PURPOSE:To evaluate the prognostic efficacy of in-office local anesthetic intra-articular injection response in predicting hip arthroscopy outcomes. METHODS:This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews using the PubMed, Embase, and Web of Science databases from inception to October 1, 2024. The articles were reviewed, and the risk of bias was assessed. Pertinent data was extracted and analyzed. RESULTS:Four studies (n = 368 patients; 48.6% women; mean age 21.6-38.8 years; level of evidence II-IV; mean follow-up 12-24 months) evaluated local anesthetic injections (lidocaine alone or with ropivacaine; 5 to 20 mL) assessed 20 to 30 minutes postinjection for femoroacetabular impingement syndrome. Definitions of positive injection response varied substantially. Three of the 4 studies showed significant associations between positive injection response and superior postoperative outcomes, with positive responders achieving higher Hip Outcome Score Activities of Daily Living, Hip Outcome Score-Sports, Nonarthritic Hip Score, and Patient-Reported Outcome Measure Information System scores (P = .003-0.045) and higher minimum clinically important difference/patient acceptable symptomatic state achievement rates. Change in Visual Analog Scale for Pain predicted substantial clinical benefit (odds ratio 1.2, P < .001), and postinjection International Hip Outcome Tool correlated with 1-year outcomes (r = 0.784, P < .001). Postoperative modified Harris Hip Score ranged from 87.5 to 87.7 in positive responders versus 81.6 to 84 in negative responders. One study found no significant correlation (P = .589), with 49% of patients with poor surgical outcomes showing good injection response. CONCLUSIONS:Based on limited available literature, it is suggested that a positive in-office response to intra-articular injection of local anesthetic portends a favorable outcome after hip arthroscopy. A negative response to in-office injection was not suggested to foreshadow a poor surgical outcome and based on the current evidence is inconclusive as a tool by which to help select surgical candidates. LEVEL OF EVIDENCE:Level IV, systematic review of Level II to IV studies.

Background: The Latarjet procedure is a common technique for treating symptomatic, recurrent anterior shoulder instability with significant glenoid bone loss and employs a standard subscapularis split to ensure optimal exposure and functional outcomes. Indications: This procedure is indicated for primary or recurrent anterior instability, particularly in high-risk patients with approximately 15% anterior glenoid bone loss. Technique Description: The patient is positioned in a beach-chair position, and sharp dissection is initiated at the superior aspect of the coracoid tip and extended inferiorly by 4 to 6 mm. The lateral border of the conjoint tendon is identified and released from the clavipectoral fascia. The coracoacromial (CA) ligament is identified and released from the coracoid using Bovie electrocautery, leaving a small segment for later capsular closure. The pectoralis minor is released from the medial coracoid border, exposing the coracoid base. After measuring the coracoid, an oscillating saw and osteotome are used to harvest the bone graft. The coracohumeral ligament is released, and the graft is prepared with a flat, bleeding surface to ensure optimal contact with the glenoid neck. Two drill holes are placed through the coracoid tip. Next, the subscapularis is split at the junction of the superior two-thirds and inferior one-third of the muscle belly, and the split is completed laterally. The plane between the subscapularis and capsule is developed. A horizontal split in the capsule is made to visualize the glenoid neck and anterior glenoid face. The anterior glenoid surface is cleared of capsule and decorticated. The graft is drilled using an offset guide, and cannulated screws are placed for fixation. A suture anchor is placed between the coracoid graft drill holes to secure fixation, while a suture is passed through the CA ligament stump and anteroinferior capsule, reinforcing the glenohumeral ligament complex and augmenting anterior stability. Results: Early outcomes of the standard Latarjet technique are favorable, including reduced recurrence of instability through glenoid augmentation and a conjoint tendon sling effect, with lower complication and reoperation rates and higher return to sport rates compared with other stabilization surgeries (eg, arthroscopic Bankart). 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. Discussion/Conclusion: Surgeons should consider the Latarjet technique in indicated patients.

