Posterior Labral Repair Using Knotless "All-Suture" Suture Anchors

Isolated posterior instability is well described but relatively uncommon, accounting for less than 10% of all shoulder instability cases. When nonoperative management fails, surgical outcomes demonstrate improved patient-reported outcomes with a high level of return to sport. Knotless suture anchor and "all-suture" suture anchor technology are now available and used for instability procedures in the shoulder. This technical description describes knotless "all-suture" suture anchor fixation for isolated posterior labral tears.

Effects of Lateral Opening-Wedge Distal Femoral Osteotomy on Meniscal Allograft Transplantation: A Biomechanical Evaluation

Background

Lateral meniscal deficiency with valgus malalignment increases the rate of lateral compartment osteoarthritis. Lateral meniscal allograft transplantation (LMAT) with a concomitant varus-producing opening-wedge distal femoral osteotomy (DFO) is an option yet to be evaluated biomechanically.

Purpose/Hypothesis

The purpose of this study was to clarify the biomechanical effects of the realignment procedure in the setting of LMAT. We hypothesized that (1) given the dependence of the lateral compartment on the lateral meniscus, a DFO and increasing degrees of varus would be insufficient to restore lateral compartment pressures to normal from a lateral meniscus-deficient state, and that (2) LMAT would restore lateral compartment pressures to the intact state while DFO would decrease lateral compartment pressures for any given state of the meniscus.

Study Design

Controlled laboratory study.

Methods

Ten cadaveric knees underwent opening-wedge varus-producing DFO secured by an external fixator. Anatomic alignment was standardized to 6° of mechanical valgus, and each joint was tested in full extension. Submeniscal placement of thin film pressure sensors allowed for the recording of contact pressure, peak contact pressure, and contact area. The specimens were loaded on a biaxial dynamic testing machine with loading angles between 9° valgus and 6° varus of mechanical alignment. Conditions tested included intact meniscus, meniscal deficiency, and meniscal transplantation.

Results

Isolated varus-producing DFO to 6° in the meniscus-deficient state failed to restore joint pressures and contact areas to the intact state, with significant changes in mean contact pressure (175%), mean peak contact pressure (135%), and contact area (-41%) (all P < .05 vs intact), while LMAT restored all outcome measures (all P > .05 compared with intact). After LMAT, every additional 1° of DFO correction contributed to a decrease in the mean contact pressure, peak pressure, and contact area of 5.6% (-0.0479 N/mm²), 5.9% (-0.154 N/mm²), and 1.4% (-6.99 mm²) for the lateral compartment and 7.3% (+0.034 N/mm²), 12.6% (+0.160 N/mm²), and 4.3% (+20.53 mm²) for the medial compartment, respectively.

Conclusion

Isolated DFO was inadequate to restore load distribution in meniscus-deficient knees, while concomitant LMAT restored near normal forces and improved the lateral compartment biomechanical profile.

Clinical Relevance

Our findings support the concomitant use of LMAT and varus-producing DFO in the setting of lateral meniscal deficiency with valgus malalignment. This study provides tools for the orthopaedic surgeon to individualize the correction for each patient.

Meniscus Size Differs Between Patient and Donor Populations for Meniscus Allograft Transplantation

Purpose

To determine the extent of variability in meniscus size and anthropometric data between donors (supply) and patients (demand), to evaluate potential factors that may contribute to size discrepancies, and to determine whether the discrepancies lead to longer patient wait times.

Methods

Lateral and medial meniscal measurements, anthropometric data, and time to match a donor graft were extracted from a tissue supplier database. The frequency and distribution of meniscus size were analyzed. Body mass index (BMI), relative meniscus area, body mass to meniscus area index, and height to meniscus area index were compared between patient and donor pools via χ² tests and independent samples t-test. The effect of size on time to match was analyzed using analysis of variance and post-hoc Tukey test.

