Citations

Background: Complex repairs of radial meniscal tears have shown increased fixation strength compared to conventional sutures. A simplified 2-suture hybrid and a novel dual tie-grip repair with interconnected vertical mattress sutures spanning the tear were tested and compared to all-inside double-horizontal and tie-grip repairs. Hypothesis: The dual tie-grip repair would increase the initial compression load across the tear and show the least cyclic displacement and highest failure strength. Study Design: Controlled laboratory study. Methods: A total of 40 porcine medial menisci were assigned to 4 repair groups: double-horizontal, hybrid, tie-grip, and dual tie-grip (10 per group). Results from tie-grip repairs were used to assess the effect of vertical mattress suture interconnection. After suture placement according to the described technique and fixation, the initial compressive load, stiffness, and relief displacement were measured. The repaired specimens underwent cyclic loading between 5 and 30 N over 1000 cycles (0.75 Hz), while cyclic stiffness and displacement were measured. Ultimate stiffness and load-to-failure were analyzed at 3.15 mm/s. Results: Analysis of variance revealed that dual tie-grip and hybrid repairs showed higher initial compressive load and relief displacement than the other techniques, with dual tie-grip repair reaching the highest values for both metrics (load: 19.3 ± 2.3 N [ P < .001]; displacement: 0.75 ± 0.19 mm [ P < .001]). The double-horizontal repair had the lowest initial stiffness ( P < .001). Cyclic displacement was lowest for the dual tie-grip repair and highest for the double-horizontal repair (both P < .001). All repaired specimens stiffened during cycling without intergroup differences. Analysis of covariance for stiffness over displacement revealed higher stabilization ( P < .040) with dual tie-grip repair and reduced stabilization ( P < .001) with double-horizontal repair. Despite comparable ultimate stiffness across groups, the dual tie-grip repair failed predominantly by suture rupture at the highest ultimate load (275.5 ± 26.2 N; P < .001), whereas the double-horizontal repair failed by tissue rupture the earliest (127.2 ± 15.9 N; P < .001). Conclusion: The dual tie-grip repair provided the highest initial compression across the radial meniscal tear, the lowest cyclic displacement, and the greatest load-to-failure among all techniques in a porcine cadaveric model. The simplified 2-suture hybrid repair showed higher initial compression than other repairs and comparable cyclic stability to the tie-grip repair. Clinical Relevance: The dual tie-grip repair provided high compression across the radial tear and strong resistance to cyclic displacement. Future clinical series assessing differences in healing rates among different repair groups are warranted.

Background: A critical component of conducting systematic reviews or meta-analyses is assessing the methodological quality and bias of included studies. Several methodological quality assessment tools have been developed; however, these tools may not be relevant to observational sports medicine research, which carries numerous unique nuances and biases. Purpose: To develop the Sport Publication Observational Research Tool (SPORT), which evaluates and scores the methodological quality of observational sports medicine research. Study Design: Consensus statement. Methods: SPORT was developed through a modified Delphi approach involving members from the Herodicus Society and The FORUM. All active members were invited to participate in the process aimed at building consensus on SPORT content and scoring. After finalizing SPORT, a power analysis led to the independent selection of 55 observational clinical sports medicine studies, which were scored twice by 4 reviewers of varying training levels. Interrater and intrarater reliability for SPORT was assessed using intraclass correlation coefficients (ICCs). The distribution and percentiles for total SPORT score across the 55 studies were calculated. SPORT was also compared with the methodological index for non-randomized studies (MINORS), a commonly utilized quality assessment tool. Results: A total of 51 members participated and achieved 100%, 100%, 98.0%, and 98.0% completion rates for rounds 1 through 4, respectively. The final SPORT included 19 subscores related to methodological quality and bias and achieved 94% consensus approval. Mean SPORT completion time was 6 minutes and 19 seconds per study, which varied significantly by reviewer training level. The subscore "peer review" demonstrated unacceptable reliability and was removed. The remaining 18 subscores exhibited ICC ranges of 0.599 to 0.955 for interrater reliability and 0.530 to 0.936 for intrarater reliability. Total SPORT score demonstrated excellent agreement, for interrater (ICC, 0.967) and intrarater reliability (ICC, 0.966). Median SPORT score across the 55 studies was 20.0 and skewed toward lower scores. There was a moderate significant correlation between SPORT and MINORS ( r [53] = 0.575; P < .001). Conclusion: An objective tool to assess the methodologic quality of observational sports medicine research (SPORT) was successfully developed through a modified Delphi approach with numerous content experts in the field. This tool may be useful in assessing the methodological quality of primary observational sports medicine studies included in systematic reviews and meta-analyses.

