Blood Flow Restriction during Walking Does Not Impact Body Composition or Performance Measures in Highly Trained Runners.

Blood flow restriction (BFR) is a commonly used training modality that has been demonstrated to enhance muscle characteristics such as size and function. The purpose of this study was to determine if a 4-week walking program with or without BFR in healthy, active adults has an effect on body composition, anaerobic, and aerobic running performance. Thirty-three participants, randomized among three groups, completed the walking program, which included five sets of 2 min walking intervals with 1 min rest, with or without BFR, or 10 min walking with BFR. Assessments completed before and after the walking program included body composition, 40-yard sprints, and a VO2MAX test on a treadmill. A two-way ANOVA revealed no changes among the groups nor for any variables at any time (p > 0.05). Additionally, one main effect for time indicated the VO2 at V-slope threshold was greater following training for all groups combined (p = 0.001). The results demonstrate that low volume and intensity walking with BFR for 4 weeks did not provide a sufficient stimulus for changing body composition or performance metrics in a group of very active adults. Longer or more isolated exposure of BFR on the limbs may contribute to more pronounced adaptations.

Manipulation Under Anesthesia and Lysis of Adhesions Are the Most Commonly Reported Treatments for Arthrofibrosis of the Knee After Arthroscopy or Anterior Cruciate Ligament Reconstruction in Both Pediatric and Adult Patients.

Purpose: To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations. Methods: A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients. Results: A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications. Conclusions: Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications. Level of Evidence: Level IV, systematic review of Level I-IV studies.

Psychological Readiness Is Weakly Related to Physical Function Tests at Return to Sport for Men and Not at All for Women Following Anterior Cruciate Ligament Reconstruction and Rehabilitation.

PURPOSE: To assess the relationships between physical function tests of the operative limb and psychological readiness to return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction (return to sport after injury [ACL-RSI]) by sex. A secondary purpose was to quantify sex-specific differences in physical function test outcomes. METHODS: Patient records were retrospectively identified as cases who performed RTS physical function testing (strength, horizontal hops, vertical jumps, single-leg leg press, and drop landing knee excursion, etc.), and completed a 6-question ACL-RSI survey at the time point they were cleared to RTS. Independent t-tests compared all variables between sex at P ≤ .05. Correlations and regression models were produced per sex to identify factors related to operative limb physical function tests and ACL-RSI scores. RESULTS: With a total of 127 patients (63 men; 64 women), there was no difference in ACL-RSI scores and leg press repetitions between sex (P = .32 and P = .12, respectively). There were sex differences for all other physical performance outcomes (P < .001 for all). To estimate readiness using physical function test scores, the men's regression model identified knee excursion (ß = 0.345; P = .033) as the only contributor to ACL-RSI (R2 = 0.089), whereas there was no relationship between physical performance outcomes and ACL-RSI in women (R2 = 0.00, P = 1.00). CONCLUSIONS: Men and women reported similar ACL-RSI scales, indicating high readiness to return to sport. Likely due to sex-related physiological differences, men performed better at most physical function tests. Further, male ACL-RSI could be predicted using only one physical function outcome and 91% variability of the ACL-RSI coming from other contributors not evaluated, as indicated by R2. No physical function variables predict ACL-RSI in women. The evaluated variables are considered the primary indicators relevant for patients to be permitted to RTS yet cannot adequately predict psychological readiness in these patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical outcomes of oral epithelial dysplasia managed by observation versus excision.

