Adding Lateral Retinacular Release to Medial Patellofemoral Ligament Reconstruction Fails to Demonstrate Clinical Benefit Compared With Isolated Medial Patellofemoral Ligament Reconstruction.

Purpose: To compare functional outcomes and failure rates between medial patellofemoral ligament (MPFL) reconstructions with and without lateral retinacular release (LRR) at minimum 1-year follow up. Methods: A retrospective review identified consecutive patients from 2013 to 2019 at a single center who met all of the following inclusion criteria: at least 1 confirmed patellar dislocation, patellar tilt (evidenced by tight retinaculum on operative examination or patellar tilt on radiographs), underwent either MPFL reconstruction alone or combined with LRR, had available preoperative documentation and imaging, and were at least 1 year out of surgery. Patients were excluded if they had previous surgery to the ipsilateral limb or had any concomitant procedure performed. Demographics and preoperative imaging were evaluated. Failure rates and functional outcome scores were obtained including Kujala, Patient-Reported Outcomes Measurement Information System, International Knee Documentation Committee, Single Assessment Numeric Evaluation, and Knee injury and Osteoarthritis Outcome Scores. Clinical failure was defined as revision MPFL reconstruction on the affected knee or at least 1 instance of postoperative patellar dislocation. Results: A total of 18 patients underwent isolated MPFL reconstruction (mean follow-up = 29.3 ± 8.3 months, range = 15.1-42.8 months), and 31 underwent MPFL reconstruction combined with LRR (mean follow up = 36.0 ± 11.3 months, range = 14.0-51.9 months). At final follow-up, there were no statistical differences between the isolated MPFL and MPFL combined with LRR cohorts for any of the functional outcome scores (P > .05 for all). At the time of final follow-up, no patients who underwent isolated MPFL and 19.3% (n = 6) or patients undergoing MPFL combined with LRR experienced clinical failure (P = .073), as defined by subsequent patellar dislocation or revision MPFL reconstruction. Of these, 2 patients underwent revision MPFL reconstructions with distal tubercle transfer for borderline abnormal TT:TG (i.e., >15 mm). Conclusions: MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up. In addition, there were no differences in rates of achieving MCID between both groups. Level of Evidence: Level III, retrospective cohort study.

Occupational and Functional Outcomes following Patellofemoral Arthroplasty in U.S. Military Servicemembers.

The functional outcomes in patients undergoing patellofemoral arthroplasty (PFA) with high occupational demands have not been fully examined. This study assessed return to work and conversion to TKA rates following PFA in a young, military cohort. Patient demographics, pain scores, and surgical information were retrospectively collected for all active-duty military members who underwent PFA over a 4-year period. The data were then analyzed to calculate return to work, conversion to TKA, and perioperative complications rates. A total of 48 servicemembers with 60 total PFAs (36 unilateral, 12 bilateral) were included, with a mean follow up of 2.2 years. At the final follow-up, 83% of servicemembers returned to military service or completed their service obligation after PFA. Conversion to TKA occurred in three (6.2%) patients at an average of 2.4 years after PFA, resulting in a PFA annual revision rate of 2.3%. The mean numeric rating scale for pain improved from 4.9 ± 2.6 at baseline to 2.5 ± 2.0 postoperatively (p < 0.001). Servicemembers with at least one prior ipsilateral knee procedure had a significantly decreased odds ratio (OR) for both occupational outcome failure (OR, 0.03; 95% confidence interval [CI], 0-0.29) and overall failure (OR, 0.13; 95% CI, 0.02-0.78). At an average of 2 years following PFA, 83% of military members returned to duty, with a low rate of revision to TKA. Prior ipsilateral knee procedure decreased the probability of medical separation. LEVEL OF EVIDENCE: IV.

Outcomes of Open Versus Arthroscopic Treatment of HAGL Tears.