Background: Rotator cuff tears are a common orthopaedic injury often resulting in shoulder pain and functional impairment. Despite the prevalence of rotator cuff tears, the incidence of retear after rotator cuff repair (RCR) remains high. There is growing interest in the use of structural augmentation in RCR to decrease retear rates and improve patient outcomes. Purpose: The purpose of this systematic review and meta-analysis was to compare the clinical and imaging outcomes of structural augmentation versus standard RCR in patients with full-thickness rotator cuff tears. The effectiveness of different augment subtypes was also assessed. Study Design: Meta-analysis; Level of evidence, 3. Methods: A comprehensive literature search was conducted in CENTRAL, Embase, and Medline from inception to November 13, 2024. Eligible studies included comparative trials evaluating structural augmentation in RCR for repairable full-thickness tears. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized controlled trials and the MINORS (Methodological Index for Non-randomized Studies) score for observational studies. Meta-analyses were performed via a random effects model, with subgroup analyses performed by study design and augment type. Results: Twenty-four studies (12 randomized controlled trials and 12 cohort studies) were included in this review, all of which evaluated biologic augments (xenograft, allograft, autograft). Structural augmentation significantly reduced the risk of retear by 35% as compared with standard RCR (risk ratio, 0.65; 95% CI, 0.48-0.89; P = .01). Retears were confirmed radiographically by magnetic resonance imaging or ultrasound. Subgroup analysis revealed the greatest reduction in retear rates with allograft augmentation (risk ratio, 0.34; 95% CI, 0.21-0.56). No significant differences were observed in patient-reported outcomes, including pain scores, American Shoulder and Elbow Surgeons scores, or Constant scores. Conclusion: Structural augmentation in RCR significantly reduces retear rates, particularly with allografts, but does not improve short-term patient-reported outcomes. Further research is needed to identify which patient and tear characteristics may influence the effectiveness of augmentation.

Background: Optimized surgical fixation and meniscal stabilization during rehabilitation increase healing success. However, the latest generation of all-inside devices has not yet been biomechanically compared with inside-out suture tape (IO-ST) repair. Hypothesis: (1) The contact area of a suture anchor (SA) would compensate for a meniscal defect better than polyether ether ketone anchors (PA); (2) adjustable tensioning for all-inside meniscal repair fixation would result in higher initial load than IO-ST repair; and (3) stiffer constructs would decrease secondary displacement. Study Design: Controlled laboratory study. Methods: This study investigates human menisci (N = 39) via microscopic imaging and a biomechanical testing protocol. For the imaging protocol, needles of an all-inside SA or PA device and an IO-ST device were inserted after staining to measure the iatrogenic defect created by the needle insertion (n = 20) and the length, width, and meniscus contact area of deployed all-inside anchors (n = 6). For biomechanical testing, menisci with longitudinal bucket handle tears were prepared, and single stitches were repaired (each n = 9). After suture tensioning (50 N) and fixation, initial load, initial stiffness, and relief displacement were measured. Constructs underwent cyclic loading between 2 and 20 N, with 10,000 cycles (0.75 Hz), and stiffness and displacement were measured. Ultimate stiffness and load-to-failure were analyzed at 3.15 mm/sec. Results: All-inside needles created greater iatrogenic meniscal defects ( P < .001) than IO-ST repair. While PAs were longer ( P < .001), SAs were wider with a greater meniscal contact area (both P < .001). IO-ST repair resulted in the lowest initial load ( P < .001) and relief displacement ( P < .001), whereas SA repair resulted in a higher initial load ( P < .007) and stiffness ( P < .023) than PA repair. The overall stiffer SA fixation ( P < 001) significantly reduced cyclic displacement compared with other repairs ( P < .044). The PA group failed due to an anchor fracture at a significantly lower load (84.3 ± 10.7 N; P < .001) than the IO-ST (136.4 ± 10.5 N) and the SA repair (122.1 ± 17.5 N), with a suture-based failure mode. The ultimate stiffness of SA constructs was higher ( P < .045) than that of other repairs. Conclusion: While all-inside devices showed improved primary stability, the IO-ST construct demonstrated the highest load-to-failure. In a human cadaveric model, meniscal repair with a more compact and conforming SA was stiffer and reduced cyclic displacement compared with PA and IO-ST repair. Clinical Relevance: All-inside SA repair improved primary stability. Future clinical series will define the overall significance of healing rates.