Results

The lateral meniscus patient population showed a greater frequency of larger size requirements compared to the donor population (P < .001) and the medial meniscus patient population showed a higher frequency of smaller meniscus size requirements (P < .001). The medial meniscus analysis showed significantly smaller meniscus areas (P < .001) in the patient population contributing to the observed trend of an increased body mass to meniscus area index and height to meniscus area index. The time to match a donor meniscus was affected by the patient meniscus size.

Conclusions

This analysis demonstrates variations in frequency of meniscus sizes between donor and patient populations. This variation is attributed to differences in anthropometric data between patient and donor populations. This work identifies a mismatch between demand and supply for certain patient sizes contributing to longer times to match.

Clinical Relevance

This work associated donor and patient mismatches with longer wait times. This can be useful for patient counseling as well as provide a framework to determine whether there are solutions within the current meniscus donor pool that can be used to meet this clinical need.

Potential causal role of synovial complement system activation in the development of post-traumatic osteoarthritis after anterior cruciate ligament injury or meniscus tear

Anterior cruciate ligament (ACL) injury and meniscal tear (MT) are major causal factors for developing post-traumatic osteoarthritis (PTOA), but the biological mechanism(s) are uncertain. After these structural damages, the synovium could be affected by complement activation that normally occurs in response to tissue injury. We explored the presence of complement proteins, activation products, and immune cells, in discarded surgical synovial tissue (DSST) collected during arthroscopic ACL reconstructive surgery, MT-related meniscectomy and from patients with OA. Multiplexed immunohistochemistry (MIHC) was used to determine the presence of complement proteins, receptors and immune cells from ACL, MT, OA synovial tissue vs. uninjured controls. Examination of synovium from uninjured control tissues did not reveal the presence of complement or immune cells. However, DSST from patients undergoing ACL and MT repair demonstrated increases in both features. In ACL DSST, a significantly higher percentage of C4d+, CFH+, CFHR4+ and C5b-9+ synovial cells were present compared with MT DSST, but no major differences were seen between ACL and OA DSST. Increased cells expressing C3aR1 and C5aR1, and a significant increase in mast cells and macrophages, were found in ACL as compared to MT synovium. Conversely, the percentage of monocytes was increased in the MT synovium. Our data demonstrate that complement is activated in the synovium and is associated with immune cell infiltration, with a more pronounced effect following ACL as compared to MT injury. Complement activation, associated with an increase in mast cells and macrophages after ACL injury and/or MT, may contribute to the development of PTOA.

Rate of Conversion to Matrix-Induced Autologous Chondrocyte Implantation After a Biopsy: A Multisurgeon Study

Background

Autologous chondrocyte implantation (ACI) and matrix-induced autologous chondrocyte implantation (MACI) are performed to treat focal chondral defects (FCDs); both are 2-step procedures involving a biopsy, followed by transplantation. There is little published research evaluating ACI/MACI in patients who undergo a biopsy alone.

Purpose

To determine (1) the value of ACI/MACI cartilage biopsies and concomitant procedures in patients with FCDs of the knee and (2) the conversion rate to cartilage transplantation as well as the rate of reoperation.

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective review was performed of 46 patients (63% female) who underwent a MACI (or ACI) biopsy between January 2013 and January 2018. Preoperative data, intraoperative data, and postoperative outcomes were assessed at a minimum of 2 years after the biopsy. The conversion rate from a biopsy to transplantation and the reoperation rate were calculated and analyzed.

Results

Among the 46 patients included, 17 (37.0%) underwent subsequent surgery, with only 12 undergoing cartilage restoration surgery, for an overall transplantation rate of 26.1%. Of these 12 patients, 9 underwent MACI/ACI, 2 underwent osteochondral allograft transplantation (OCA), and 1 underwent particulated juvenile articular cartilage implantation at 7.2 ± 7.5 months after the biopsy. The reoperation rate was 16.7% (1 patient after MACI/ACI and 1 patient after OCA) at 13.5 ± 2.3 months after transplantation.