BACKGROUND: Lesions that involve humeral avulsions of the glenohumeral ligament (HAGLs), although less common, are primary contributors to recurrent events of dislocation and subluxation of the glenohumeral joint. PURPOSE: To describe the clinical presentation, examination, and surgical outcomes of patients presenting with HAGL lesions who underwent repair using an arthroscopic or open technique. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter retrospective review of prospectively collected data was performed of skeletally mature patients without glenohumeral arthritis who presented with HAGL lesions and subsequently underwent arthroscopic or open repair between 2005 and 2017. Independent variables included patient characteristics, clinical presentation, physical examination findings, and arthroscopic findings. Dependent variables included pre- and postoperative Single Assessment Numeric Evaluation (SANE) score, Western Ontario Shoulder Instability Index (WOSI) score, and range of motion outcomes. RESULTS: Eighteen patients diagnosed with a HAGL lesion who underwent primary arthroscopic repair (n = 7) or open repair (n = 11) were included. There were 17 male patients and 1 female patient with a mean age of 24.9 years (range, 16-38 years). Mean follow-up duration was 50.9 months (range, 24-160 months). Seventeen patients (94.4%) reported pain as the most common symptom, and 7 (38.9%) reported sensation of instability. Scores significantly improved from pre- to postoperative for the arthroscopic and open groups (P < .001): SANE (mean ± SD; arthroscopic, 30.7 ± 15.7 to 92.1 ± 12.2; open, 45.5 ± 8.50 to 90.7 ± 5.24) and WOSI (arthroscopic, 51.4 ± 11.4 to 2.49 ± 3.70; open, 45.5 ± 7.37 to 11.5 ± 5.76). The magnitude of improvement in SANE scores was significantly higher for patients treated arthroscopically (Δ60.0; open, Δ46.5; P = .012). Postoperative WOSI scores were also significantly better in the arthroscopic cohort (2.49 ± 3.70; open, 11.5 ± 5.76; P = .00094). CONCLUSION: Symptomatic HAGL tears present primarily with pain as opposed to instability, necessitating a high index of suspicion for injury. The tears may be treated successfully with an arthroscopic or open technique with significant improvements in patient-reported outcomes and stability.

Rates of Anterior Cruciate Ligament Rerupture in Adolescent Patients with and without Patella Alta.

The objective of this study was to compare rates of anterior cruciate ligament (ACL) failure among adolescent patients to evaluate patella alta as a high-risk variable. Demographic and surgical data were retrospectively queried for patients ≤18 years of age with primary ACL reconstruction performed at a single academic center between 2011 and 2016 and minimum of 2-year clinical surveillance. Patellar height indices, including Caton-Deschamps index (CDI) and Insall-Salvati index (ISI), were retrospectively calculated from preoperative imaging to assess the presence of patella alta. Failure was defined as (1) ACL graft rerupture, (2) Lachman's grade 2 + , (3) presence of pivot shift, and (4) side-to-side difference of 3 mm on KT-1000 arthrometer. A total of 184 patients (84 females and 100 males) and 192 knees were identified, with an average age of 16.2 ± 1.8 years. Of these, 30 (15.63%) experienced ACL failure. Male sex was the only significant risk factor for rerupture (p = 0.026). The mean CDI was 1.06 ± 0.17 and mean ISI was 1.04 ± 0.15. Of the 49 knees that met criteria for patella alta on radiographic evaluation, rerupture occurred in seven (14.29%). Patella alta was not a significant risk factor for ACL failure among adolescent patients (p = 0.359 and 0.277). Only male sex was associated with increased rates of ACL failure. Age, graft selection technique, fixation construct, and presence of patella alta were not risk factors for reinjury. This study is a therapeutic case series and reflects level of evidence IV.

Senior Military Rank Is Associated With Higher Rates of Return to Running and Unrestricted Activity Among Military Servicemembers After Surgical Repair of Patellar Tendon Rupture at 1-Year Follow-up.

