Following Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Autograft, the Incidence of Anterior Knee Pain Ranges From 5.4% to 48.4% and the Incidence of Kneeling Pain Ranges From 4.0% to 75.6%: A Systematic Review of Level I Studies.

Purpose: To (1) perform a systematic review of level I randomized controlled trials (RCTs) detailing the incidence of anterior knee pain and kneeling pain following anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) autograft and (2) investigate the effect of bone grafting the patellar harvest site on anterior knee and kneeling pain. Methods: A systematic review of level I studies from 1980 to 2023 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome evaluated was the presence of donor site morbidity in the form of anterior knee pain or kneeling pain. A secondary subanalysis was performed to assess for differences in the incidence of postoperative pain between patient groups undergoing ACLR with BPTB receiving harvest site bone grafting and those in whom the defect was left untreated. Results: Following full-text review, 15 studies reporting on a total of 696 patients met final inclusion criteria. Patients were followed for an average of 4.78 years (range, 2.0-15.3), and the mean age ranged from 21.7 to 38 years old. The incidence of anterior knee pain, calculated from 354 patients across 10 studies, ranged from 5.4% to 48.4%. The incidence of postoperative pain with kneeling was determined to range from 4.0% to 75.6% in 490 patients from 9 studies. Patients treated with bone grafting of the BPTB harvest site had no significant difference in incidence of any knee pain compared with those who were not grafted, with incidences of 43.3% and 40.2%, respectively. Conclusions: Based on the current level I RCT data, the incidences of anterior knee pain and kneeling pain following ACLR with BPTB autograft range from 5.4% to 48.4% and 4.0% to 75.6%, respectively. Level of Evidence: Level I, systematic review of RCTs.

Medial Ulnar Collateral Ligament Reconstruction With Allograft Provides Excellent Clinical Outcomes, High Rates of Return to Play, and a Low Incidence of Postoperative Complications: A Systematic Review.

PURPOSE: To perform a systematic review evaluating clinical outcomes in patients undergoing medial ulnar collateral ligament reconstruction (MUCLR) with soft-tissue allograft. METHODS: A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes evaluated were patient-reported outcome scores, return to play (RTP) rates, incidence of postoperative complications, and rates of graft rupture or mechanical failure. RESULTS: The literature search identified 395 articles, and 5 studies met final inclusion criteria after full-text review. A total of 274 patients were analyzed in the included studies and follow-up ranged from 3.0 to 7.6 years. Two studies (number of patients = 141) reported outcomes exclusively of MUCLR with allograft, whereas 3 studies (number of patients = 133) reported outcomes in patients undergoing MUCLR with either allograft or autograft. Allograft sources included gracilis, semitendinosus, plantaris, peroneus longus, and palmaris longus. Level of patient athletic competition ranged from recreational athletes to the professional level; however, nonathletes in the setting of trauma were also included. The RTP rate after MUCLR with soft-tissue allograft was 95.3%, and 89.3% of patients returned to a similar or greater level of play postoperatively. The Timmerman-Andrews score was reported in 2 studies, and the means postoperatively ranged from 94.55 to 97. Postoperative complication rates were low (range, 0% to 20%), and there were no reported incidences of allograft rupture or mechanical failure. CONCLUSIONS: Based on the available data, soft-tissue allograft for MUCLR in athletic patient populations provides excellent clinical outcomes, high rates of RTP, and low rates of postoperative complications and graft failure at short-term follow-up. There remains a lack of high-quality evidence directly comparing autograft versus allograft outcomes in elite overhead-throwing athletes to support allograft as an acceptable alternative for MUCLR in this patient population. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Postoperative Radiographic Outcomes Following Primary Open Coracoid Transfer (Bristow-Latarjet) Vary in Definition, Classification, and Imaging Modality: A Systematic Review.