Conclusion

Arthroscopic surgery with debridement, chondroplasty, loose body removal, meniscectomy/meniscal repair, and other treatment approaches of knee compartment abnormalities at the time of a biopsy appeared to be sufficient in improving function and reducing pain in patients with knee FCDs.

Predictors of Bone Loss in Anterior Glenohumeral Instability

BACKGROUND

Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis.

HYPOTHESIS/PURPOSE

The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects.

RESULTS

Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher.

CONCLUSION

An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes.

REGISTRATION

NCT02075775 (ClinicalTrials.gov identifier).

Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone-Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis

PURPOSE

To systematically review the literature in order to compare the efficacy and safety of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and hyaluronic acid (HA) injections for the treatment of knee osteoarthritis (OA).

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I studies that compared the clinical efficacy of at least 2 of the following 3 injection therapies: PRP, BMAC, and HA for knee OA. The search phrase used was knee AND osteoarthritis AND randomized AND ("platelet rich plasma" OR "bone marrow aspirate" OR "hyaluronic acid"). Patients were primarily assessed based on patient-reported outcome scores (PROs) including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) score.

RESULTS

Twenty-seven studies (all Level I) met inclusion criteria, including 1,042 patients undergoing intra-articular injection(s) with PRP (mean age 57.7 years, mean follow-up 13.5 months), 226 patients with BMAC (mean age 57.0 years, mean follow-up 17.5 months), and 1,128 patients with HA (mean age 59.0 years, mean follow-up 14.4 months). Non-network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p < 0.01), and Subjective IKDC scores (p < 0.001) in PRP patients when compared to HA patients. Similarly, network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p = 0.03), and Subjective IKDC (p < 0.001) scores in BMAC patients when compared to HA patients. There were no significant differences in post-injection outcome scores when comparing PRP to BMAC.

CONCLUSION

Patients undergoing treatment for knee OA with PRP or BMAC can be expected to experience improved clinical outcomes when compared to HA patients.

LEVEL OF EVIDENCE

I, Meta-Analysis of Level I studies.

Physical Therapy for the Treatment of Shoulder Instability

Shoulder instability is the separation of the humeral head from the glenoid. Injury to the static and dynamic stabilizers can result in instability. Anterior shoulder instability is the predominant form of instability. It is usually a result of trauma. Posterior shoulder instability often presents with an insidious onset of pain. Multidirectional instability of the shoulder is symptomatic laxity in more than one plane of motion. The primary goal of rehabilitation is to restore pain-free mobility, strength, and functioning. Rehabilitation implements range of motion and strengthening exercises to restore proprioceptive control and scapular kinematics.

Left Knee Open Rectus Femoris Repair With Achilles Allograft Augmentation: A Case Report

CASE

We present a case of a 48-year-old man with a subacute tear of his left rectus femoris, repaired using Achilles tendon allograft. After fixation distally to the patella using suture anchors and a Krackow suture technique, the allograft was fixed proximally to the remnant rectus femoris tendon with multiple sutures in a variety of stitch configurations. The patient recovered excellently, regaining near-normal flexion and an intact straight leg raise without an extensor lag.

CONCLUSION

The literature regarding repair of subacute and chronic rectus femoris ruptures is limited. We provide an additional option for operative repair of subacute and chronic ruptures using Achilles tendon allograft.

Incorporating Biologics Into Your Sports Medicine Practice: Who, What, When, Why, and How?

Orthobiologic techniques can be used in the treatment of a variety of sports medicine pathologies, using an evidence-based approach focused on the value of all available approaches. The orthopaedic surgeon should be aware of the indications for and any technical pearls and pitfalls related to the use of orthobiologic agents as treatment for, or as an adjunct to management of, common sports medicine injuries and pathologies. Expected outcomes, including return to sport/activity, as well as potential complications and how to avoid them, should be considered. Although promising results have been reported, significant lack of high-level studies, inconsistent findings, and variability among current research make it challenging to reach a definitive conclusion about application, target populations, and overall effectiveness.

Surgeon variation in glenoid bone reconstruction procedures for shoulder instability

BACKGROUND

Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice.