Purpose: To evaluate 1-year outcomes in active-duty servicemembers who underwent patellar tendon rupture repair and to identify baseline variables associated with return to activity. Methods: We performed a retrospective review of all active-duty servicemembers undergoing primary patellar tendon rupture repair between 2009 and 2014. All patients had a minimum 12-month follow-up. Demographic variables were recorded, as well as ability to return to impact activities and remain on active-duty status. Rates of recurrent rupture and revision surgery were identified. Univariate analysis was performed to assess relations between outcomes and baseline variables. Results: A total of 123 patients met the inclusion criteria (average age, 33.5 ± 6.6 years; 99% male patients) with a mean follow-up period of 4.3 ± 2.2 years. Whereas 67.4% of patients returned to running at an average of 8.3 months from index surgery, only 42.4% of patients resumed unrestricted occupational function. Higher rates of return to running were observed among patients with senior military rank (P = .046). Senior military rank was also associated with a higher rate of return to unrestricted active-duty status (P = .006). Logistic regression analysis showed an association between postoperative pain (odds ratio [OR], 0.684; 95% confidence interval [CI], 0.56-0.84; P < .001) and return to running, between postoperative pain (OR, 0.77; 95% CI, 0.60-0.98; P = .033) and return to active duty, and between rank (OR, 2.06; 95% CI, 1.04-4.07; P = .037) and return to active duty. Patients who sustained injuries during deployment had a higher rate of recurrent rupture (26.1% vs 9.3%, P = .028). Conclusions: At 1-year follow-up, approximately two-thirds of military servicemembers undergoing primary patellar tendon repair had returned to running after surgery, whereas fewer than one-half returned to full military duty. Younger age and more senior military rank were associated with higher rates of return to running. Additionally, servicemembers of higher rank, particularly officers, had statistically higher rates of return to unrestricted activity. Level of Evidence: Level IV, therapeutic case series.

Occupational Outcomes and Revision Rates for Medial Unicondylar Knee Arthroplasty in U.S. Military Servicemembers.

This study evaluates return to work and revision rates for medial unicondylar knee arthroplasty (UKA) in a high-demand military cohort. Patient demographic and clinical variables were isolated from the medical records of active-duty military servicemembers with at least 2 years of postoperative follow-up and correlated with return to work, medial UKA survivorship, and perioperative complications. The medial UKA annual revision rate was calculated as the percentage of implants revised per observed component year. A total of 39 servicemembers underwent 46 primary medial UKAs (32 unilateral and 7 bilateral) with a mean follow-up of 3.9 (2.0-6.6) years. At a minimum of 2 years postoperatively, 33 (85%) servicemembers returned to military service or successfully completed their service obligation. Older servicemembers (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.45, 0.99) had a significantly decreased OR for knee-related medical separation. Nine servicemembers (20%) had conversion to TKA at an average of 2.4 (range, 0.6-5.6) years with a medial UKA annual revision rate of 5%. When compared with Navy/Air Force, Army/Marine servicemembers had an increased TKA conversion rate (OR = 5.40; 95% CI: 1.13, 25.81). Older age decreased the likelihood of medical separation and Army/Marines service was the sole risk factor associated with conversion to TKA. The level of evidence is IV, therapeutic case series.

Editorial Commentary: The Evolution of Regional Anesthesia in Arthroscopic Rotator Cuff Repair: From Throbbing Shoulders to Paralyzed Diaphragms.

Rotator cuff repair may result in significant postoperative pain. Although opioids were once the gold standard, addiction and other side effects are of significant concern. Nonsteroidal anti-inflammatory drugs reduce pain, sleep disturbance, and need for opioids, but they may impair soft tissue healing. The use of gabapentinoids is equivocal. Intralesional analgesia carries a risk of glenohumeral chondrolysis. Cryotherapy is beneficial, but it is often not covered by insurance companies. Suprascapular nerve block addresses innervation of only 70% versus interscalene block, but the latter has a higher incidence of unintended, temporary motor and sensory deficits of the upper extremity and hemidiaphragmatic paresis, despite similar pain scores. Although neurodeficits and diaphragmatic hemiparesis resolve by 3 weeks, temporary complications affect length of hospital stay, initiation of physical therapy, and patient satisfaction. These variables contribute to the challenge of postoperative pain control amid a growing wave of modalities aimed at improving the extent and duration of patient-focused analgesia, especially the application of continuous block infusions.

Cartilage Restoration of Bipolar Lesions Within the Patellofemoral Joint Delays Need for Arthroplasty: A Systematic Review of Rates of Failure.

