To address the concurrent escalation in shoulder instability revision procedures for reverse shoulder arthroplasty (RSA), an operation that has seen significantly expanded utilization over the past two decades due to broader surgical indications and improved implant designs. Prosthetic instability remains a prevalent and challenging complication following RSA. Current observations show a wide variance in reported dislocation rates, which are driven by a diverse array of newly identified patient, technical, and neurological risk factors. A comprehensive clinical and radiographic workup is required to identify the specific underlying etiology of prosthetic instability—such as loss of compression, loss of containment, impingement, or implant loosening. Determining this precise root cause is essential to effectively guide subsequent revision surgery and optimize patient outcomes.
Increased recurrence rates following isolated arthroscopic Bankart repair, particularly in young, high-risk athletes, have prompted adoption of adjunctive surgical strategies. Two commonly utilized techniques are arthroscopic Bankart repair with Remplissage and the Latarjet procedure. Despite widespread use of both options, the optimal indications remain debated. This review synthesizes contemporary evidence regarding indications, clinical scenarios and outcomes, recurrence risk, return to sport and complication profiles following these procedures. Both arthroscopic Bankart repair with remplissage and Latarjet demonstrate excellent outcomes, providing return to sport rates exceeding 80
To evaluate and discuss controversies that have arisen as management of acute and chronic Achilles tendon ruptures continues to evolve. Areas of debate include operative versus nonoperative treatment, best repair or reconstruction techniques, timing of post-op weightbearing protocols, and newer functional rehabilitation interventions. With the incidence of Achilles tendon ruptures increasing, the goal of this review is to provide a resource in determining best treatment options. Evidence demonstrates that operative and nonoperative management yield comparable long-term functional outcomes. However, surgical repairs offer lower rerupture rates and earlier return to activity. There is a trend towards minimally invasive techniques for primary repairs, favored due to reduced wound complications and faster recovery. Earlier surgical intervention after injury shows improved functional outcomes. For chronic ruptures, flexor hallucis longus tendon transfer is the workhorse of secondary reconstruction. Early functional rehabilitation has been shown to be safe and effective across treatment strategies. The management of Achilles tendon injuries remains a complex clinical challenge that demands a comprehensive understanding of the tendon biomechanics, and distinct pathophysiological differences between acute and chronic presentations. Selection between operative and non-operative management requires individualized consideration, while adhering to evidence-based rehabilitation protocols is paramount to successful functional outcomes. Navigating these patient specific treatment options for various patient populations promotes optimal recovery in the short and long term.
Periacetabular osteotomy (PAO) is an established and effective surgical treatment for symptomatic acetabular dysplasia in adolescents and young adults with healthy articular cartilage. While outcomes and technical surgical considerations are well described, perioperative management practices vary significantly across institutions. The purpose of this narrative review was to synthesize current literature on evidence-based best practices for perioperative management of patients undergoing PAO and to identify knowledge gaps for future investigation. A comprehensive review of the literature was performed focusing on perioperative care across four phases: preoperative, intraoperative, acute postoperative, and rehabilitation. Areas of emphasis included laboratory evaluation and nutritional optimization, mental health screening, patient education, blood loss mitigation strategies, pain control, venous thromboembolism and heterotopic ossification (HO) prophylaxis, and postoperative rehabilitation protocols. Strong evidence exists to support specific intraoperative practices such as tranexamic acid administration, controlled hypotension, and fascia iliacus blocks for pain control. Conversely, limited or heterogeneous evidence exists regarding preoperative laboratory testing, psychosocial interventions, standardized opioid prescribing, venous thromboembolism prophylaxis regimens, and rehabilitation protocols. Psychosocial health and preoperative educational interventions appear underutilized despite growing evidence of their impact on outcomes. Significant gaps remain, particularly regarding preoperative optimization and rehabilitation strategies. Continued high-quality research is needed to establish standardized, evidence-based perioperative care pathways to further improve outcomes following PAO.