IMPORTANCE: Oral potentially malignant disorders, including oral epithelial dysplasia (OED), are a group of conditions with an increased risk of progression to oral cancer. Clinical management of OED is challenging and usually involves monitoring with repeated incisional biopsies or complete surgical excision. OBJECTIVE: To determine if complete surgical excision of OED impacts malignant transformation or improves survival outcomes in lesions that progress to malignancy. DESIGN: A retrospective review of all patients diagnosed with OED between 2009 and 2016 was completed, and patients were followed until January 2022 for disease course and outcomes. RESULTS: Hundred and fifty-five cases of OED met the inclusion criteria. Among the 61 lesions managed by observation, 15 progressed to cancer. Among the 94 lesions managed by surgical excision, 27 progressed to cancer. The overall malignant transformation rate was 27%, with an annual rate of 6.4%. Surgical excision with or without histologically negative margins did not decrease malignant transformation but was associated with lower oncologic staging at the time of diagnosis and improved survival. CONCLUSIONS AND RELEVANCE: Surgical excision of OED with or without negative margins did not reduce the rate of transformation to oral cancer but resulted in lower oncologic staging at diagnosis, leading to improved patient outcomes. Our results support the implementation of more extensive tissue sampling to improve cancer diagnosis and patient outcomes.

Intake of Artificial Sweeteners by Children: Boon or Bane?

BACKGROUND: Sugar is the main culprit in many health dysfunctions. Excessive sugar intake can negatively affect oral health, precipitate diabetes, and lead to weight gain and obesity. Sucrose is the primary form of sugar, and is strongly correlated with dental caries. Artificial sweeteners are chemically synthesized sugar substitutes that are generally regarded as being low-calorie. OBJECTIVE: This review examines the current evidence in the literature for the need for artificial sweeteners and outlines its implications for the health of children. We briefly outline its adverse effects, and concerns regarding their safety. REVIEW RESULTS: Artificial sweeteners are a widely used food additive. Six main artificial sweeteners are approved by the food and drug administration (FDA). The conflicting results and divergent regulatory norms of each sweetener are a constant cause of concern and debate. However, most studies have spotlighted the beneficial effects of artificial sweeteners. Dental caries diminish with the increase in sweetener intake. An increase in appetite and eventually weight gain is observed in individuals consuming artificial sweeteners. CONCLUSION: Artificial sweeteners are indeed a bane according to present studies, although more research on recently discovered non-nutritive artificial sweeteners is required. It also has a positive effect on overall health disorders. If one curbs the onset of dental caries, then the eventual rise is highly unlikely. CLINICAL SIGNIFICANCE: Artificial sweeteners' effect on lowering dental caries will help to reduce the caries index in general. Oral hygiene is maintained, and the growth of oral bacterium is depressed. Research on novel sweeteners will help to compare their efficacy in caries prevention compared to existing ones. It is necessary to educate people on artificial sweeteners and its implication as one can use them by being aware of their properties.

Are 6-Month Functional and Isokinetic Testing Measures Risk Factors for Second Anterior Cruciate Ligament Injuries at Long-T Follow-Up?

INTRODUCTION: Second anterior cruciate ligament (SACL) injuries are a devastating complication following return to sport (RTS). Appropriate and safe RTS criteria that reduce the risk of SACL injuries are needed. The goal of this study was to investigate the relationship between functional and isokinetic testing at 6 months following primary ACL reconstruction (ACLR) as risk factors for SACL injuries. METHODS: Patients with primary ACLR from 1990 to 2010 were identified. Those with 6-month postoperative functional and isokinetic testing and a minimum of 2-year follow-up were included. Functional testing included vertical jump, single-leg hop, and single-leg triple hop. Isokinetic testing included concentric quadriceps and hamstrings (HSs) strength at 60 and 180 degree/s speeds. Statistical analysis evaluated the significance of the various tests between those with and without a secondary tear. RESULTS: In total, 344 patients with a mean age of 26.0 ± 9.8 years at an average time of 9.1 ± 3.5 years of follow-up were analyzed. Fifty-nine patients (17%) experienced SACL injuries at an average time of 4.8 years following ACLR with 34 (58%) ipsilateral graft ruptures and 25 (43%) contralateral tears. Several isokinetic measures were significantly different between the NO SACL and the SACL groups: quadriceps 60 degree/s limb symmetry index (LSI) (75 vs. 82% p = 0.01), HS 60 degree/s LSI (92 vs. 97%, p = 0.04), quadriceps 180 degree/s involved/body weight (BW) (41 vs. 47%, p = 0.04), and HS 180 degree/s involved/BW (30 vs. 34%, p = 0.04). Patients with involved limb peak quadriceps torque value greater than 65 or 50% of BW (60 and 180 degree/s) had a 2.2 and 3.1 times higher risk of an SACL injury. CONCLUSIONS: Patients with certain elevated isokinetic scores in the injured limb at 6 months after ACLR experienced a higher rate of subsequent ACL injuries than those who had lower peak torque. Although a quantitative only analysis may not be sufficient to determine RTS criteria, clinicians should caution high-performing patients about the risk of subsequent ACL injury. LEVEL OF EVIDENCE: Cohort study; 3.

