BACKGROUND:Osteochondritis dissecans (OCD) of the humeral capitellum is a rare and challenging condition to treat. Several surgical options exist, but in the last few years, the pendulum has swung from debridement and microfracture to restoration of the articular surface. Osteochondral autografts from the rib and knee have been described, but donor-site morbidity is a concern. PURPOSE:To expand the results of fresh osteochondral allograft transplantation (FOCAT) in a previously published report with inclusion of additional patients and a longer follow-up period. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:After institutional review board approval, the charts of patients who underwent FOCAT for OCD of the capitellum between 2006 and 2022 by a single surgeon were reviewed. The majority of cases (94%) had unstable lesions (Minami grades 2 and 3). A trial of nonoperative treatment had failed in all. All patients underwent diagnostic arthroscopy, followed by a mini-open, ligament-sparing approach with grafting using commercially available guides and instruments. RESULTS:A total of 35 patients were identified, of whom 25 were male. The mean age was 16 ± 3.9 years (range, 11-32 years). There were 24 baseball players (19 pitchers and 5 position players), 5 gymnasts, 3 cheerleaders/tumblers, 1 tennis player, 1 student (who did not participate in athletics), and 1 patient with avascular necrosis from chemotherapy. Eighteen patients had a mean flexion contracture of 14.1°± 11.9°. A single osteochondral allograft plug was used in 23 patients (mean diameter, 11.3 ± 2.8 mm), and 12 patients required 2 plugs (Mastercard technique). The mean follow-up was 92.6 ± 54.5 months (range, 24-204 months). There was significant improvement in Oxford (from 25.5 ± 4.9 to 46.7 ± 3.5; P < .00001) and visual analog scale for pain (from 7.5 ± 2 to 0.3 ± 1.0; P < .0001) scores. The mean Single Assessment Numeric Evaluation score at the time of follow-up was 90.6 ± 10.8 (range, 60-100). In overhead athletes, there was significant improvement in the Kerlan-Jobe Orthopaedic Clinic score (from 40.8 ± 11.8 to 90.6 ± 10.8; P < .00001). A postoperative magnetic resonance imaging scan was obtained in 16 (46%) patients at a mean of 32.6 months. In all cases, the graft was incorporated. All overhead athletes were able to return to their sport and perform at the same level or higher for >2 years. Two elbows required a subsequent arthroscopy for loose-body removal; otherwise, there were no other complications. CONCLUSION:FOCAT is an excellent option for treating OCD lesions of the humeral capitellum. Excellent outcomes and high return-to-sport rates were observed, with midterm follow-up showing no graft failures. FOCAT eliminates donor-site morbidity.

Background: Ulnar collateral ligament reconstruction (UCLR) has allowed the return of overhead athletes to throwing sports. We describe a new double suspensory (DS) technique using a single tunnel in the ulna and humerus, achieving fixation with adjustable loop buttons. Methods: Inclusion criteria included skeletally mature baseball players with clinical and magnetic resonance imaging diagnosis of UCL insufficiency who failed a trial of structured nonoperative treatment. A total of 36 baseball players underwent DS UCLR, between 2011 and 2017, by 1 surgeon with minimum 2-year follow-up. The graft was fixated with an adjustable button loop on the humeral side and a tension slide technique with a button on the ulnar side. Pre- and postoperative Kerlan-Jobe Orthopaedic Clinic and Single Assessment Numerical Evaluation and postoperative Conway scores were obtained. Results: The mean age was 19.8 +/- 4.6 years (range, 14-35 years). All were male. Mean years played before surgery was 14.3 +/- 4.6 years (range, 8-28 years). There were 32 (89%) pitchers and 4 (11%) position players. There were 13 (36%) high school, 20 (55%) college, 2 (6%) minor league, and 1 (3%) adult league athletes. The mean follow-up was 55.3 +/- 23.7 months (range, 26-97 months). There was significant improvement in Kerlan-Jobe Orthopaedic Clinic (33.2 +/- 19.9 to 89.7 +/- 15.1, P < .0001) and Single Assessment Numerical Evaluation (20.7 +/- 16.7 to 93.6 +/- 11.9, P < .0001) scores. Using Conway scoring, 25 (69%) had excellent, 5 (14%) good, 3 (8%) fair, and 3 (8%) poor scores. Mean return to play was 9 +/- 1.5 months (range, 6-16 months). Only 1 (3%) athlete required a revision surgery and ultimately returned to play and 1 (3%) hardware removal. None developed ulnar nerve symptoms. Conclusion: DS fixation for UCLR in baseball players can lead to excellent clinical results and early return to play. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Introduction: We introduce a new sign on a Merchant view present in acute patellar tendon ruptures (APTR). We aim to determine the accuracy, sensitivity, and specificity of this new radiographic sign and measure the effect of a tutorial on these measures between trainees and non-trainees. Methods: Lateral and Merchant radiographs (22 images) of knees with four conditions (patellar instability, APTR, quadriceps tendon rupture, and controls) were randomly shown to 50 trainees and non-trainees who were asked to make a diagnosis based on radiographs. A brief tutorial was administered describing the "Empty Merchant Sign" and the same 22 images were randomly shown after the tutorial. Accuracy, sensitivity, specificity, and positive predictive value were calculated between the two image types and the effect of tutorial on these measures was assessed. Results: After the tutorial: 1. the "Empty Merchant Sign" had a higher specificity (100%) and positive predictive value (99%) compared to the lateral radiograph (81% and 64% respectively, P < 0.001), 2. There was significant improvement (from 56% to 95.3%; P < 0.001) in the accuracy of the Merchant view, making it as accurate as the lateral view (95.3% vs. 90.7%, respectively; P = 0.113). There was no difference in the accuracy of the Merchant view between trainees (97.2%) and non-trainees (90.5%) (P = 0.079). Conclusion: The "Empty Merchant Sign" is a highly sensitive and specific diagnostic sign in cases of APTR. With very little training, physicians can identify this sign to diagnose APTRs on a Merchant view.

