leading to focal lesions with risk of fragmentation and secondary damage of the articular cartilage. It remains controversial if surgical treatment of such lesions is equally successful in skeletally immature and mature patients. Purpose: To determine (1) the long-term clinical success rate after internal fixation of unstable OCD in skeletally immature and mature patients based on physeal status, (2) if patient-specific and procedural variables influence the risk of failure, and (3) patient-reported outcome measures over time. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective cohort study was conducted investigating skeletally immature and mature patients treated for unstable OCD lesions of the knee between 2000 and 2015. The healing rate was assessed by radiological imaging and clinical follow-up. Failure was defined as any definitive reoperation for the initially treated OCD lesion. Results: A total of 81 patients met inclusion criteria, including 25 skeletally immature patients and 56 patients with closed physes at the time of surgery. After a mean follow-up time of 11.3 ± 4 years, 58 (71.6%) patients had healed lesions, whereas the lesions failed to heal in 23 (28.4%) patients. No significant difference in risk of failure was observed based on physeal maturation status (hazard ratio, 0.78; 95% CI, 0.33-1.84; P = .56). Lateral versus medial condylar lesion location conferred an increased risk of failure ( P < .05) for both skeletally immature and mature patients. Multivariate analysis of skeletal maturity status showed that a lateral femoral condylar location was an independent risk factor for failure (hazard ratio, 0.22; 95% CI, 0.1-0.5; P < .05). The mean patient-reported outcome scores (International Knee Documentation Committee [IKDC] score and Knee injury and Osteoarthritis Outcome Score [KOOS]) increased significantly after surgery and remained high at the final follow-up ( P < .05). The final scores (mean ± SD) at a mean follow-up of 135.8 months (range, 80-249 months) were IKDC, 86.6 ± 16.7; KOOS Pain, 88.7 ± 18.1; KOOS Symptoms, 89.3 ± 12.6; KOOS Activities of Daily Living, 89.3 ± 21.6; KOOS Sport and Recreation, 79.8 ± 26.3; and KOOS Quality of Life, 76.7 ± 26.3. Conclusion: The long-term results after internal fixation of OCD fragments show high rates of healing and sustainable subjective improvement of knee function and quality of life. A healing rate of 72% was noted at a mean follow-up of 11.3 years. The stage of skeletal maturity had no significant influence on the rate of failure. Lateral femoral condylar lesion location is an independent risk factor for failure in skeletally mature and immature patients.

Background: Lesions that involve humeral avulsions of the glenohumeral ligament (HAGLs), although less common, are primary contributors to recurrent events of dislocation and subluxation of the glenohumeral joint. Purpose: To describe the clinical presentation, examination, and surgical outcomes of patients presenting with HAGL lesions who underwent repair using an arthroscopic or open technique. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective review of prospectively collected data was performed of skeletally mature patients without glenohumeral arthritis who presented with HAGL lesions and subsequently underwent arthroscopic or open repair between 2005 and 2017. Independent variables included patient characteristics, clinical presentation, physical examination findings, and arthroscopic findings. Dependent variables included pre- and postoperative Single Assessment Numeric Evaluation (SANE) score, Western Ontario Shoulder Instability Index (WOSI) score, and range of motion outcomes. Results: Eighteen patients diagnosed with a HAGL lesion who underwent primary arthroscopic repair (n = 7) or open repair (n = 11) were included. There were 17 male patients and 1 female patient with a mean age of 24.9 years (range, 16-38 years). Mean follow-up duration was 50.9 months (range, 24-160 months). Seventeen patients (94.4%) reported pain as the most common symptom, and 7 (38.9%) reported sensation of instability. Scores significantly improved from pre- to postoperative for the arthroscopic and open groups ( P < .001): SANE (mean ± SD; arthroscopic, 30.7 ± 15.7 to 92.1 ± 12.2; open, 45.5 ± 8.50 to 90.7 ± 5.24) and WOSI (arthroscopic, 51.4 ± 11.4 to 2.49 ± 3.70; open, 45.5 ± 7.37 to 11.5 ± 5.76). The magnitude of improvement in SANE scores was significantly higher for patients treated arthroscopically (Δ60.0; open, Δ46.5; P = .012). Postoperative WOSI scores were also significantly better in the arthroscopic cohort (2.49 ± 3.70; open, 11.5 ± 5.76; P = .00094). Conclusion: Symptomatic HAGL tears present primarily with pain as opposed to instability, necessitating a high index of suspicion for injury. The tears may be treated successfully with an arthroscopic or open technique with significant improvements in patient-reported outcomes and stability.