Sex-specific differences in outcomes after anterior shoulder surgical stabilization: a meta-analysis and systematic review of literature.

BACKGROUND: Anterior shoulder instability frequently occurs in young, physically active individuals and may be treated with surgical stabilization. Previous studies have shown that males more often require surgical management for anterior shoulder instability and may have a higher frequency of recurrent instability episodes after surgical management, but females have been found to have increased incidence of apprehension after surgical stabilization. The purpose of this study is to review the literature and assess anterior shoulder surgical stabilization postoperative outcomes between males and females to identify and describe sex-based differences. METHODS: A systematic search of electronic databases was conducted to identify level I-IV clinical studies on anterior shoulder instability published between 1960 and August 2020. We included studies that evaluated sex-specific outcomes in patients who underwent anterior shoulder instability procedures. A meta-analysis of the data was performed to analyze sex-specific outcomes. RESULTS: Thirty studies (2.1%) met inclusion criteria, representing 9829 patients. Of the studies that reported the number of male and female patients, 74% were male and 26% were female. Twenty-six studies used Bankart repair alone, two used open Latarjet procedure alone, and two had a Bankart repair group and Latarjet procedure group. Instability recurrence, return to sport, and apprehension were included in the meta-analysis. Our meta-analysis demonstrated a significantly higher rate of instability recurrence for males than for females who underwent arthroscopic Bankart repair (risk ratio [RR] = 1.25; 95% confidence interval [CI] = 1.03, 1.52; P = .0239). We did not identify a significant difference between males and females in rates of apprehension (RR = 0.68; 95% CI = 0.37, 1.27; P = .2300) or return to sport (RR = 0.98; 95% CI = 0.81, 1.18; I2 = 0%; P = .8110) for arthroscopic Bankart repair or open Latarjet procedure. CONCLUSION: For patients who underwent arthroscopic Bankart repair for anterior shoulder stabilization, recurrent rates of instability were significantly higher for males than for females. When open Bankart and Latarjet procedures were included, there was no difference. No difference was seen between males and females after arthroscopic Bankart repair or open Latarjet procedures with regard to return to sport or apprehension.

Nonoperative Management of Posterior Shoulder Instability: What Are the Long-Term Clinical Outcomes?