BACKGROUND:The gold standard for patellar tendon repair is a transosseous technique. Suture anchor repair has gained popularity, with recent biomechanical studies demonstrating significantly less gap formation during cyclic loading and significantly higher ultimate failure loads as compared with transosseous repair. These findings have not been substantiated in a large clinical cohort.PURPOSE:To report demographic and epidemiologic data, clinical and surgical findings, and outcomes and complications of anchor and transosseous suture repairs of acute patellar tendon ruptures.STUDY DESIGN:Cohort study; Level of evidence, 3.METHODS:All patients who underwent a primary repair of a traumatic patellar tendon rupture within 45 days of injury between 2006 and 2016 were retrospectively reviewed. Surgery was performed at a multisurgeon (120 surgeons) multicenter (14 centers) community-based integrated health care system. Patient demographic information, repair type, complications, and time from surgery to release from medical care were recorded.RESULTS:A total of 361 patients (374 knees) met our inclusion criteria. The mean age was 39.8 years (range, 9-86 years), and 91.7% were male. There were 321 transosseous and 53 anchor repairs. There was no significant difference in the mean age (P = .27), sex (P = .79), tourniquet time (P = .93), or body mass index (P = .78) between the groups. There was a significant difference in rerupture rate between transosseous and anchor repairs (7.5% vs 0%, respectively; P = .034). Based on logistic regression, transosseous repair had 3.24 times the odds of reoperation verseus anchor repair (95% CI, 0.757-13.895; P = .1129). The infection rate was 1.6% for transosseous repair and 7.5% for anchor repair (P = .160). There was no difference in time to release from medical care: 18.4 weeks for anchor and 17.1 weeks for transosseous repairs (P = .92).CONCLUSION:Anchor repair demonstrated a significant decrease in rerupture rate when compared with transosseous repair. There was no difference in reoperation rate, infection rate, or time to release from medical care.

Background: Patellar tendon rupture following Total Knee Arthroplasty (TKA) is rare. There is no consensus on optimal treatment. Methods: All patients who underwent a primary repair of a traumatic patellar tendon rupture following a TKA between 2008 and 2016, were retrospectively reviewed. Patient information, implant, repair type (anchor vs. bone tunnel), graft use, and complications were recorded. Results: Twenty-six patients met our inclusion criteria. The average age was 69.7+11 years. There were 19 females (73.1%). The average time from TKA to PT rupture was 13.6 months (range: 0- 135 months). The average incidence was 62.32 per 100,000 TKA. PT was repaired with anchors (A) in 9 (4 with a graft) and trans-osseous tunnels (TO) in 12 (5 required graft), and 5 with other methods. There was a significant improvement in KSS from 61 to 83 (P=0.023). There was a significant difference in time from PT tear to surgery in patients with grafts (42 days) and those without grafts (6 days) (P<0.001). Compared to A repair, TO had 2.39 times odds of re-tear (95% CI: 0.38,15.4; P=0.354) and 1.37 times odds of infection (95% CI:0.074,25.6; P=0.83). Repairs with a graft had a 1.90 times odds of re-tear (95% CI: 0.29, 12.19; P=0.49) and 6.3 time odds of infection (95% CI 0.26, 166.7; P=0.25). Conclusion: Surgical repair of PT tears following TKA leads to significant clinical improvement, regardless of the fixation method or graft use. We found no difference in outcomes between A and TO repairs and or with graft use.

Introduction: Rupture of a Quadriceps Tendon (QT) following a Total Knee Arthroplasty (TKA) is a rare complication. The purpose of this study was to report outcomes and complications of QT repair following TKA. Methods: From a cohort of 437 QT repairs, 19 individuals were identified who had previously undergone a TKA on the ipsilateral leg. Data was collected on individuals with a minimum follow up of 3 months post QT repair (n=16), including Knee Society Scores, pre and post-operative lag, and pre and post-operative range of motion. Results: 13 patients were treated with End-to-End (EE) repairs and 6 were treated with transosseous or suture anchor repair (ATO). In the ATO group, there was no difference in pre (68.0 ± 22.5) and post KSS (82 ± 9.16) (p=0.231), but in the EE group, there was a significant improvement in KSS (pre=67.8 ± 13.1, post=86 ± 16.75, p=0.0027). There was significant difference in post-operative extension lag between ATO (26.0 ± 12.6) vs. EE (4.0 ± 2.74) (p=0.0083). Four out of six ATO patients had extension lag ≥10 degree extensor lag (66.7%) compared to 2 out of 13 (15.4%) patients in the EE group. Compared to EE, ATO repair had an 8.00 times odds of re-tear (95% CI: 0.53,120.6; p=0.133) and 2.75 times greater risk of infection (95% CI: 0.284, 26.61; p=0.382). Conclusion: Patients who underwent EE repair had better functional improvements compared to the ATO group and smaller extension lag.