METHODS

A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice.

RESULTS

All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss.

CONCLUSIONS

Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

Osteochondral Allograft Transplantation

Background:

Articular cartilage lesions are a significant cause of morbidity and impaired knee function, and attempts to surgically repair damaged cartilage have failed to reliably reproduce native cartilage. Thus, osteochondral allograft transplantation is an effective one-step procedure to repair large cartilage defects.

Indications:

Osteochondral allograft transplantation is indicated for young active patients with large focal defects, those with a history of previous cartilage repair, and those with cartilage-related degenerative disorders such as osteonecrosis, osteochondritis dissecans, and/or post-traumatic osteochondral defects.

Technique Description:

In short, after the focal chondral defect is identified, a socket is created with specific dimensions in depth and diameter. The donor cartilage is then secured in a graft station, and a sizing guide is placed through a bushing to confirm the allograft harvest location. Using stabilization from the graft station arm, a coring reamer is then advanced through the donor cartilage, and a saw is used to allow for easy removal of the graft from the donor condyle. The plug is then fashioned to fit the exact dimensions of the socket created earlier in the procedure. A cut on the donor plug is made to fashion the plug to the appropriate depth. A rongeur is used to make the plug more bullet shaped at the end to allow the plug to enter the socket more easily. Small holes are then drilled into the base of the socket to help promote incorporation of the plug into the socket during the healing process. After the socket is irrigated, the plug is then placed into the socket, and a tamp is used to gently tap the cartilage until it is flush with the surrounding surface.

Results:

After an appropriate rehabilitation protocol is followed for up to 10 months postoperatively, osteochondral allograft transplantation allows for near-to-complete restoration of patient functionality and strength, with return to full activity possible within 1 year.

Conclusion:

Acute repair of large focal chondral defects is effective in restoring knee strength and functionality and is associated with high patient satisfaction. 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.

Pectoralis Major Tendon Repair: Transosseous Suture Technique

Background:

Pectoralis major ruptures are rare injuries that occur in young men between 20 and 40 years of age, typically during resistance training in the eccentric phase of muscle contraction. As the incidence of these ruptures increases with increasing activity levels and use of anabolic steroids, it is important to understand effective repair techniques.

Indications:

Repair of the ruptured pectoralis major tendon is indicated for young, active patients seeking to regain full functionality of the affected upper extremity.

Technique Description:

In short, after the pectoralis major is identified, the insertion site is revealed just lateral to the biceps tendon. The site for the bone trough is then exposed through cauterization of superficial tissue, and a cortical bone trough is drilled vertically using a small round burr. The location of 3 pilot holes is identified just lateral to the cortical bone trough, and then the holes are drilled to allow for placement of the anchors later in the procedure. The tendon itself is then identified, and sutures are placed in the bulk of the muscle tendon in a Krackow fashion. After the tendon is properly sutured, it is placed under tension to test the structural integrity of the suture pattern and ensure proper load capacity. The sutures are then passed through the pilot holes, the tendon is pulled down into the trough, and the sutures are tied down to the bone.

Results:

After an appropriate rehabilitation protocol is followed for up to 6 months postoperatively, the transosseous suture technique in the context of pectoralis major tendon repairs allows for adequate tissue to bone healing and near-complete restoration of patient functionality and strength.

Conclusion:

Acute repair of pectoralis major tendon tears using a transosseous suture technique is effective in restoring upper extremity strength and functionality and is associated with high patient satisfaction. 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.

Latissimus Dorsi Tendon Repair

Background:

Latissimus dorsi tendon ruptures are rare injuries that can occur in overhead or throwing motions and are almost always sports related.

Indications:

Latissimus dorsi tendon ruptures are largely treated nonoperatively, although surgical repair is indicated for the young active patient looking to return to a high level of sport and for those with complete avulsion injuries or mid-substance tendon tears.