Background: Synthesizing comparisons between the Latarjet procedure and arthroscopic Bankart repair with remplissage (ABRR) is clinically relevant given their overlapping indications and potential as viable surgical options for recurrent anterior shoulder instability. However, previous systematic reviews have exclusively focused on the open Latarjet (OL) approach and included follow-up durations of less than 2 years. Therefore, purpose of this systematic review is to compare mid- to long-term clinical outcomes of ABRR versus both the OL and the arthroscopic Latarjet (AL) procedures across a wide range of glenoid bone loss to further enhance surgical decision-making. Methods: A comprehensive search of the PubMed, Embase, and Web of Science databases was performed in accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analysis guidelines, for studies published between 2014 and 2024. Studies that compared outcomes between ABRR and either OL or AL and had a minimum clinical follow-up of 2 years were included. Patient-reported outcome measures (PROMs), range of motion (ROM), and recurrent instability, revision, and complication rates were collected. Qualitative and quantitative analyses were performed. Meta-analyses were conducted using R with the ''Metafor'' package. Results: Of the 5,005 abstracts screened, 6 studies were included. Three hundred thirty-three patients underwent ABRR (mean age 27.3 ± 8.3 years, 22.4% female) and 468 underwent OL or AL (mean age 28.4 ± 9.2 years, 20.1% female). PROMs and ROM improved postoperatively across both groups but demonstrated high heterogeneity. The ABRR group had significantly higher single assessment numeric evaluation scores (92.5 ± 12 vs. 89.1 ± 12.2, P = .025; 95% confidence interval 0.7-10.2; Iˆ2 83%). There was no statistical difference in external rotation at 90° abduction (ABRR 67.6 ± 17.2° vs. 75.6 ± 18.4°, P = .968). The Latarjet procedure reported significantly higher complication rates (7.7% vs. 1.6%, P = .002; 95% confidence interval 0.08-0.57; Iˆ2 0%), while there were no significant differences in recurrent instability (P = .273, Iˆ2 14%) and revision rates (P = .067, Iˆ2 0%). Conclusion: When compared across a wide range of glenoid bone loss levels, both ABRR and Latarjet procedures are effective for managing anterior shoulder instability, with comparably high PROMs and no significant differences in ROM. ABRR offers a safer surgical risk profile with significantly fewer complications and is a viable option in the appropriate patient population. However, there is likely a limit of glenoid bone loss at which ABRR may not be safely performed due to the elevated risk of recurrent instability.

Background: Arthrofibrosis is a complication of anterior cruciate ligament reconstruction (ACLR), and it is possible that graft choice such as the quadriceps tendon (QT) autograft may be a risk factor. With the increasing popularity of the QT autograft, it is important to compare it with other graft choices. Purpose/Hypothesis: The purpose of this study was to identify whether graft choice, QT versus bone–patellar tendon–bone (BTB) autograft, is a risk factor for early return to the operating room for arthrofibrosis after ACLR. It was hypothesized that the rate of arthrofibrosis surgery would be higher for the QT autograft recipients. Study Design: Cohort study; Level of evidence, 3. Methods: A single-center retrospective chart review was conducted between January 2010 and November 2022. Skeletally mature patients who underwent primary ACLR with either QT or BTB autograft were considered for inclusion. Patients who received an alternate graft or those undergoing revision ACLR were excluded. The primary outcome of interest was return to the operating room for arthrofibrosis release (either manipulation under anesthesia or lysis of adhesions). Results: Of 1726 included patients (1155 receiving a BTB autograft and 571 receiving a QT autograft), 5.2% (n = 60) of BTB recipients and 6.5% (n = 37) of QT recipients required subsequent arthrofibrosis. There was no significant association between graft type and subsequent arthrofibrosis ( P = .275). There was a significant association with graft type and presence of a cyclops lesion (65.0% of BTB grafts and 40.5% of QT grafts; P = .018). After removing those patients with chronic tears who underwent ACLR at >1 year, patients who required arthrofibrosis were found to have a significantly shorter time between injury and ACLR (mean, 59.23 ± 48.46 days) than those who did not require arthrofibrosis (mean, 81.7 ± 72.63 days) ( P≤ .01). Significantly more female patients (9.25%) than male patients (2.79%) required arthrofibrosis (hazard ratio, 3.82; P < .001), and patients who required arthrosis were significantly younger (mean, 22.52 ± 9.35 years) than those who did not (mean, 25.74 ± 10.83 years) ( P = .001). Conclusion: Study findings indicated no statistically significant difference in the rate of secondary arthrofibrosis surgery between patients who underwent ACLR with either QT or BTB autograft.