Osteonecrosis of the femoral head (ONFH) is a progressive condition disproportionately affecting young adults and is a leading indication for total hip arthroplasty in young adults. This review aims to provide a contemporary overview of ONFH with emphasis on treatment strategies aimed to prevent femoral head collapse and disease progression as supported by recent clinical research from the past five years. The 2019 revised ARCO classification has emerged as the most clinically applicable staging system, guiding treatment selection based on lesion size, location, and collapse status. Core decompression remains the surgical mainstay for pre-collapse disease. Recent evidence supports the addition of hip arthroscopy to improve clinical outcomes and increase native hip survival rates. Augmentation strategies including bone marrow aspirate concentrate (BMAC), mesenchymal stem cells (MSCs), bone grafting, and hip arthroscopy have demonstrated the most promising results when combined with core decompression in early-stage disease. Pharmacologic agents, including bisphosphonates and denosumab, have shown meaningful benefit in slowing disease progression but remain adjunctive. Total hip arthroplasty continues to demonstrate excellent long-term outcomes for post-collapse stages, even in younger patient populations. Management to prevent collapse and disease progression of ONFH remains a challenge. Joint preservation through early surgical intervention with augmentation strategies, such as addition of hip arthroscopy, bone grafting, and biologic regenerative biologic therapies represent promising advancements in ONFH management. However, the existing literature remains limited by heterogeneous study designs, small sample sizes, and inconsistent outcome reporting.
To summarize contemporary evaluation and management of acetabular labral tears, particularly in the setting of femoroacetabular impingement syndrome (FAIS), including diagnosis, nonoperative care, surgical decision-making, and rehabilitation. The acetabular labrum is critical for maintaining hip stability, preserving the suction seal, and distributing load. Evaluation includes history, provocative examination, radiographs to assess CAM and Pincer morphology, and advanced imaging to confirm labral pathology and exclude alternative pain generators. Nonoperative treatment, including activity modification, targeted physical therapy, and selective intra-articular injections, is first-line. Appropriately selected patients often achieve significant pain relief and functional improvement with arthroscopic hip preservation surgery. Current surgical strategies prioritize labral preservation through repair when viable, reconstruction for irreparable tissue, correction of underlying osseous abnormalities, and meticulous capsular management. Acetabular labral tears are a common source of hip pain frequently associated with FAIS. A structured diagnostic approach and stepwise management encompassing nonoperative and appropriately indicated surgical intervention optimize outcomes. Individualized, phase-based rehabilitation with objective testing and sport-specific criteria supports return to activity and sport, with typical return occurring around 6–8 months but varying widely by sport and athlete demands.
Acetabuloplasty is a common component of hip arthroscopy for pincer-type and mixed femoroacetabular impingement (FAI), yet the optimal degree of correction remains controversial. Historically, rim trimming has often been guided by radiographic normalization, particularly of the lateral center-edge angle (LCEA). The purpose of this review is to synthesize current evidence regarding acetabular morphology, radiographic assessment, clinical outcomes related to the degree of acetabular correction, and intraoperative strategies that support optimal correction during acetabuloplasty. Recent literature suggests that acetabular overcoverage should not be viewed as a uniform indication for [aggressive] rim resection. Although the LCEA remains a useful measure of acetabular coverage, it incompletely captures focal versus global overcoverage, acetabular version, and dynamic impingement. Mid-term studies have demonstrated favorable outcomes after hip arthroscopy for pincer morphology, with no consistent relationship between postoperative LCEA normalization and patient-reported outcomes. In addition, patients with residual postoperative overcoverage may achieve outcomes comparable to those with normalized coverage and may actually demonstrate lower rates of conversion to arthroplasty. At the same time, excessive rim resection risks iatrogenic undercoverage, instability, edge loading, and accelerated degeneration. Current evidence supports a patient specific rather than radiographically uniform approach to acetabuloplasty. Successful treatment appears to depend on restoring functional femoroacetabular clearance while preserving sufficient acetabular coverage for joint stability and load distribution. Incremental resection, dynamic intraoperative reassessment, labral preservation, and balanced correction of acetabular- and femoral-sided pathology are central to this strategy. Future studies should emphasize three-dimensional assessment, standardized reporting, and longer-term evaluation of joint preservation.