Technique Description:

Depending on the degree of tendon retraction, anteroinferior or posteroinferior axillary incision is made. After the tendon is mobilized, sutures are placed in a Krackow fashion through the bulk of the tendon, and the tendon footprint is prepared by gently decorticating the surface of the humerus, just anterior and inferior to the teres major insertion point. Two Arthrex Pec Buttons are then loaded into the superior and inferior limbs of the suture tape and 2 unicortical holes are drilled into the footprint of the insertion site. The superior button is placed first and then tensioned to allow the latissimus dorsi to be pulled to the bone. Next, the second button is placed, though this is not tensioned until later at the time of the biceps tenodesis. Finally, the procedure is visualized and well inspected to ensure appropriate location of the tendon and securing hardware.

Results:

After an appropriate rehabilitation protocol is followed for up to 6 months postoperatively, acute repair of a ruptured latissimus dorsi tendon allows for near to complete restoration of patient functionality and strength, with return to full activity possible within 6 to 8 months.

Conclusion:

Surgical repair of a ruptured latissimus dorsi tendon is effective in restoring upper extremity strength and functionality and is associated with high patient satisfaction. 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.

In-Office Diagnostic Needle Arthroscopy Using the NanoScope™ Arthroscopy System

Diagnostic needle arthroscopy performed in office is a safe and cost-effective method for accurate evaluation of intra-articular pathology, improving clinical decision making. This minimally invasive approach is an effective alternative to traditional diagnostic techniques of diagnostic surgical arthroscopy and magnetic resonance imaging (MRI). Needle arthroscopy is considered low-risk, with an extremely low complication rate when performed with appropriate technique and indications. The purpose of this article is to describe an approach to an in-office diagnostic procedure using a needle arthroscopy system.

Sex-Based Differences in Adult ACL Reconstruction Outcomes

PURPOSE OF REVIEW

In the setting of ever improving outcomes following anterior cruciate ligament (ACL) reconstruction, both objectively and subjectively, there remains continued interest in better understanding the differences in outcomes between male and female patients. The current review investigates the recent literature surrounding the roles of biological sex in adult ACL reconstruction outcomes.

RECENT FINDINGS

Within the past five years, the most prominent and recurrent difference between male and female patient cohorts is the subjective report of pain and function. Female patients have been consistently shown to have worse self-reported outcomes following ACL reconstruction. Specific and quantifiable subjective outcomes that are highlighted include the International Knee Documentation Committee (IKDC) subjective score, the Knee injury and Osteoarthritis Outcome Score (KOOS), and patient-acceptable symptom state (PASS). Current research on the topic of biological sex-based differences in ACL reconstruction outcomes can be divided into four main categories: patient-reported subjective outcomes; physical assessment and gait analysis; kinematics; and rates of reinjury, revision, and contralateral reconstruction. This chapter provides a summary of recent literature focused on these four main areas of interest related to ACL reconstruction outcomes in males and females.

Predictors of Mid- to Long-Term Outcomes in Patients Experiencing a Knee Dislocation: A Systematic Review of Clinical Studies

Knee dislocations (KDs) are devastating injuries for patients and present complex challenges for orthopaedic surgeons. Although short-term outcomes have been studied, there are few long-term outcomes of these injuries available in the literature. The purpose of this study is to determine factors that influence mid- to long-term clinical outcomes following surgical treatment of KD. A review of the current literature was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies published from 2010 to 2019 with a minimum 2-year follow-up that reported outcomes following surgical treatment of KDs. Ten studies (6 level III, 4 level IV) were included. At mid- (2-10 y) to long-term (>10 y) follow-up, concomitant arterial, cartilage, and combined meniscus damage were predictive factors for inferior Lysholm and International Knee Documentation Committee (IKDC) scores when compared with patients without these associated injuries. Although concomitant neurological damage may influence short-term outcomes due to decreased mobility, at longer follow-up periods it does not appear to predict worse clinical outcomes when compared with patients without concomitant neurological injury. Frank and polytrauma KDs have been associated with worse mid- to long-term outcomes when compared with transient and isolated KDs. Patients who underwent surgery within 6 weeks of trauma experienced better long-term outcomes than those who underwent surgery longer than 6 weeks after the initial injury. However, the small sample size of this study makes it difficult to make valid recommendations. Lastly, female sex, patients older than 30 years at the time of injury and a body mass index (BMI) greater than 35 kg/m² are factors that have been associated with worse mid- to long-term Lysholm and IKDC scores. The results of this review suggest that female sex, age >30 years, BMI >35 kg/m², concomitant cartilage damage, combined medial and lateral meniscal damage, KDs that do not spontaneously relocate, and KDs associated with polytrauma may predict worse results at mid- to long-term follow-up.