PURPOSE:To evaluate and qualitatively synthesize studies performed in the past decade that report return to sport (RTS) after anterior shoulder instability surgery and identify study, patient, and surgical characteristics that reduce heterogeneity in RTS outcomes, to help guide surgeons and patients in collaborative decision-making and set appropriate expectations of postoperative athletic performance. METHODS:A systematic review of PubMed, Embase, and Web of Science databases was conducted for all studies published between January 2015 and March 2025 reporting RTS or return to preinjury level (RTPL) following surgical treatment for anterior shoulder instability. Exclusion criteria included non-English studies, studies reporting less than a 2-year follow-up, and studies reporting any shoulder instability other than anterior, including atraumatic instability. The risk of bias was assessed, and data were extracted. Heterogeneity in procedure-specific RTS outcomes was qualitatively assessed through subgroup analyses of study, patient, and surgical characteristics. RESULTS:A total of 123 studies encompassing 10,992 athletes were included. Across 9,581 patients, RTS rates ranged from 50% to 100%, and RTPL ranged from 19.4% to 100%. RTS was most consistent following open iliac crest (100%) and open Bankart repair (91.6%-100%), while wider ranges were observed after arthroscopic Bankart (50%-100%) and open Latarjet (50%-100%). RTPL exhibited rates of 100% after open iliac crest and 19.4% to 97.1% after open Latarjet. Female athletes had higher and more consistent RTS (91.4%-100%) and RTPL (74.1%-76.9%) compared to males (RTS, 73.9%-100%; RTPL, 39.4%-97.1%). Ranges of RTS and RTPL narrowed in studies with a prospective design (RTS, 87%-98%; RTPL, 38%-97%), revision procedures (RTS, 77.9%-100%; RTPL, 42.9%-95.4%), and among elite athletes (RTS, 81.8%-100%). Patients with >20% glenoid bone loss exhibited narrower RTPL (78.3%-95.4%) than those with <20% (70%-100%). Sport type, athlete level, and bone defect tracking status further influenced RTS variability. CONCLUSIONS:Anterior shoulder stabilization procedures lead to high, though varied, reported RTS and return to preinjury rates across all studied cohorts. Ranges of RTS rates are influenced by procedure type, clinical follow-up duration, athletic level, and revision surgery status. LEVEL OF EVIDENCE:Level IV, systematic review of Level I to IV studies.

Purpose:To assess the diagnostic capability of radiographs (XRs) to detect pincer lesions compared with 3-dimensional (3D) computed tomography scans in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Methods:We performed a retrospective review of all patients who underwent hip arthroscopy for FAIS between September 1, 2020, and October 2, 2022. Preoperative imaging was reviewed. Pincer lesions were defined as a lateral center-edge angle greater than 40°; a Tönnis angle greater than 0°; the presence of the ischial spine, crossover, or posterior wall sign; and the presence of overcoverage greater than 80%. Under "select criteria," patients were classified as having a pincer lesion on XRs and 3D computed tomography reconstructions (CTRs) based on the lateral center-edge angle or Tönnis angle alone, whereas "all criteria" added the presence of the crossover sign and coverage percentage. Statistical analysis was performed to determine the diagnostic accuracy of XRs compared with 3D CTRs. Results:A total of 69 patients met the inclusion criteria. There were 21 male patients (30.4%) and 48 female patients (69.6%). The mean age was 33 ± 13.5 years. χ2 Analysis for select criteria found that 3D CTR was more likely than XRs to detect a pincer lesion. χ2 Analysis for all criteria found that 3D CTR was more likely than XRs to detect a pincer lesion. χ2 Analysis further showed that when using XRs, a pincer lesion was more likely to be detected under all criteria than under select criteria. Likewise, when using 3D CTR, a pincer lesion was more likely to be detected under all criteria than under select criteria. Conclusions:In this study, we found that 3D CTR detected pincer lesions in patients undergoing hip arthroscopy for FAIS with significantly higher sensitivity than XRs alone. Level of Evidence:Level III, retrospective cohort study.

Background Corticosteroid injections (CSI) are commonly used for the treatment of shoulder pain in patients with osteoarthritis (OA) and rotator cuff arthropathy (RCA). These injections may increase the risk of infection following eventual shoulder arthroplasty. Purpose The purpose of this study was to perform a systematic review and meta-analysis of existing data to explore the relationship between preoperative CSI’s and postoperative periprosthetic joint infection (PJI) following shoulder arthroplasty. Methods A literature search was performed on PubMed, Embase, and Web of Science databases through September 29, 2023. Of the 4,221 retrieved, 7 studies including 136,233 patients were included for qualitative analysis. Studies describing patients receiving CSI prior to shoulder arthroplasty and the effect on postoperative infection risk were included in the systematic review and subsequent meta-analysis. Assessment of risk of bias was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results Receiving a corticosteroid injection prior to shoulder arthroplasty was found to have a statistically significant association with increased risk for PJI (OR: 1.13. 95%; CI: 1.06-1.19; p < 0.0001). The rate of PJI increased when injections were given closer to the time of surgery. Patients who received an injection at any time point before surgery had a 5.4% risk of PJI compared to 7.9% and 9.0% in patients receiving an injection within 3 months and 1 month of surgery respectively. This time dependent association however did not reach statistical significance: 1 month OR 1.48; 95% Cl: 0.86-2.53; p = 0.16, 3 months OR 1.95; 95% Cl: 0.95-4.00; p = 0.07. Conclusion The results of this systematic review and meta-analysis demonstrate that patients receiving corticosteroid shoulder injections prior to shoulder arthroplasty may be at an increased risk for prosthetic joint infection postoperatively. While time dependent stratification did not reach statistical significance, our findings indicate a clear trend of increased risk for patients receiving injections closer to surgery.