OBJECTIVE: To report the injury characteristics, radiographic findings, and long-term outcomes of nonoperative management for posterior shoulder instability (PSI). DESIGN: A retrospective review of 143 patients with PSI using a large geographic database. SETTING: Single county between January 1994 and July 2012. PATIENTS: A clinical history and diagnosis of PSI, one confirmatory imaging study to support the diagnosis, and a minimum of 5 years follow-up were required for inclusion. Patients with seizure disorders, anterior-only instability, multidirectional instability, and superior labrum from anterior to posterior diagnosis were excluded. INTERVENTIONS: Patients with PSI were managed nonoperatively or operatively. MAIN OUTCOME MEASURES: Pain, recurrent instability, and progression into glenohumeral osteoarthritis at long-term follow-up. RESULTS: One hundred fifteen patients were identified. Thirty-seven (32%) underwent nonoperative management. Twenty (54%) patients were diagnosed with posterior subluxation, 3 (8%) with a single dislocation, and 7 (19%) with multiple dislocations. Symptomatic progression of glenohumeral arthritis was observed in 8% (3) of patients. Pain improved in 46% (17) of patients and worsened in 19% (7). Recurrent instability and progression to osteoarthritis occurred in 15% (3/20) of patients with a traumatic instability event compared with 0% of atraumatic patients after nonoperative management (P = 0.234). Pain at follow-up was more common in nonoperative than operative patients (P = 0.017). CONCLUSIONS: Nonoperative management is a viable option for many patients with posterior shoulder instability; however, many may continue to have posterior shoulder pain.

Nonoperative management of anterior shoulder instability can result in high rates of recurrent instability and pain at long-term follow-up.

BACKGROUND: Data on the long-term outcomes of nonoperative treatment of anterior shoulder instability are lacking, particularly for the US population. The purpose was to (1) describe the characteristics of patients with anterior shoulder instability treated nonoperatively, (2) assess the long-term outcomes of nonoperative management in a US population, and (3) identify risk factors for poor outcomes following nonoperative management. METHODS: A geographic cohort of >500,000 subjects was used to identify patients treated nonoperatively for anterior shoulder instability. Only patients aged <40 years at the time of initial instability with minimum 10-year follow-up were included. Medical records were reviewed to obtain demographic characteristics, physical examination findings, clinical history data, imaging results, treatment details, and clinical and/or radiographic progression. Recurrent pain, recurrent instability, and the development of symptomatic osteoarthritis (OA) were the primary outcomes evaluated. RESULTS: The study included 254 patients (73% male) with a median age of 19 years (range, 16-26 years) at the time of initial instability. At median 17-year follow-up, 37.5% experienced recurrent instability, 58.4% had recurrent pain, and 12.2% had symptomatic OA development. Factors associated with recurrent pain at final follow-up were multiple instability events prior to presentation (hazard ratio [HR], 2.43; P < .01) and increased pain at the initial visit (HRs of 0.79 for mild, 1.74 for moderate, and 1.39 for severe; P < .01); patients with multiple instability events prior to presentation also had an increased risk of recurrence (P < .01). Factors increasing the risk of the development of symptomatic OA included increased pain at the initial visit (P = .05), seizure disorder (HR, 27.01; P < .01), and smoking (HR, 5.15; P < .01). CONCLUSIONS: At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. Overall, 37.5% of patients experienced recurrent shoulder instability, 58.4% had recurrent shoulder pain, and 12.2% had symptomatic OA development. Risk factors associated with adverse clinical outcomes included increased pain at the initial visit, recurrent instability prior to presentation, seizure disorder, and smoking.

Reliability of a simple fluoroscopic image to assess leg length discrepancy during direct anterior approach total hip arthroplasty.

BACKGROUND: Direct anterior approach (DAA) total hip arthroplasty (THA) in a supine position provides a unique opportunity to assess leg length discrepancy (LLD) intra-operatively with fluoroscopy. Reported fluoroscopic techniques are useful but are generally complicated or costly. Despite the use of multiple techniques for leg length assessment, LLD continues to be a major post-operative source of patient dissatisfaction further emphasizing the importance of near-anatomic restoration. The utility of an alternative direct measurement of LLD on an intra-operative fluoroscopic pelvic image during DAA THA has not been reported. AIM: To determine the reliability of a novel simple intra-operative measurement of LLD using a parallel line technique on a single fluoroscopic digital image of the pelvis. METHODS: One hundred and seventy-one patients who underwent DAA THA were included for analysis. Intra-operative fluoroscopic and post-operative anterior-posterior radiographs were imported to TraumaCad and calibrated for LLD measurement. LLD was measured on each image using the right-left hip differences in lesser trochanter to pelvic reference line distances. Pelvic reference points included the teardrops and ischia. Fluoroscopic LLD was compared to the gold-standard measurement of LLD measured on a post-operative radiograph. RESULTS: Mean absolute difference in teardrop referenced LLD between fluoroscopic and post-operative radiographs was 2.17 mm and based on the ischia mean absolute difference was 2.63 mm. Linear regression of fluoroscopic and post-operative radiograph LLD based on teardrop and ischia LLD found r 2 values of 0.57 and 0.84, respectively. Mean absolute difference between fluoroscopic and post-operative x-ray LLD was within 5 mm in 95% of cases regardless of pelvic reference. CONCLUSION: This study demonstrates that a single fluoroscopic view obtained during DAA THA for leg length assessment is clinically useful.