Objective Subchondral insufficiency fracture of the knee (SIFK) is associated with high rates of osteoarthritis (OA) and arthroplasty. The implantable shock absorber (ISA) is an extra-capsular implant that unloads the medial knee compartment. This study compared the 2-year freedom from arthroplasty rates in subjects with medial knee OA and SIFK when treated with an ISA versus a matched cohort of patients treated non-surgically. Design This retrospective case-control study compared 2-year conversion rates to arthroplasty in SIFK score-, age-, and body mass index (BMI)–matched control subjects without prior surgical history with ISA-implanted subjects from an ongoing prospective study. Baseline and final radiographs, and MRIs were reviewed for evaluation of meniscus or ligament injuries, insufficiency fractures, and subchondral edema. Kaplan-Meier analysis assessed survival. Results Forty-two patients (21 Control: 21 ISA), mean age = 52.3 ± 8.7 years, BMI = 29.5 ± 3.9 kg/m 2 , 40% female were evaluated. Both ISA and Control arms had the same numbers of low ( n = 4), medium ( n = 11), and high-risk ( n = 6) SIFK scores. One- and 2-year freedom-from-arthroplasty rates were both 100% for ISA subjects, and 76% and 55%, respectively, for Controls ( P = 0.001 for cross-group comparison). Control knees with low, medium, and high-risk SIFK scores had respective 1- and 2-year survival rates of 100% and 100%, 90% and 68% ( P = 0.07 vs. ISA), and 33% and 0% ( P = 0.002 vs. ISA). Conclusions ISA intervention was strongly associated with avoidance of arthroplasty at a minimum 2 years, especially in patients with high-risk SIFK scores. SIFK severity scoring predicted relative risk of conversion to arthroplasty through at least 2 years in non-surgically treated subjects.

Purpose To evaluate the cost‐effectiveness of 3 isolated meniscal repair (IMR) treatment strategies: platelet‐rich plasma (PRP)–augmented IMR, IMR with a marrow venting procedure (MVP), and IMR without biological augmentation. Methods A Markov model was developed to evaluate the baseline case: a young adult patient meeting the indications for IMR. Health utility values, failure rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing IMR at an outpatient surgery center. Outcome measures included costs, quality‐adjusted life‐years (QALYs), and the incremental cost‐effectiveness ratio (ICER). Results Total costs of IMR with an MVP were $8,250; PRP‐augmented IMR, $12,031; and IMR without PRP or an MVP, $13,326. PRP‐augmented IMR resulted in an additional 2.16 QALYs, whereas IMR with an MVP produced slightly fewer QALYs, at 2.13. Non‐augmented repair produced a modeled gain of 2.02 QALYs. The ICER comparing PRP‐augmented IMR versus MVP‐augmented IMR was $161,742/QALY, which fell well above the $50,000 willingness‐to‐pay threshold. Conclusions IMR with biological augmentation (MVP or PRP) resulted in a higher number of QALYs and lower costs than non‐augmented IMR, suggesting that biological augmentation is cost‐effective. Total costs of IMR with an MVP were significantly lower than those of PRP‐augmented IMR, whereas the number of additional QALYs produced by PRP‐augmented IMR was only slightly higher than that produced by IMR with an MVP. As a result, neither treatment dominated over the other. However, because the ICER of PRP‐augmented IMR fell well above the $50,000 willingness‐to‐pay threshold, IMR with an MVP was determined to be the overall cost‐effective treatment strategy in the setting of young adult patients with isolated meniscal tears. Level of Evidence Level III, economic and decision analysis.

» Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm. » The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time. » Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments. » In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

Background: Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources. Purpose: To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated. Results: Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient. Conclusion: Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.

» Hamstring injuries are common among active and athletic individuals, especially those involved in high-speed running, distance running, or sports requiring sudden directional changes. Acute hamstring strains often occur as an eccentric strain during running or a stretch-type injury caused by simultaneous hip flexion and knee extension. Proximal hamstring tendinopathy is an overuse injury of the hamstring tendon as a result of chronic cicatrization of the musculotendinous unit. » Repeated stress to the hamstring tendon leads to increased cellularity of tendon fibers, disruption of collagen, and subsequent microinjury of the tissue that attaches the tendon to bone. » Management of hamstring injuries generally begins with nonoperative modalities consisting of eccentric rehabilitative exercise programs. Although various other treatment modalities are available, the comparative efficacy of these supportive measures is not well differentiated at this time. » In this article, we review the current literature with regard to the nonoperative treatment of hamstring injuries, specifically focusing on acute hamstring muscle strains and proximal hamstring tendinopathy in order to provide supplementary insight on the effectiveness of current modalities.