Background: Accurate and reliable assessment of tibial torsion is important for the identification and treatment of tibial rotation malalignment; however, the ideal rotational measurement modality and technique are controversial. This study compares rotational measurements between computed tomography (CT), magnetic resonance imaging (MRI), biplanar erect radiograph (BER) reconstructions, and three-dimensional (3D) reconstructed CT before and after standardized training of observers to evaluate the reliability of each assessment method.Methods: Eight adult cadaveric specimens underwent CT, MRI, and BER imaging. Tibial torsion was measured by three independent observers (one resident and two experienced orthopaedic surgeons) both before and after standardized measurement instruction. Reliability for inter-observer measurement was evaluated using the Intraclass Correlation Coefficient (ICC). Measurement values for CT, MRI, and BER reconstructions were compared to 3D CT reconstructions analyzed using custom software to align and measure tibial torsion (used as the reference standard).Results: Before training, there was poor inter-observer reliability for CT (ICC=0.492, p=0.014) and moderate interobserver reliability for MRI (ICC=0.633, p=0.002). There was no inter-method reliability between 3D CT and MRI for two of the three surgeons and moderate to good reliability between 3D CT and CT. After training, the interobserver reliability for CT improved to 0.536 and the inter-observer reliability for MRI improved to 0.701. The BER measurements (no observer involvement) had moderate reliability compared to the 3D CT reconstructions (ICC=0.69, p=0.026). Measurement error was 4 degrees for CT pre-training and 7 degrees post-training, and 7 degrees for MRI pre-training and 8 degrees post-training.Conclusions: A standardized training regimen for MRI measurements improved both inter-observer and intraobserver reliability. Inter-method reliability between CT, MRI, and BER compared to reference 3D CT reconstructions demonstrated that all imaging modalities are a valid means to measure tibial rotation but differ in reliability from moderate to good. When assessing tibial torsional deformities, it is important to consider these variations from true rotation and feel comfortable using them for pre-operative planning purposes.Level of Evidence: N/A for a cadaveric imaging study. Key Concepts:•A standardized training regimen for MRI measurements of tibial torsion significantly improved inter-observer and intra-observer reliability.•CT, MRI, and BER measurements are valid imaging modalities compared to 3D CT reference standards for measuring tibial rotation.•Established manual measurements of tibial torsion from MRI may be improved with adequate training.•Measurement error of up to 8 degrees can be seen from true tibial torsion during the imaging assessment.

Purpose:To compare the reliability and accuracy of radiographic measurements obtained from 2-dimensional (2D) radiographs and 3-dimensional (3D)-reconstructed computed tomography (CT) images in the assessment of femoroacetabular impingement syndrome (FAIS).Methods:Consecutive patients with FAIS from January 2018 to December 2020 were identified and included in this study. Two fellowship-trained surgeons and 2 fellows performed blinded radiographic measurements. Lateral center-edge angle (LCEA) and Tönnis angles were measured on anteroposterior pelvic radiographs, and alpha angles were measured on frog lateral radiographs. Reliability coefficients for individual measurement accuracy were performed using the Cronbach alpha and intra- and inter-rater intraclass correlation coefficients (ICCs). Composite measurements for LCEA, Tönnis angle, and alpha angle were compared with the corresponding 3D value using paired sample t-tests.Results:Fifty-three patients with FAIS with standardized 2D radiographic and 3D-reconstructed CT imaging were included. All reliability metrics met thresholds for internal reliability. Inter-rater ICCs for LCEA, Tönnis angle, and alpha angle were (0.928, 0.888, 0.857, all P < .001). When we compared 2D radiographic measurements with 3D-reconstructed CT values, there was a significant difference in the LCEA for 2 authors: surgeon 1 (mean [M] = -9.14, standard deviation [SD] = 5.7); t(52) = -11.6, P < .001, and surgeon 2 (M = -5.9°, SD = 4.7); t(52) = -9.2, P < .001. Significant differences were seen for Tönnis angle for 2 authors: fellow 2 (M = 3.9°, SD = 5.6); t(52) = 5.1, P < .001, and surgeon 2 (M = -2.6°, SD = 4.1); t(52) = -4.6, P < .001. Alpha angle measurements compared to the 3D-reconstructed alpha angle at 2 o'clock was significantly different for 3 authors: fellow 1 (M = 11.9°, SD = 16.2); t(52) = 5.3, P < .001; fellow 2 (M = 10.4°, SD = 18.6); t(52) = 4.1, P = .002; and surgeon 2 (M = -6.5°, SD = 16.2); t(52) = -2.9, P = .005. Positive mean values indicate 2D radiographic measurements overestimated 3D reconstruction values and negative mean values indicate underestimation.Conclusions:The use of 2D radiographs alone for preoperative planning of FAIS may lead to inaccuracies in radiographic measurements.Level of Evidence:Level, III retrospective cohort study.