PURPOSE: The purpose of the present review is to systematically review the available literature for failure rates and complications of cartilage restoration of bipolar chondral defects in the patellofemoral (PF) joint to assess the ability to treat these lesions without arthroplasty. METHODS: PubMed and MEDLINE databases were queried between 2000 to 2020 using the keywords "osteochondral" and "knee" and "microfracture," "autologous chondrocyte implantation (ACI)," or "transplantation." Patient selection included patients with bipolar chondral lesions of the patellofemoral joint that were treated with cartilage restoration procedures. Treatment of PF joints were reviewed for surgical indications/technique, rates of failure, defect characteristics, and time to failure. For the purposes of this study, failure was defined by each individual author on their respective studies. RESULTS: After screening 1,295 articles, there were 8 publications analyzed quantitatively and 10 articles analyzed both quantitatively and qualitatively. A total of 249 knees involved bipolar lesions of the patellofemoral joint. The weighted average age was 36.5 ± 10.4 years, and weighted average follow-up was 89.0 ± 31.7 months. There were failures in 0% to 50% of cases, revision procedures in 0% to 10% of cases, conversion to arthroplasty in in 0% to 50% of cases, and unsatisfactory outcome without revision in 0% to 8.3% of cases. The range in average failure rate was 0% to 50.0% (I2 = 68.0%), whereas the range in average time to failure was 2.9 to 6.8 years (I2 = 79.0%). CONCLUSION: From the available data, established cartilage restoration procedures may provide favorable patient-reported function, avoidance of secondary surgery, and joint preservation in at least 80% of patients at short- to mid-term follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Cartilage Restoration for Tibiofemoral Bipolar Lesions Results in Promising Failure Rates: A Systematic Review.

PURPOSE: The purpose of the present study is to systematically review the available literature for management of bipolar lesions within the tibiofemoral joint and determine whether tibiofemoral cartilage restoration is an effective treatment modality. METHODS: PubMed and MEDLINE databases were queried between 2000 and 2020 using the following keywords: "osteochondral" and "knee" and "microfracture," "autologous chondrocyte implantation (ACI)," or "transplantation." Articles were reviewed for the presence of a bipolar or "kissing" tibiofemoral lesion and reported lesion size, concomitant procedures, failure rates, and time to failure. RESULTS: After screening 1,295 articles, there were 4 articles available for analysis and a total of 152 knees involving the management of bipolar tibiofemoral lesions. Age ranged from 14 to 60 years, and mean follow-up was between 12 and 240 months. There was 1 retrospective cohort study (36 knees) and 3 case series (mean, 38.7 ± 17.5 knees). There were 58 knees treated with bipolar osteochondral allograft (OCA) transplantation, 58 knees treated with bipolar ACI, 20 knees treated with femoral OCA and tibial debridement, and 16 knees treated with femoral OCA and tibial microfracture. There were 37 failures (24.3%): 16 patients (10.5%) were converted to unicompartmental or total knee arthroplasty, 4 restorative procedures (2.6%) were revised, and 8 patients (1.6%) had unsatisfactory outcomes only. The remaining 15 failures (9.9%) had an unspecified combination of objective failure. The mean rate of failure ranged between 0% and 44.1% (I 2 = 83.2%). The mean time to failure ranged between 2.7 and 4.1 years (I 2 = 79.1%). CONCLUSIONS: Cartilage restoration, through both ACI and OCA, had failure rates between 0% and 44% in patients with bipolar lesions of the tibiofemoral compartment. Although a higher level of evidence is required to prove efficacy, the current study demonstrates midterm survivorship rates between 55% and 100%, which may delay the need for secondary arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Advanced 3-Dimensional Characterization of Hill-Sachs Lesions in 100 Anterior Shoulder Instability Patients.

PURPOSE: We sought to qualitatively and quantitatively describe characteristics of Hill-Sachs lesions (HSL) in a cohort of anterior shoulder instability patients using advanced 3-dimensional (3-D) modeling software and assess the impact of various HSL parameters on the HSL volume, location, and orientation in patients with anterior shoulder instability. METHODS: A total of 100 recurrent anterior instability patients with evidence of HSL with a mean age of 27.2 years (range = 18 to 43 years) were evaluated. Three-dimensional models of unilateral proximal humeri were reconstructed from CT scans, and the volume, surface area (SA), width, and depth of identified HSLs were quantified along with their location (medial, superior, and inferior extent). Multiple angular orientation measures of HSLs were recorded, including Hill-Sachs rim (HSLr) angle in order to classify the level and location of potential humeral head engagement. Mann-Whitney U test assessed the relationship between measured parameters. RESULTS: By volume, larger HSL had greater humeral head surface area (HH SA) loss (P = .001), HSL width (P = .001), were more medial (P = .015), and more inferior (P = .001). Additionally, more medial lesions had greater HSLr angles (P = 0.001). The mean depth, width, and volume of HSLs were 3.3 mm (range = 1.2-7.1 mm), 16.0 mm (range = 6.2-30.4 mm) and 449.2 mm3 (range = 62.0-1365.6 mm3), respectively. The medial border of the HSL extended to 17.2 ± 4.4 (range = 9.3-28.3 mm) off the most medial edge of the HH cartilage margin (medialization). The mean HSLr was 29.3 ± 10.5°. CONCLUSION: There was a statistically significant association between HSL medialization and HSL volume, position, and orientation. More medialized HSL have larger volume, greater width, more SA loss and higher lesion angles and are more inferior in the humeral head. As it has been established that more medialized lesions have poorer clinical outcomes, this study highlights that HS lesions have varying angles and medialization, which may portend eventual treatment and outcomes. LEVEL OF EVIDENCE: IV, case series.