Persistent pain after total hip arthroplasty (THA) is a common complication requiring extensive diagnostic effort and is often associated with potentially invasive and morbid treatment options. With THA volume expected to steadily increase there is a similarly growing need for creative and effective diagnostic and therapeutic options for these clinically challenging patients. Hip arthroscopy has emerged as a promising tool in the setting of persistent pain after THA with expanding indications and promising outcomes. The purpose of this article was to provide a review of the current state of literature regarding arthroscopic and endoscopic solutions for common causes of persistent pain after THA with a focus on patient selection, indications, surgical considerations, outcomes, and complications. The most common indication for hip arthroscopy after THA is iliopsoas tendinopathy, showing excellent outcomes with symptom resolution in greater than 90
Accurate interpretation of pediatric elbow imaging depends on understanding the developmental relationship between the radial head and the capitellum. While the traditional sequence of pediatric elbow ossification centers provides a useful framework, it does not capture morphologic variability, asynchronous maturation, and eccentric ossification patterns that may mimic pathology. This review synthesizes current evidence on pediatric elbow ossification with particular emphasis on normal and variant radial head development. The following key questions are addressed: (1) How frequently does eccentric radial head ossification occur on MRI? (2) What is its magnitude and relationship to age and sex? (3) How should normal variants be distinguished from pathology? Recent findings reveal that the capitellum commonly ossifies eccentrically before centralizing with growth. In our cohort of 66 children, radial head ossification was eccentric in 68–71
While social determinants of health are known to contribute to disparities in orthopaedic care, associations between social deprivation and total joint arthroplasty (TJA) outcomes remain unclear. This review assessed the relationship between social deprivation and multiple aspects of total joint arthroplasty, including access to care, early postoperative outcomes, resource utilization, and patient-reported functional recovery. Recent studies have increasingly used composite deprivation indices including the Area Deprivation Index (ADI), Social Vulnerability Index (SVI), Social Deprivation Index (SDI), and Distressed Communities Index (DCI) to examine disparities in TJA care. Higher levels of social deprivation were consistently associated with reduced arthroplasty utilization, increased early postoperative complications, longer hospital stays, higher costs, and greater likelihood of non-home discharge. Associations with emergency department use were frequent, whereas findings related to readmissions were mixed. Relationships between deprivation and patient-reported outcomes were less consistent. Across multiple studies, deprivation was not uniformly associated with failure to achieve clinically meaningful improvement but was more frequently linked to failure to achieve patient-acceptable symptom states and challenges in sustaining functional recovery. Social deprivation is an important determinant of access, perioperative outcomes, and healthcare utilization following TJA, with ADI demonstrating the most consistent association. Although socially deprived patients generally achieve meaningful postoperative improvement, they are less likely to reach optimal recovery thresholds. Incorporating deprivation measures into perioperative planning may help identify patients who would benefit from targeted interventions. Future studies should standardize index use and evaluate strategies to reduce socioeconomic disparities in arthroplasty outcomes.