The routine use of tranexamic acid (TXA) in shoulder arthroplasty has grown in popularity due to the perceived benefits of reduction in intra-operative blood loss and the related adverse sequelae. Both intravenous (IV) and oral (PO) formulations of TXA exist and there is minimal data regarding the optimal route of administration. This study aimed to assess whether there was a significant difference in efficacy between the administration of PO vs. IV TXA prior to total shoulder arthroplasty. We hypothesized equivalence in preoperative (preop) to postoperative change in hemoglobin (Hg) and hematocrit (Hct) as well as the length of stay (LOS), 90-day readmission, transfusion rates and adverse events between the two routes. A single-center retrospective chart review was conducted between May 2022 and January 2023. All patients undergoing primary anatomic or reverse total shoulder arthroplasty during this period were included. Patients undergoing revision shoulder arthroplasty or arthroplasty for fracture were excluded. The primary outcome of interest was the change (Δ) in preop to postoperative day 1 Hg and Hct reported as ΔHg and ΔHct. Intraoperative estimated blood loss (EBL), transfusion rates, patient demographics, LOS, and adverse event data were also collected. Two hundred and thirty patients who underwent shoulder arthroplasty met the inclusion criteria. A total of 176 patients received preoppreop IV TXA and 54 patients received preop PO TXA. There was no significant difference between groups in the mean ΔHg (1.69 in the IV group and 2.52 in the PO group, P = .11) or ΔHct (5.19 in the IV group and 5.04 in the PO group, P = .42). There was no significant difference in LOS, transfusion rates, or 90-day readmission between groups. There was a significant difference in the mean EBL between the two groups (123.78cc in the IV group and 173.06cc in the PO group, P < .001). Our study was adequately powered at 0.95. There was no statistically significant difference between the IV and PO TXA groups when comparing preop to postoperative day 1 change in Hg and Hct, LOS, transfusion rates, surgical site infections, and 90-day readmission indicating similar efficacy between the two routes of administration. EBL was found to be significantly higher in the PO TXA group, though the clinical significance of this finding is indeterminate. Given these findings, however, PO TXA may be a reliable alternative to IV TXA in primary shoulder arthroplasty.

PURPOSE:The aim of this study was to use a systematic review and network meta-analysis (NMA) to compare the failure strength, maximum strength, stiffness, and displacement of available constructs for distal biceps repair. METHODS:An NMA was conducted to determine the performance of 2 all-suture suture anchors (2x ASA), 2 intramedullary cortical buttons (2x IM CB), 2 suture anchors (2x SA), extramedullary cortical buttons (EM CB), extramedullary cortical button plus interference screw (EM CB+IFS), interference screw (IFS), single intramedullary cortical button (IM CB), single suture anchor (SA), transosseous suture (TOS), tension slide technique (TST), and tension slide technique plus suture tape (TST+ST). Analysis consisted of arm-based network meta-analysis under Bayesian random-effects model with Markov Chain Monte Carlo (MCMC) sampling. Biomechanical outcomes were summarized as treatment effects and their corresponding 95% confidence intervals (CI). Rank probabilities were calculated and used to generate each treatment's surface under the cumulative ranking (SUCRA) curve. Biomechanical properties were compared to native tendon. Displacement >10 mm was defined as clinical failure. RESULTS:Twenty-one studies were included. For failure strength, no construct outperformed the native tendon but 2× SA, IFS, SA, and TOS demonstrated poorer failure strength. For the maximum load to failure, EM CB+IFS outperformed the native tendon. Compared to native tendon, EM CB+IFS, EM CB, and 2×IM CB were stiffer, while 2x SA and IFS were less stiff. No construct demonstrated >10 mm of displacement, but constructs with displacement above the mean (3.5 mm) included 2× ASA, 2xIM CB, and TOS. CONCLUSIONS:The fixation constructs that consistently demonstrated comparable or better biomechanical properties (failure strength, maximum strength, and stiffness) to native tendon in distal biceps tendon repair were the extramedullary cortical button with or without interference screw and two intramedullary cortical buttons. No construct demonstrated displacement beyond standard definitions for clinical failure. CLINICAL RELEVANCE:This network meta-analysis of biomechanical studies suggests that extramedullary cortical button and two intramedullary cortical buttons may be the most stable construct for distal biceps repair fixation, with equivalent or better biomechanical properties compared to native tendon.