Both Debridement and Microfracture Produce Excellent Results for Osteochondritis Dissecans Lesions of the Capitellum: A Systematic Review.

PURPOSE: To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD). METHODS: A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return-to-sport rates, patient-reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded. RESULTS: Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non-randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from -4° to 6° of flexion and -0.4° to 14° of extension, with prono-supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations. CONCLUSIONS: Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid-term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects. LEVEL OF EVIDENCE: Level IV, systematic review of studies, all Level IV evidence.

Multiple Instability Events at Initial Presentation Are the Major Predictor of Failure of Nonoperative Treatment for Anterior Shoulder Instability.

PURPOSE: To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long-term outcomes of nonoperative treatment after the index traumatic anterior instability event. METHODS: The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long-term outcomes (recurrence rate, pain at last follow-up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan-Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. RESULTS: A total of 379 patients met the study criteria, with an average follow-up period of 10.2 years (range, 0.53-25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow-up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow-up (HR, 4.21; P < .001). CONCLUSIONS: Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. LEVEL OF EVIDENCE: Level III, retrospective database review.

Incidence of Hip Dysplasia Diagnosis in Young Patients With Hip Pain: A Geographic Population Cohort Analysis.

BACKGROUND: Hip dysplasia is a common source of hip pain and a known cause of early osteoarthritis of the hip. PURPOSE: To (1) define the population-based incidence of hip dysplasia diagnosis in young patients presenting with hip pain in a large geographically defined cohort, (2) analyze trends regarding presentation and diagnosis of hip dysplasia, and (3) report the rate and type of surgical interventions used to treat this population. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A geographic epidemiological database was queried to identify patients aged 14 to 50 years with hip pain between the years 2000 and 2016. Patient medical records were analyzed, and demographic, imaging, clinical, and treatment history were recorded. Incidence trends were examined by use of linear regression with confidence intervals for age and calendar year. RESULTS: Overall, 1893 patients were included. Of these, 156 patients (196 hips) had a diagnosis of hip dysplasia. The incidence of hip dysplasia diagnosis in patients who reported hip pain was 12.7 per 100,000 person-years. Patients with dysplasia had a mean age of 26.7 ± 9.8 years, while the highest age-adjusted incidence occurred at age 14 to 18 years in both male and female patients. Female patients had double the age-adjusted incidence of male patients (cases per 100,000 person-years: 16.8 [95% CI, 13.9-19.7] vs 8.7 [95% CI, 6.6-10.8]; P < .01). Of the patients who underwent magnetic resonance imaging, 77% had imaging consistent with labral pathology. Patients were treated with physical therapy (67%), intra-articular steroid injection (29%), hip arthroscopy (10%), and periacetabular osteotomy (9%). The use of hip arthroscopy significantly increased over time (P < .01), whereas the use of steroid injection and periacetabular osteotomy did not (P < .28 and P < .08, respectively). CONCLUSION: The incidence of hip dysplasia diagnosis in patients presenting with hip pain was 12.7 per 100,000 person-years. Female patients had twice the age-adjusted incidence of male patients, and the highest age-adjusted incidence occurred in the age range of 14 to 18 years in both sexes. The use of hip arthroscopy to treat patients with hip dysplasia significantly increased over time.