Purpose To establish international expert consensus on surgical techniques, complications, and rehabilitation protocols for lateral extra‐articular procedures (LEAPs) performed adjunctively with anterior cruciate ligament reconstruction. Methods Fifty‐five knee surgeons from 17 countries on 5 continents completed a 3‐round modified Delphi process. In the final round, 16 statements on LEAP techniques and complications were scored on a 5‐point Likert scale; ≥75% “agree/strongly agree” constituted consensus. When appropriate, strength of recommendation was graded. Statements lacking support were revised until consensus or abandonment. Results Six statements achieved unanimous consensus (100%), 2 had strong consensus (90%‐99.9%), and 3 reached consensus (75%‐89.9%); 4 were removed. Key technical recommendations were as follows: (1) in iliotibial band procedures, the graft strip should pass beneath the lateral collateral ligament; (2) an anatomic technique is mandatory for anterolateral ligament reconstruction; and (3) no single LEAP is clinically superior to another. Unanimous agreement indicated that modern LEAPs do not increase lateral compartment osteoarthritis risk, carry a low complication rate, and do not necessitate changes to rehabilitation or return‐to‐play timelines. Conclusions Consensus defined core surgical principles and confirmed the safety of adding LEAPs to anterior cruciate ligament reconstruction. When an iliotibial band graft is used, it should be routed deep to the lateral collateral ligament and fixed between 0° and 60° of knee flexion under low tension. For anterolateral ligament reconstruction, femoral fixation should be in full extension at a posterior‐proximal point relative to the lateral epicondyle. Although no single LEAP proved superiority, adherence to these principles permits safe, effective surgery without altering standard rehabilitation or return‐to‐sport protocols and without increasing osteoarthritis risk. Level of Evidence Level V, expert opinion.

Purpose To define expert consensus on whether and how lateral extra‐articular procedures (LEAPs) should accompany anterior cruciate ligament (ACL) reconstruction to optimize outcomes in ACL‐deficient knees. Methods Fifty‐five knee surgeons from 17 countries on 5 continents completed a 3‐round modified Delphi process. Twenty‐one statements on patient selection for combined ACL reconstruction (ACLR) + LEAPs were graded on 5‐point Likert scales; ≥75% “agree/strongly agree” signified consensus. Strength of recommendation was ranked, and statements failing the threshold were revised or discarded after discussion. Results One statement achieved unanimous agreement (100%): it is strongly recommended to add a LEAP for active patients ≤25 years receiving hamstring‐autograft ACLR to reduce graft failure. Strong consensus (≥90%) supported LEAPs in primary ACLR when grade 3 pivot shift (97.9%), knee hyperextension (97.9%), skeletally immature status (79.5%), revision ACLR (91.5%), return to pivoting sports (93.2%), active patients ≤25 years using nonhamstring grafts (90.7%), grade 3 Lachman test (90%), and when multiple relative risk factors coexist (statement 36, 97.1%). Consensus (75%‐89.9%) favored LEAPs for chronic symptomatic ACL deficiency (86.1%), posterior tibial slope >12° (85.7%), and a history of contralateral ACL injury (88.9%). Eight statements did not reach consensus regarding small‐diameter autografts, female athletes, imaging signs of anterolateral injury (e.g., Segond fracture, lateral femoral‐notch sign), and concomitant meniscal procedures. One statement on LEAPs with primary ACL repair was withdrawn because the project focused on reconstruction. Conclusions International experts strongly recommend adding a LEAP in young active patients undergoing hamstring‐autograft ACLR and in cases of high‐grade rotational or anterior laxity, knee hyperextension, revision surgery, or returning to pivoting sports. Unresolved issues include small graft size, female athletes, imaging findings of rotational instability, and concurrent meniscal procedures, highlighting priorities for future research. Level of Evidence Level V, expert opinion.