Background: The incidence of anterior cruciate ligament (ACL) injuries has rapidly increased. Patients with ACL injuries frequently present with concomitant meniscal pathologies. Posterior medial meniscal root tears (PMMR) are less commonly seen with acute ACL injuries as compared with lateral tears and are often degenerative in nature or more rarely in an acute setting. Clinical studies have demonstrated medial meniscal deficiency to be a significant risk factor for graft failure and poor postoperative clinical outcomes. As such, given its demonstrated efficacy, there has been growing interest in transtibial meniscal repair mechanisms in combination with an ACL reconstruction as a potential solution to this challenging pathology. Indication: Patients are indicated for surgery when presenting with symptomatic ACL deficiency verified on provocative testing and advanced imaging and objective insufficiency of the medial meniscal root. Contraindications for this procedure include advanced osteoarthritis (Kellgren–Lawrence grade ≥3) on weight-bearing x-rays, age <50 years, and body mass index (BMI) > 30 as well as poor-quality meniscal tissue and unrepairable chondral defects. Technique Description: The ACL stump is debrided and a burr hole is created. A femoral aiming guide is used to drill the femoral tunnel. Following medial collateral ligament (MCL) release, a healing bony bed is prepared with a curette and shaver at the anatomic tibial footprint. An aiming device is then used through the anterior medial portal to create 2 transosseous tibial tunnels. A vertical mattress suture and simple suture are placed through the meniscal root, shuttled through the posterior and anterior transosseous tunnels, respectively. The tibial ACL tunnel is placed using a standard guide to avoid tunnel convergence with the root tunnels and prevent graft tunnel mismatch. After graft passage, interference screws are inserted while maintaining graft tension. The sutures are then tied over a cortical button over the tibia. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities with low rates of graft failure. Discussion/Conclusion: Recent advancements in our understanding of the relationship between the medial meniscus and the ACL should prompt surgeons to continue considering such combined treatments in indicated patients. 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.

IntroductionRadial meniscus tears significantly compromise knee biomechanics due to loss of the circumferential fiber connections and have been shown to be biomechanically equivalent to a total meniscectomy. There is a paucity of data regarding the biomechanical performance of radial meniscal repairs and numerous technical challenges associated with surgical repair. Further, current repair methods have been shown to lead to high rates of incomplete, nonanatomical healing of the meniscus and can potentially cause progressive joint degeneration and osteoarthritis. This is particularly true for the avascular portions of the meniscus. As a result, such injuries have been historically treated with a partial meniscectomy. There has been a growing interest in transtibial repair mechanisms as a potential solution to this challenging pathology.ObjectivesThe purpose of this technical note is to detail a method for repairing a complete radial tear of the medial meniscus using a single-tunnel transtibial technique.MethodsAfter a thorough history and clinical examination, and imaging, the patient was diagnosed with a complex medial meniscal tear with a primary radial tear component. A single tunnel transtibial meniscal repair was indicated and performed.ResultsAn anatomic repair was achieved with tension across the defect. The patient successfully returned to activities.ConclusionsSingle-tunnel transtibial repairs of radial tears in the meniscus may provide increased stability by anchoring the meniscal leaflets to the tibia as well as a potential biological benefit by releasing growth factors and progenitor cells from the bone marrow.

Purpose: To compare the different interventions described in the literature for the surgical treatment of small and medium complete rotator cuff tears. Methods: A systematic review of randomized controlled trials of small-medium, full-thickness rotator cuff tears published since 2000 was performed. Clinical characteristics, re-tear rates, range of motion (ROM), and patient-reported outcomes (PRO) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model. Interventions were ranked for each domain (re-tear risk, pain, ROM, and PROs) via surface under the cumulative ranking curves. Results: A total of 18 studies comprising 2046 shoulders (47% females, mean age 61 +/- 3 years, mean follow-up 21 +/- 5 months) were included. Interventions that ranked highest for minimizing re-tear risk included arthroscopic single-row repair (A+SR) or double-row repair (A+DR) with or without platelet-rich plasma (PRP). Open repair and A+SR repair with acromioplasty (ACP) ranked highest for pain relief. Interventions that ranked highest for ROM improvement included open repair, PT, and A+DR with or without ACP. Interventions that ranked highest for PROs included arthroscopic footprint microfracture with or without SR, open repair, and A+SR with or without ACP. Conclusions: Based on a network meta-analysis of level 1 studies, arthroscopic rotator cuff repair with a SR or DR construct demonstrates similar retear rates, PROs, and clinical outcomes. The highest-ranking treatment for minimizing retears was arthroscopic repair with DR constructs and PRP augmentation, although open repair and arthroscopic SR remain reliable options with excellent clinical outcomes. Addition of PRP to DR constructs trended toward a 56% decreased risk of retear as compared to DR repair alone. Although no single treatment emerged superior, several interventions offered excellent clinical improvements in pain, ROM, and PROs that exceeded minimal clinically important difference thresholds.