Although Surgical Techniques Differ, Similar Outcomes Can Be Obtained When Operating After Single Versus Multiple Anterior Shoulder Dislocations.

PURPOSE: To compare the differences in preoperative pathology, surgical technique, and overall outcomes between patients treated surgically after a single anterior glenohumeral joint dislocation and those undergoing surgery after multiple dislocations. METHODS: An epidemiologic database was used to identify all patients younger than 40 years undergoing surgery for anterior shoulder instability between January 1, 1994, and July 31, 2016, in a defined geographic area. Patient medical records were reviewed to obtain demographic information, patient history, physical examination findings, imaging findings, clinical progression, surgical details, and outcomes. Comparative analysis was performed between patients who underwent surgery after a single dislocation and those who underwent surgery after multiple preoperative dislocations. RESULTS: The study population consisted of 187 patients who had a single anterior shoulder dislocation (n = 55) or multiple anterior shoulder dislocations (n = 132) prior to surgery. The mean follow-up period was 103.3 months (range, 0.3-328.4 months). Demographic characteristics were not significantly different between groups. Although the presence of Hill-Sachs lesions on radiographs was more common in the multiple-dislocation group (42.1%) than in the single-dislocation group (18.8%, P = .005), there were no other significant differences in concomitant pathology between groups. Latarjet procedures were more commonly performed in the multiple-dislocation group (12.5% vs 2.1% in the single-dislocation group, P = .04). There were no other significant differences in surgical techniques and characteristics between groups. Rates of survival free from recurrent instability (P = .790), revision surgery (P = .726), and progression to symptomatic osteoarthritis (P = .588) were not significantly different between groups. CONCLUSIONS: Although patients with multiple dislocations prior to surgery were more likely to show radiographic evidence of Hill-Sachs lesions and undergo the Latarjet procedure than those who received surgery after a single dislocation, no significant differences in outcomes with respect to recurrent instability, revision surgery, or progression to symptomatic osteoarthritis were found between these 2 groups at long-term follow-up. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Articular Cartilage Defects of the Glenohumeral Joint: A Systematic Review of Treatment Options and Outcomes.

OBJECTIVE: To report radiographic and magnetic resonance imaging findings, patient-reported outcomes, and complications and/or reoperations following nonarthroplasty surgical intervention for focal glenohumeral cartilage defects. DESIGN: A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Patients were included if they possessed a chondral defect of the humeral head, glenoid, or both, which had been treated with a joint preserving nonarthroplasty procedure. Risk of bias assessment was performed using the Methodological Index for Non-Randomized Studies scoring system. Study demographics, surgical technique, imaging findings, patient-reported outcomes, complications, failures, and reoperations were collected. RESULTS: Fourteen studies with 98 patients (100 shoulders) met the inclusion criteria. Patient ages ranged from 7 to 74 years. The nonarthroplasty surgical techniques utilized included microfracture (67 shoulders), osteochondral transplantation (28 shoulders), chondrocyte transplantation (4 shoulders), and internal fixation (1 shoulder). The rates of radiographic union and progression of osteoarthritis ranged between 90% to 100% and 57% to 100%, respectively. Visual analog scores ranged from 0 to 1.9 at final follow-up. Mean postoperative ASES (American Shoulder and Elbow Surgeons) shoulder scores ranged from 75.8-100. Mean postoperative CSS (Constant Shoulder Score) scores ranged from 83.3-94. Mean postoperative SSV (Subjective Shoulder Value) ranged from 70% to 99%. Failure and reoperation rates ranged between 0% to 35% and 0% to 30%, respectively, with the most common reoperation being conversion to prosthetic arthroplasty. CONCLUSIONS: In this systematic review, nonarthroplasty surgical techniques demonstrated acceptable rates of radiographic healing, improved patient reported outcomes, minimal complications, and low rates of failure or reoperation. Joint preserving techniques are likely viable options to prolong function of the native shoulder and provide short- to midterm pain relief in young and highly active patients. LEVEL OF EVIDENCE: Level IV.