Recommended Musculoskeletal and Sports Ultrasound Terminology: A Delphi-Based Consensus Statement

OBJECTIVES

The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus was developed to provide a reference to improve clarity and consistency in communication.

METHODS

A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%.

RESULTS

Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein.

CONCLUSIONS

The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Platelet-Rich Plasma Versus Hyaluronic Acid for Hip Osteoarthritis Yields Similarly Beneficial Short-Term Clinical Outcomes: A Systematic Review and Meta-analysis of Level I and II Randomized Controlled Trials

PURPOSE

To systematically review the literature to compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) injections for the treatment of hip osteoarthritis (OA).

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that compared the clinical efficacy of PRP and HA injections for hip OA. The search phrase used was hip, osteoarthritis, platelet-rich plasma, hyaluronic acid, randomized. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Visual Analog Scale (VAS) for pain, and the Harris Hip Score (HHS). Subanalyses were performed for any outcome score in which ≥3 studies reported results.

RESULTS

Six studies (5 level I, 1 level II) met inclusion criteria, including 211 patients undergoing intra-articular injection with PRP (mean age 60.0 years, mean follow-up 12.2 months) and 197 patients with HA (mean age 62.3 years, mean follow-up 11.9 months). No significant differences were found in the weighted improvement of any outcome score (WOMAC, VAS, or HHS) from preinjection to postinjection between groups. When excluding a study with the highest risk of bias to eliminate heterogeneity, pooled subanalysis demonstrated no significant differences in WOMAC subscores between PRP and HA groups. Similarly, in a pooled subanalysis that isolated patients treated with leukocyte-poor PRP, no significant differences in WOMAC subscores were found between PRP and HA groups.

CONCLUSION

Patients undergoing treatment for hip OA with either PRP or HA injections can expect to experience similarly beneficial short-term clinical outcomes.

LEVEL OF EVIDENCE

II, systematic review of level I and II studies.

SpeedBridge Knotless Double-Pulley Rotator Cuff Repair

Rotator cuff tears remain a common injury, and may require rotator cuff repair, one of the most frequently performed orthopaedic procedures. Achieving an ideal construct during rotator cuff repair is crucial, and while many techniques exist to accomplish this, they are continuously evolving to improve stability and biomechanics of the repaired shoulder. Improving efficiency of the procedure alongside the increasing complexity of innovative techniques remains of the utmost importance. The double-pulley SpeedBridge technique achieves medial fixation in a double-row, transosseus-equivalent repair, and the knotless nature of the technique creates for a low-profile construct and improves overall efficiency. The purpose of this Technical Note is to describe a reproducible and efficient approach to arthroscopic rotator cuff repair using the SpeedBridge knotless double-pulley technique.

Shoulder Surgery as an Effective Treatment for Shoulder-Related Sleep Disturbance: A Systematic Review

PURPOSE

The purpose of this systematic review is to evaluate the current literature in an effort to investigate sleep quality and disturbances and the association with clinical outcomes of patients undergoing shoulder surgery.

METHODS

A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to PRISMA guidelines. All English-language literature reporting clinical outcomes and sleep quality and disturbance after shoulder surgery was reviewed by 2 independent reviewers. Outcomes assessed included patient-reported outcomes (PROs) and sleep quality. Specific PROs included the Pittsburgh Sleep Quality Index (PSQI), Visual Analog Scale (VAS) for pain, Simple Shoulder Test (SST), University of California Los Angeles (UCLA) Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Score (ASES). Study methodology was assessed using the Modified Coleman Methodology Score. Descriptive statistics are presented.