Management of symptomatic patients with an irreparable rotator cuff tear who have failed conservative management remains challenging. Arthroscopic superior capsular reconstruction is a relatively new procedure that prevents superior migration of the humeral head while optimizing the force coupling required to allow for elevation of the arm. Early results are promising and significant pain relief and improvement in functional outcomes had been demonstrated. Several surgical techniques for superior capsular reconstruction utilizing autograft, allograft, and xenograft had been described. This chapter discusses in detail the authors’ preferred technique for arthroscopic superior capsular reconstruction using an acellular dermal allograft.

Objectives: Rupture of the distal biceps is common and demonstrates excellent short- and long-term clinical outcomes following surgical repair. Prior studies have individually evaluated the biomechanical construct strength of multiple fixation devices, but none has comprehensively evaluated constructs in a head-to-head comparison. We sought to compare the failure strength, maximum strength, stiffness and displacement of available constructs for distal biceps repair. Methods: A network meta-analysis was conducted to determine the relative performance of 2 all-suture suture anchors, 2 intramedullary cortical buttons, 2 suture anchors, extramedullary cortical buttons, extramedullary cortical button plus interference screw, interference screw, single intramedullary cortical button, single suture anchor, trans-osseous suture, tension slide technique and tension slide technique plus suture tape. Analysis consisted of arm-based network meta-analysis under Bayesian random-effects model with Markov Chain Monte Carlo (MCMC) sampling. Geometry of the network was represented visually via a network plot with nodes representing treatments and edges representing direct comparative evidence. Biomechanical outcomes of fixation techniques were summarized as treatment effects and their corresponding 95% confidence intervals (CI). Rank probabilities were calculated and used to generate each treatment’s surface under the cumulative ranking (SUCRA) curve. Results: A total of 21 studies were included in the network meta-analysis. For failure strength, the two intramedullary cortical buttons ranked highest (92.73%). For maximum strength, the extramedullary cortical button alone (86.96%) and extramedullary button plus interference screw (83.40%) ranked highest. The two intramedullary cortical buttons ranked highest in stiffness (98.75%), followed by the extramedullary cortical button with interference screw (88.75%) and extramedullary cortical button (75.00%). Finally, with respect to demonstrating the least displacement after loading, the two suture anchors (89.43%) ranked highest, followed by tension slide technique with suture tape (73.14%) and extramedullary cortical button (72.71%). Conclusions: The fixation constructs that demonstrated the greatest overall biomechanical performance in distal biceps tendon repair were the extramedullary cortical button and two intramedullary cortical buttons. Two suture anchors demonstrated the least displacement after loading. Figure 1. Cochrane risk of bias summary of included studies. Figure 2. Evidence networks for outcomes of failure strength (A), maximum strength (B), stiffness (C), and displacement (D). The thickness of each line connecting two nodes is proportional to how often these two interventions were compared, while the size of each node is proportional to the respective patient sample size. Figure 3. Forest plot displaying the effect difference of each intervention on (A) failure strength, (B) maximum strength, (c) stiffness, and (D) displacement.

Purpose: To evaluate the biomechanical properties of the labral suction seal in the native labrum and after rim preparation, labral augmentation, and labral reconstruction. Methods: Eight hemi-pelvises were dissected to the level of labrum and mounted for biomechanical testing. Each specimen was tested in axial distraction starting with the native labrum and then sequentially following rim preparation from 12 to 3 o'clock, labral augmentation, and segmental labral reconstruction using the iliotibial band allograft. In each condition, the specimens were compressed to 250 N and then distracted at 10 mm/s with force and displacement continuously recorded. Each test was repeated 3 times, and the mean peak force, displacement at peak force, and work were calculated. Data were reported as a percentage of the intact values to account for sex and size differences. Statistical testing was performed via a repeated-measures analysis of variance with a post hoc Tukey analysis. Results: Peak loads occurred within 2.21 to 3.11 mm of displacement. The mean peak force, displacement at peak force, and work relative to the intact condition were the following: rim preparation (91.1% +/- 8.5%, 94.4% +/- 14.3%, 93.4% +/- 23.5 %, respectively), augmentation (66.1% +/- 27.6%, 78.2% +/- 16.3%, 55.7% +/- 30.7%, respectively), and reconstruction (55.6% +/- 25.7%, 64.7% +/- 31.4%, 38.7% +/- 27.2%, respectively). There was no significant difference in peak force following the rim preparation (P = .807), but peak force was significantly decreased after augmentation and reconstruction (P = .010 and P < .001, respectively). There was no significant difference in displacement at peak force following rim preparation or augmentation (P = .936 and P = .125, respectively), but displacement at peak force was significantly decreased after reconstruction (P = .005). The work from the suction seal was significantly less in both augmentation and reconstruction states compared to the intact labrum (P = .004 and P < .001, respectively) and rim preparation (P = .017 and P < .001, respectively). Conclusions: The results show that the suction seal is not significantly changed following rim preparation. Relative to the rim preparation, labral augmentation may recreate the labral suction seal better than labral reconstruction.