Abstract Introduction: Labral injury at the time of open and arthroscopic hip preservation surgery for symptomatic femoroacetabular impingement (FAI) is managed with debridement versus refixation by the treating surgeon based on tear pattern, tissue quality, and hip morphology. While refixation has been favored based on mid-term outcomes in some series, differences in the long-term patient reported outcomes (PROMS) have not been defined in well-designed and matched prospective series. Methods: This study consisted of a prospective, multi-center cohort that underwent primary surgical treatment for symptomatic FAI. Patients were included if they underwent corrective osteoplasty and a labral refixation or a labral debridement procedure. Using a ratio of 1:1, hips with labral refixation and labral debridement were matched by age, sex, and surgical approach. Postoperative assessments were conducted at a minimum 8 years after surgery using PROMS and assessment of reoperations. Results: A total of 237 hips (n=188 labral refixation, n=49 labral debridement) met the inclusion criteria for the current study. 48 hips from the labral refixation and 48 hips from debridement groups with mean follow-up of 10.3±1.7 years and 10.6±2.1 years respectively were included. No significant differences were observed in the femoral head, acetabular cartilage grade, or labral grade between the groups. The mHHS improved 19.8±19.6 and 23.4±16.8 from baseline to the final follow-up in the labral refixation and debridement groups, respectively (p=0.43). There were no significant differences in PROMS between the labral refixation and debridement groups. Overall, 66% and 76% of the labral refixation and debridement groups achieved the MCID for the mHHS respectively (p=0.30). There were more revision surgeries with labral refixation than with debridement (10.4% vs. 2.1%, p=0.09), but more conversions to total hip replacement in the labral debridement group (8.3% vs. 4.2%, p=0.38), but neither of these differences were statistically significant. Discussion: Both labral refixation and debridement are effective with durable improvement in PROMS at a mean of 10 years in a prospective cohort of patients treated surgically for symptomatic FAI. No significant differences in baseline or final PROMS were observed, and similar rates of revision and conversion to hip replacement were observed in the debridement and refixation groups.

Background: Recent biomechanical evidence for adjustable suture anchor (ASA)–based posterior medial meniscus root (PMMR) fixation has shown promising results compared with conventional transtibial pull-out repair (TPOR). However, ASA fixation has not been evaluated in human tissue to 100,000 cycles. Hypothesis: ASA repair would lead to increased primary fixation strength and less cyclic displacement than conventional TPORs. Study Design: Controlled laboratory study. Methods: A total of 32 human medial menisci were used, 8 of which were intact specimens and served as native controls. For the others, PMMR tears were created and repaired using 3 different techniques (n = 8 group). Two conventional PMMR repairs were prepared consisting of two No. 2 simple sutures (TSS) and two No. 2 sutures in a Mason-Allen (MA) configuration, all tied over a cortical button. The knotless ASA repair was fixed in MA with repair sutures tensioned at 120 N (MA-120). The repairs’ initial force, stiffness, and relief displacement from the tensioned state toward repair unloading (2 N) were measured after fixation. All repair constructs were loaded for 100,000 cycles, with displacement and stiffness measured, and finally were pulled to failure. Results: The TPORs demonstrated similar primary fixation and cyclic loading behavior except for initial cyclic displacement (cycle 10). The ASA repair provided a higher initial repair load ( P < .001) and stiffness ( P < .001) with relief displacement similar to conventional TPORs. Lower initial cyclic displacement ( P < .011; cycle 10) with overall higher repair stiffness ( P < .011) resulted in significantly lower displacement ( P < .001) throughout testing for ASA repair. Although both TPORs were completely loose after 100,000 cycles, the ASA repair achieved near-native dynamic meniscal stabilization. The TSS repair had lower overall ultimate load ( P < .001) and ultimate stiffness ( P < .023) compared with the ASA repair. All repairs had lower ultimate stiffness and loads than the native meniscus ( P < .001). Conclusion: The ASA repair resulted in improved primary PMMR fixation that was stiffer with less cyclic displacement than conventional TPORs and approached that of the human meniscal function after 100,000 load cycles in a cadaveric model. However, all repair techniques had lower ultimate strength than the native human PMMR. Clinical Relevance: Knotless ASA meniscus root fixation resulted in higher tissue compression and less displacement in a cadaveric model; however, future clinical series with surveillance imaging will define the overall significance of healing rates.

Collaboration between military and civilian investigators is necessary to develop strategies for optimizing treatments to diminish the sequelae of non–battle-related musculoskeletal injuries, which are highly prevalent among servicemembers. The 2024 Extremity War Injuries Symposium provided a forum whereby a diverse group of clinicians and researchers could develop strategies for optimizing treatments and diminishing the sequelae of conditions that are highly prevalent among active individuals. Key points were as follows: 1. The value of collaborations between military and civilian investigators cannot be overemphasized. These synergies can leverage the capabilities of established infrastructures in order to answer important questions pertaining to short-term outcomes—for example, warrior readiness of anterior cruciate ligament reconstructions among servicemembers and long-term posttraumatic osteoarthritis (PTOA) outcomes among civilian cohorts. 2. Current and future prospective trials will inform future treatment decisions related to multiligamentous knee injuries and glenohumeral instability. 3. Novel approaches to addressing PTOA in the acute postinjury period will need longitudinal surveillance to measure their impact on improving clinical outcomes and diminishing residual functional deficits.

Background: Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI). Purpose: To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort. Study Design: Cohort Study; Level of evidence, 3. Methods: Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed. Results: Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score ( P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up. Conclusion: Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.