Prospective Outcomes of Cryopreserved Osteochondral Allograft for Patellofemoral Cartilage Defects at Minimum 2-Year Follow-up.

OBJECTIVE: To analyze the clinical outcomes, knee function, and activity level of patients after treatment of full-thickness cartilage defects involving the patellofemoral compartment of the knee with cryopreserved osteochondral allograft. DESIGN: Nineteen patients with cartilage defects involving the patellofemoral compartment were treated. The average age was 31 years (range 15-45 years), including 12 females and 7 males. Patients were prospectively followed using validated clinical outcome measures including Veterans RAND 12-item Health Survey (VR-12), International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Tegner activity scale. Graft incorporation was evaluated by magnetic resonance imaging (MRI) or second-look arthroscopy. RESULTS: The cartilage defects included the patella (n = 16) and the femoral trochlea (n = 3). Mean VR-12 scores increased from 31.6 to 46.3 (P < 0.01), mean IKDC increased from 40.0 to 69.7 (P < 0.01), mean KOOS increased from 53.9 to 80.2 (P < 0.01), and mean Tegner scores increased from 3.0 to 4.9 (P < 0.01), at average follow-up of 41.9 months (range 24-62 months). Of the 3 patients who underwent second-look arthroscopy, all demonstrated a well-incorporated graft. Mean MOCART score for the 6 patients with follow-up MRI was 62.5 (range 25-85). The reoperation rate was 21.1% and 2 patients (12.5%) experienced progressive patellofemoral osteoarthritis requiring conversion to patellofemoral arthroplasty. CONCLUSION: Patients with unipolar cartilage defects involving the patellofemoral compartment of the knee can have positive outcomes at minimum 2-year follow-up after surgical treatment with a cryopreserved osteochondral allograft when concomitant pathology is also addressed, but the reoperation rate is high and bipolar cartilage lesions may increase the failure rate.

Understanding the Implications of the Meniscal Ossicle: Patient Presentation, Treatment, and Outcomes.

The meniscal ossicle is observed in clinical practice, yet there currently is limited information on its potential clinical significance. The purpose of this study was to assess the clinical presentation, imaging findings, and clinical treatment and outcomes of a series of patients identified as having a meniscal ossicle. An institutional database was reviewed to identify knees with a meniscal ossicle. Clinical presentation, magnetic resonance imaging (MRI), treatment, and outcomes were analyzed. Radiographs were graded using Kellgren-Lawrence (KL) scores. MRIs were reviewed for the presence and location of meniscal ossicles and additional knee pathology. Knee arthroplasty rates were recorded with the remaining patients contacted to obtain final International Knee Documentation Committee (IKDC) and Tegner's scores. Failure was defined as conversion to arthroplasty or failing IKDC score (< 75.4). Forty-five meniscal ossicles in 45 patients (26 males and 19 females) with a mean age of 51 years (standard deviation [SD] = 19.0) were included. Pain was the most common presenting symptom (89%). Forty-two patients (93%) had an associated meniscus root tear on MRI. Eighteen percent of patients that did not have an ossicle on initial imaging subsequently developed an ossicle. Mean KL grades progressed significantly from baseline of 1.84 (SD = 1.0) to 2.55 (SD = 0.93 p < 0.01) on final follow-up. Thirty-nine percent of baseline radiographs showed KL grades of less than 2 compared with only 15% of follow-up radiographs (p = 0.04). Mean IKDC score obtained for patients ≤ 60 at an average follow-up of 3.1 years (SD = 3.2) was 65.2 (SD = 19.0). Eight out of 45 patients (18%) had progressed to total knee arthroplasty (TKA) by latest available follow-up. Sixty-two percent of patients met failure criteria at latest available follow-up. The meniscal ossicle is most commonly found in the posterior horn or root of the medial meniscus and is highly suggestive to be sequelae of a posterior root tear. Therefore, the presence of a meniscal ossicle should alert the orthopaedic surgeon to the high likelihood of the patient having a meniscus root tear. These patients have shown to have poor clinical outcomes and worsening arthritis.