RESULTS

Sixteen studies (11 level IV, 2 level III, 3 level II) with a total of 2748 shoulders were included (age, 12-91 years; follow-up, 0.25-132 months). In total, 2198 shoulders underwent arthroscopic rotator cuff repair (RCR), 131 shoulders underwent arthroscopic capsular release, 372 shoulders underwent total shoulder arthroplasty (TSA), 18 shoulders underwent comprehensive arthroscopic management, and 29 shoulders underwent sternoclavicular joint procedures. All shoulder surgeries improved self-reported sleep and PROs from before to after surgery. In RCR patients, PSQI scores were significantly associated with VAS scores, SST scores (r = 0.453, r = -0.490, P < .05, respectively), but not significantly associated with UCLA Shoulder rating scale or the ASES scores (r = 0.04, r = 0.001, P > .05, respectively). In TSA patients, PSQI scores were significantly associated with ASES scores (r = -0.08, P < .05). All 4 RCR studies and 1 TSA study using PSQI found significant improvements in mean PSQI scores within 6 to 24 months (P < .05).

CONCLUSIONS

Surgical intervention for rotator cuff tear and glenohumeral osteoarthritis significantly improves self-reported sleep in patients with shoulder pain. However, there remains a dearth of available studies assessing the effects of surgical intervention for adhesive capsulitis, sternoclavicular joint instability, and sternoclavicular osteoarthritis on sleep. Future studies should use sleep-specific PROs and quantitative measures of sleep to further elucidate the relationship between sleep and the effect of shoulder surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Shoulder Stabilization Versus Immobilization for First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-analysis of Level 1 Randomized Controlled Trials

BACKGROUND

Multiple studies have compared redislocation rates after stabilization and immobilization for patients experiencing a traumatic, first-time anterior shoulder dislocation (ASD).

PURPOSE

To systematically review the literature to compare rates of recurrent instability and subsequent instability surgery in patients undergoing treatment for a first-time ASD with surgical stabilization versus shoulder immobilization.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 randomized studies that compared outcomes of surgical stabilization versus immobilization for treatment of primary ASD. The following search phrase was used: (glenohumeral OR anterior shoulder) AND (conservative OR nonoperative OR nonsurgical OR physiotherapy) AND (Bankart OR repair OR stabilization OR surgical OR surgery OR arthroscopic OR arthroscopy) AND (instability OR dislocation). Patients with soft tissue disruption alone as well as those with additional minor bony lesions (Hill-Sachs, Bankart) were included. Recurrent instability and subsequent instability surgery rates, the Western Ontario Shoulder Instability Index (WOSI), and range of motion were evaluated.

RESULTS

A total of 5 studies met inclusion criteria, including 126 patients undergoing surgical stabilization (mean age, 23.6 years; range, 15.0-39.0 years) and 133 patients undergoing treatment with sling immobilization only (mean age, 23.1 years; range, 15.0-31.0 years). Mean follow-up was 59.7 months. Overall, 6.3% of operative patients experienced recurrent instability at latest follow-up compared with 46.6% of nonoperative patients (P < .00001). Similarly, 4.0% of operative patients underwent a subsequent instability surgery compared with 30.8% of nonoperative patients (P < .00001). These same trends were demonstrated when data were isolated to nonoperative patients immobilized in internal rotation. When comparing the operative and nonoperative groups at latest follow-up, 1 study found significantly improved WOSI scores among operative patients (P = .035) and 1 study found significantly improved abducted external rotation in nonoperative patients (P = .02).

CONCLUSION

Patients, particularly active men in their 20s and 30s, undergoing treatment for a first-time ASD with a surgical stabilization procedure can be expected to experience significantly lower rates of recurrent instability and a significantly decreased need for a future stabilization procedure when compared with patients treated nonoperatively.