Meniscal ramp lesions are disruptions of the posterior meniscotibial attachment of the medial meniscus and are commonly associated with anterior cruciate ligament injuries. However, they can be frequently missed when reviewing standard magnetic resonance imaging and difficult to treat. In this presentation, we describe our approach to repair a meniscal ramp lesion using a minimally invasive all-inside technique. We use this technique for the following surgical indications: meniscal tears involving the peripheral and meniscocapsular attachment of the posterior horn resulting in increased meniscal translation. The procedure is performed using standard arthroscopic portals along with a posteromedial portal placed using spinal needle localisation to ensure access around the lesion. Advantages of this technique include a minimally invasive repair that avoids the typical medial knee incision and dissection needed for traditional inside-out repairs, as well as direct visualisation of the repair site to ensure an appropriately tensioned anatomic repair. Technical pearls including adequate arthroscopic visualisation of the posteromedial compartment allowing the creation of a posteromedial working portal, direct passage of sutures through the edges of the ramp lesion facilitating an anatomic repair, and tensioning of the repair with arthroscopic knots to ensure restoration of the posterior horn stability are all critical to a good outcome. Furthermore, the use of two different curve directions for more displaced tears may be necessary to achieve an anatomic repair. In this case and in our experience, we use a Corkscrew SutureLasso 45° curve left for the meniscus bite and right for the capsular bite, as well as a long 8.25 mm by 70 mm twist-in cannula to accommodate the passing of insertion instrumentation in larger patients.

Anatomic posterolateral corner (PLC) reconstruction is utilized for ligamentous knee instability associated with PLC injury in patients who desire a return to active lifestyles1,2. The fibular collateral ligament (FCL) and popliteal tendon (PLT) are reconstructed in anatomic fashion according to techniques described by LaPrade et al.3-7.Description:Various PLC reconstruction techniques have been described; however, the preferred reconstruction technique of the senior author is the method developed by LaPrade et al. that restores the anatomy of the 3 primary stabilizers of the PLC, including the FCL, PLT, and popliteofibular ligament3,5,6.Alternatives:Alternative nonoperative treatments include knee immobilization for 4 weeks and physical therapy. Surgical alternatives include PLC repair, which involves repair of the lateral collateral ligament, PLT, and/or popliteofibular ligament if structures can be anatomically reduced to their attachment site. However, repair of acute grade-III PLC injuries with staged treatment of concurrent cruciate injuries is associated with a substantially higher postoperative PLC failure rate8-10.Rationale:Clinical outcomes have demonstrated that primary repairs have significantly higher rates of reoperation compared with reconstruction; therefore, reconstruction is recommended. Treatment of grade-III PLC injuries with reconstruction of midsubstance tears and any associated cruciate ligament tears results in significantly improved objective stability11. In addition, anatomic PLC reconstruction has demonstrated improved subjective and objective patient outcomes compared with nonsurgical treatment or repair5,11,12.Expected Outcomes:Reconstruction of the PLC offers excellent outcomes after surgery. Studies have shown that the fibular-based technique for treatment of a chronic isolated PLC injury showed good results in terms of clinical outcome, restoring knee varus and rotational stability13.Important Tips:Patients with associated proximal tibiofibular joint instability will benefit from this reconstruction because this technique will add stability to the joint.This surgical approach is technically demanding, requiring proficiency with surgical dissection.Damage to the common peroneal nerve can potentially occur. Careful dissection and placement of retractors should be observed.Risks include surgical failure due to unrecognized malalignment; especially in chronic cases, the patient should have a complete evaluation of the standing alignment and tibial slope12.Acronyms and Abbreviations:FCL = fibular collateral ligamentPFL = popliteofibular ligamentPLC = posterolateral cornerIT = iliotibialIKDC = International Knee Documentation CommitteeACL = anterior cruciate ligamentPCL = posterior cruciate ligamentPEEK = polyetheretherketonePROM = passive range of motion.