Ulnar collateral ligament (UCL) injuries are increasingly prevalent among overhead throwing athletes, with reconstruction rates rising 193
To review postoperative rehabilitation protocols after surgery for patellar instability, including medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy (TTO), trochleoplasty, and combined procedures. A secondary aim was to compare published recommendations with guidance generated by selected artificial intelligence (AI) platforms. Sixty three protocol entries were included: 35 isolated MPFLR, 9 isolated TTO, 4 isolated trochleoplasty, and 15 combined procedures. Isolated MPFLR showed the most consistent rehabilitation pattern, favoring immediate weight bearing as tolerated (66
Arthrogenic muscle inhibition (AMI) is a key neurophysiological mechanism that impairs voluntary quadriceps activation following total knee arthroplasty (TKA), potentially limiting functional recovery despite technically successful surgery. This review aims to synthesize current evidence on the neurophysiological mechanisms underlying AMI and to propose a mechanism-based rehabilitation framework targeting these inhibitory processes. Emerging evidence indicates that AMI is mediated by altered afferent input from the joint, leading to changes in spinal reflex excitability and supraspinal motor control. Mechanisms such as presynaptic inhibition, reduced α-motoneuron excitability, and impaired γ-loop function contribute to diminished quadriceps activation. In addition, recent studies suggest that AMI may manifest at the level of motor unit recruitment and firing behavior, reflecting persistent neuromuscular adaptations. These inhibitory processes are further influenced by joint effusion, pain, and pre-existing neuromotor deficits in patients with knee osteoarthritis. AMI represents a multilevel sensorimotor dysfunction that may act as a major limiting factor in postoperative recovery after TKA. A targeted rehabilitation approach addressing peripheral, spinal, and supraspinal mechanisms—including effusion control, neuromuscular electrical stimulation, blood flow restriction training, and sensorimotor retraining—may improve quadriceps activation and functional outcomes. Integrating neurophysiological principles into rehabilitation strategies may enhance recovery trajectories and should be a focus of future clinical research.
Osteochondritis dissecans (OCD) of the knee is a complex condition in pediatric and adolescent patients, and management relies heavily on lesion characteristics including size, stability, and fragmentation. The purpose of this review is to inform readers of the current understanding, treatment options, and outcomes of the disorder in pediatric and adolescent patients. While management of OCD of the knee is tailored highly to patient- and lesion-specific factors, broad management pathways are dictated first by lesion stability, and further by salvageability of unstable lesions. Lesion appearance on MRI and arthroscopy are critical in informing appropriate management. Stable lesions, especially in skeletally immature patients, should undergo 3-6 months of nonoperative management, with an initial 4-6 week period of nonweightbearing and avoidance of high impact or repetitive stress for a minimum of 3 months. Patients with stable lesions who fail nonoperative treatment are candidates for retro- or trans-articular drilling of the lesion to promote healing. Unstable lesions may be amenable to salvage approaches including arthroscopic or open fixation with metallic screws, bioabsorbable implants, autograft, and suture bridge constructs. When not salvageable, osteochondral autograft transfer, osteochondral allograft transplantation, or autologous chondrocyte implantation is recommended and pursued depending on lesion size and subchondral involvement. All techniques have good potential for success in healing, patient reported outcomes, and return to activity when applied in the appropriate circumstances. Significant heterogeneity exists in management and outcomes of OCD of the knee, largely attributed to the varying presentation and treatment modalities. Management pathway should be patient-specific, however there is a paucity of robust comparative trials within specific populations.
Similar to primary anterior cruciate ligament reconstruction (ACLR), meniscal pathology is frequently encountered during revision ACLR (RACLR). In the revision setting, however, meniscal disease often presents a greater challenge because tissue quality may be compromised, particularly when prior meniscal treatment was performed at the index ACLR. This review highlights key considerations and treatment strategies for managing extensive, complex meniscal lesions in the setting of RACLR. Graft failure significantly increases the incidence of meniscal tears. Furthermore, graft insufficiency may result in extensive, complex, and sometimes, irreparable meniscal tears. Meniscal treatment strategies, and ultimately joint preservation, have been studied to restore appropriate knee anatomy and biomechanics. Furthermore, special considerations must be made to best treat a wide range of meniscal pathologies in the RACLR, especially in a suboptimal joint environment. Graft failure requiring revision ACL reconstruction is often accompanied by extensive, complex meniscal tearing. Meniscus-preserving strategies may help restore knee anatomy and biomechanics and, in turn, may slow the progression of osteoarthritis.