Bipolar Cartilage Lesions of the Knee: A Systematic Review of Techniques, Outcomes, and Complications.

OBJECTIVE: The purpose of this systematic review was to determine (1) treatment options for bipolar cartilage lesions of the knee, (2) patient-reported outcomes following various surgical treatments, and (3) complication and failure rates following surgery. DESIGN: A literature search of PubMed, the Cochrane Library, and CINHAL was performed using PRISMA guidelines. Patients were included if they had bipolar cartilage lesions of the knee treated surgically. Lesion characteristics, surgical technique, patient-reported outcomes, complication rates, failure rates, and survivorship were recorded. RESULTS: Fourteen studies yielded 301 knees treated surgically. Patient age ranged from 15 to 74 years. Surgical techniques included 138 autologous chondrocyte implantation (ACI), 156 osteochondral allograft transplantation (OCA), and 7 osteochondral autograft transfer system (OATS). Seven studies reported a concomitant procedure rate that ranged from 0% to 88%. Eight studies reported that both reciprocal lesions received surgical treatment, while 6 studies did not specify. Lesion size ranged from 1 to 41 cm2. All reported postoperative improvements in patient-reported outcomes, but the measures were very heterogeneous. There were no major complications and the rate of minor complications ranged from 0% to 50%. Survivorship ranged from 40% to 100% for OCA, 76% to 95% for ACI, and 100% for the 1 study evaluating OATS. CONCLUSIONS: Bipolar cartilage lesions of the knee typically involve a large surface area and are most commonly treated with ACI or OCA, while OATS may be an option for smaller lesions. Improvements in mid-term patient-reported outcomes were reported for all surgical procedures and they can be performed safely with a low rate of major complications.

Tibial Plateau Cartilage Lesions: A Systematic Review of Techniques, Outcomes, and Complications.

OBJECTIVE: The purpose of this systematic review is to determine (1) current reported treatment options for isolated tibial plateau (TP) cartilage lesions, (2) patient reported outcomes following various treatments, and (3) complication rate and survivorship following various treatments. DESIGN: A literature search of PubMed, the Cochrane Library, and CINAHL was conducted adhering to PRISMA guidelines. Patients were included if they had TP cartilage lesions treated with surgery. Lesion characteristics, surgical procedure details, patient reported outcomes, complication, and failure rates were collected. RESULTS: Thirteen studies yielded 205 knees with TP cartilage lesions treated surgically. Ages ranged from 12 to 77 years. Surgical techniques included 138 treated with osteochondral allograft transplantation (OCA), 37 treated with osteochondral autograft transfer system (OATS), 11 treated with microfracture, 11 treated with an osteochondral scaffold, and 8 treated with autologous chondrocyte implantation (ACI). The patient-reported outcome measures were heterogeneous, but all reported improvements with the notable exception of one study evaluating microfracture. The rate of complications ranged from 0% to 4.6%. Failure rate ranged from 22% to 46% for OCA and 0% to 16% for OATS. No failures were reported for the additional techniques. CONCLUSIONS: Various surgical techniques have been utilized for the treatment of TP cartilage lesions. Patient-reported outcome measures were heterogeneous, but improvements were reported following all surgical treatments except for microfracture, which resulted in decreased scores at mid-term follow-up. The complication rate was low for all techniques described. However, the failure rate was higher following unicondylar OCA for salvage treatment of posttraumatic deformities.