Accuracy and Reliability of Imaging Modalities for the Diagnosis and Quantification of Hill-Sachs Lesions: A Systematic Review.

PURPOSE: To determine the reliability and accuracy of different imaging modalities in assessing Hill-Sachs lesions within the setting of anterior shoulder instability. METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the PubMed, Scopus, Embase, and Cochrane Library databases. The inclusion criteria were clinical trials or cadaveric studies that assessed the accuracy of humeral head bone loss imaging or reliability and English-language articles. The exclusion criteria were animal studies; imaging studies without measures of accuracy, reliability, or clinical predictive power; studies of shoulder injuries without humeral head bone loss; editorials; abstracts; reviews; case reports; and surveys. The search terms included "imaging" OR "radiographic" OR "CT" OR "MRI" AND "Hill-Sachs" OR "humeral head bone loss." Assessment of the methodologic quality of the included studies was performed using the original Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. RESULTS: Forty studies (2,560 shoulders) met the inclusion criteria and were assessed. For diagnosing the presence of Hill-Sachs lesions, computed tomography (CT) arthrography had the highest reported accuracy (median, 91%; range, 66%-100%). For the same assessment, CT arthrography also had the greatest reported sensitivity (median, 94%; range, 50%-100%). For the quantification of Hill-Sachs lesion parameters, reported intraobserver reliabilities were highest for 3-dimensional (3D) CT (intraclass correlation coefficient [ICC] range, 0.916-0.999), followed by 2-dimensional CT (ICC range, 0.858-0.861) and magnetic resonance imaging (MRI) (ICC range, 0.28-0.97). For the same quantification parameters, interobserver reliabilities were also reported for 3D CT (ICC range, 0.772-0.996), 2-dimensional CT (ICC range, 0.721-0.879), and MRI (κ range, 0.444-0.700). Intraobserver reliabilities for determining glenoid tracking were only reported for 3D CT (κ range, 0.730-1.00; ICC range, 0.803-0.901) and MRI (ICC range, 0.770-0.790). CONCLUSIONS: This study shows that the current literature supports a variety of different imaging modalities that provide clinically acceptable accuracy in diagnosing and quantifying Hill-Sachs lesions, as well as determining whether they will cause persistent anterior shoulder instability. Furthermore, this systematic review justifies that further research is needed to help develop a treatment algorithm on the proper imaging modalities needed to help treat patients with anterior shoulder instability that is both reliable and financially acceptable. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Control of Feeding Behavior by Cerebral Ventricular Volume Transmission of Melanin-Concentrating Hormone.

Classical mechanisms through which brain-derived molecules influence behavior include neuronal synaptic communication and neuroendocrine signaling. Here we provide evidence for an alternative neural communication mechanism that is relevant for food intake control involving cerebroventricular volume transmission of the neuropeptide melanin-concentrating hormone (MCH). Results reveal that the cerebral ventricles receive input from approximately one-third of MCH-producing neurons. Moreover, MCH cerebrospinal fluid (CSF) levels increase prior to nocturnal feeding and following chemogenetic activation of MCH-producing neurons. Utilizing a dual viral vector approach, additional results reveal that selective activation of putative CSF-projecting MCH neurons increases food intake. In contrast, food intake was reduced following immunosequestration of MCH endogenously present in CSF, indicating that neuropeptide transmission through the cerebral ventricles is a physiologically relevant signaling pathway for energy balance control. Collectively these results suggest that neural-CSF volume transmission signaling may be a common neurobiological mechanism for the control of fundamental behaviors.