This paper aims to provide an overview on current recommendations for perioperative pain control for pediatric spine surgery. Managing pediatric pain is important to decrease postoperative morbidity, improve early mobilization, and decrease narcotic analgesic use. We aimed to summarize the data on preoperative pain management, intraoperative pain management, and postoperative pain management pathways for pediatric spine surgery. Pre-operative mental health conditions have been shown to be associated with increased post-operative pain. Intravenous ketorolac and oral gabapentin use postoperatively can improve postoperative pain control and decrease opioid use. While patient-controlled anesthesia is currently widespread after pediatric spine surgery, there is increasing research on regional modalities for pain control, including erector spinae plane blocks, liposomal bupivacaine, epidural analgesia, and intrathecal morphine injections, which are associated with earlier mobilization and decreased narcotic use, with maintained or decreased pain scores. Multimodal pain control, as outlined in Enhanced Recovery After Surgery protocols, is necessary to achieve adequate pain control while decreasing narcotic usage and the associated side effects. Psychosocial factors can impact pain through anxiety and pain catastrophizing. There is increased emphasis on regional and neuraxial anesthesia modalities for pain control. Further research is needed directly comparing the effectiveness of these modalities and further exploring the effect of psychosocial factors on pain and methods to address this.
Osteochondral autograft transplantation (OATS) and osteochondral allograft transplantation (OCA) are established cartilage restoration procedures for symptomatic chondral and osteochondral defects of the knee in athletes. Postoperative rehabilitation is central to graft healing and incorporation, functional recovery, and safe return to play (RTP). This review synthesizes contemporary evidence on rehabilitation after OATS and OCA, including weight-bearing progression, bracing, range of motion, blood flow restriction training, and RTP criteria. Systematic reviews and survey studies report substantial variability in rehabilitation protocols, including weight-bearing timelines, bracing duration, continuous passive motion utilization, and RTP criteria. Few published protocols incorporate objective functional testing to guide RTP. Criteria-based frameworks that individualize progression by graft type, lesion location, and functional milestones are increasingly advocated, although supporting evidence remains limited. Blood flow restriction training may help preserve strength early after surgery, but data specific to OATS and OCA remain sparse. Return to play is commonly reported after both procedures, with earlier timelines more frequently reported after OATS than OCA. Rehabilitation after OATS and OCA requires balancing early graft protection with progressive restoration of motion, strength, and sport-specific capacity. Current evidence demonstrates wide protocol heterogeneity and continued reliance on time-based milestones, with underuse of objective RTP criteria. Standardized, criteria-driven pathways and multidisciplinary decision-making may improve consistency and optimize outcomes in athletic populations.
Reverse total shoulder arthroplasty (rTSA) is a commonly utilized procedure for rotator cuff arthropathy, irreparable rotator cuff tears, and complex proximal humerus fractures. Although rTSA significantly improves long-term pain and function, postoperative pain remains common and is closely associated with increased opioid consumption, prolonged hospitalization, delayed recovery, and reduced patient satisfaction. Within the modern context of the opioid epidemic, optimizing pain control while minimizing narcotic usage is essential. This review summarizes recent evidence on pain management strategies for rTSAs, with emphasis on regional anesthesia techniques, multimodal analgesia, periarticular injections, Enhanced Recovery After Surgery (ERAS) protocols, and patient-specific factors influencing pain outcomes. Recent studies demonstrate that interscalene nerve blocks provide effective early postoperative analgesia and reduce opioid requirements, though complications such as phrenic nerve paralysis and rebound pain persist. Alternative regional techniques, including combined suprascapular and axillary nerve blocks, could offer comparable analgesia with reduced adverse risks in select patients. Multimodal analgesia protocols consistently decrease opioid consumption, improve early pain scores, and shorten hospital length of stay, although outcomes vary based on regimen composition. Periarticular injections further enhance analgesia when used alone or as adjuncts to regional anesthesia. ERAS protocols are associated with improved postoperative outcomes in hip and knee arthroplasty, but evidence of their application remains limited in rTSA. Patient-level factors, including preoperative opioid use, mental health conditions, and comorbidity burden, strongly predict postoperative pain and prolonged opioid dependence. Postoperative pain management after rTSA has evolved toward a multimodal, patient-centered approach integrating approaches such as regional anesthesia, non-opioid multimodal analgesia, and periarticular injections. Despite recent advances, optimal regional anesthetic techniques and the implementation of standardized ERAS protocols in rTSA remain areas of necessary future investigation.