PURPOSE: To analyze radiographic outcomes by conventional radiography, computed tomography (CT), or both and complication rates of open coracoid transfer at a minimum of 12-months follow-up. METHODS: A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Medline (Ovid), and EMBASE library databases. Inclusion criteria were clinical studies reporting on open Latarjet as the primary surgical procedure(revision coracoid transfer after failed prior stabilization excluded) with postoperative radiographic outcomes at a minimum mean 1-year follow-up. Patient demographics, type of postoperative imaging modality, and radiographic outcomes and complications including graft union, osteoarthritis, and osteolysis were systematically reviewed. Data were summarized as ranges of reported values for each outcome metric. Each radiographic outcome was graphically represented in a Forest plot with point estimates of the incidence of radiographic outcomes with corresponding 95% confidence intervals and I2. RESULTS: Thirty-three studies met inclusion criteria, with a total of 1,456 shoulders. The most common postoperative imaging modality was plain radiography only (n = 848 [58.2%]), both CT and radiography (n = 287 [19.7%]), and CT only (n = 321 [22.1%]). Overall, the reported graft union rate ranged from 75% to 100%, of which 79.8% (n = 395) were detected on plain radiography. The most common reported postoperative radiographic complications after the open coracoid transfer were osteoarthritis (range, 0%-100%, pooled mean 28%), graft osteolysis (range, 0%-100%, pooled mean 30%), nonunion (range, 0%-32%, pooled mean 5.1%), malpositioned graft (range, 0%-75%, pooled mean 14.75%), hardware issues (range, 0%-9.1%, pooled mean 5%), and bone block fracture (range, 0%-8%, pooled mean 2.1%). Graft healing was achieved in a majority of cases (range, 75%-100%). CONCLUSION: Postoperative radiographic outcomes after open coracoid transfer vary greatly in definition, classification, and imaging modality of choice. Greater consistency in postoperative radiographic outcomes is essential to evaluate graft healing, osteolysis, and nonunion. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Management of Acromioclavicular Joint Injuries: A Historic Account.

There has been a rapid evolution in best practice management of acromioclavicular (AC) joint injuries. AP, Zanca, scapular Y, and dynamic axillary radiographic views provide optimal visualization of the joint and may assess for the presence of horizontal AC instability. Severity of AC joint pathology is classified according to the 6-tier Rockwood scoring system. Over 160 surgical techniques have been described for AC joint repair and reconstruction in the last decade; as a result, determining the optimal treatment algorithm has become increasingly challenging secondary to the lack of consistently excellent clinical outcomes.

The COVID-19 Pandemic Increased the Use of Virtual Fellowship Interviews, Reduced Case Volume, and Limited Sideline Coverage Opportunities During Sports Medicine Surgeon Training.

As one-year orthopaedic sports medicine fellowships rely heavily on elective cases and sports coverage, the COVID-19 pandemic necessitated fellowship programs to temporarily transition to virtual mediums for fellow education. Early in the pandemic, there was uncertainty as to how programs would address concerns of trainee readiness, adequate education, and accompanying psychological impact. However, with a return to prepandemic elective procedure volumes and sideline sports coverage responsibilities, sports medicine fellowships have regained some of their traditional education opportunities. Moreover, the implementation of novel training resources, including virtual didactics, augmented reality surgical skills labs, and telehealth medicine training are poised to outlast the current public health crisis and further supplement fellowship education. This article seeks to report on current evidence-based strategies and developments across several critical aspects of sports medicine training during the COVID-19 pandemic.

Return to Play After Shoulder Arthroscopy in Major League Baseball Pitchers vs Position Players.

Background: Recovery from shoulder arthroscopy may vary between professional pitchers and position players in Major League Baseball (MLB). The time that it takes to return to play (RTP) and the level of skills to be regained after surgery are important factors for an athlete to consider when making career decisions. Purpose: To identify MLB players who had arthroscopic shoulder surgery and observe their rates of RTP to MLB and the minor league, as well as to compare pre- and postinjury performance statistics and career metrics. Study Design: Descriptive epidemiology study. Methods: Public records (press releases, http://www.prosportstransactions.com, http://www.baseball-reference.com) were searched and analyzed to determine the number of days from shoulder arthroscopy to RTP and pre- and postinjury statistics for pitchers and position players in the MLB and minor league from 1998 to 2018. To meet inclusion criteria, a player must have undergone shoulder arthroscopy after having played at least 1 game in the MLB and had no identifiable concomitant injuries. Results: Of 134 players, 89 (66.4%) returned to MLB. Fifty-four of 89 pitchers (60.7%) and 35 of 45 position players (77.8%) returned to MLB (P = .048). Forty-nine of 54 pitchers (90.7%) and 23 of 35 position players (65.7%) who returned to MLB returned to the minor league first. The mean time to RTP was 469.6 days (range, 100-1079 days) for pitchers and 301.6 days (range, 94-1488) for position players (P = .002). The WAR statistic (wins above replacement) for the pitchers decreased significantly (P = .004) after shoulder arthroscopy. Conclusion: MLB position players returned to play at higher rates and more quickly than did pitchers. The WAR statistic declined in pitchers during the first season of RTP. Players undergoing arthroscopic shoulder surgery should be aware of these possible outcomes in time to RTP and postoperative performance.

Impact of the COVID-19 Pandemic on Sports Medicine Patient Care.

The COVID-19 pandemic has necessitated new practices in sports medicine patient care. Telehealth has been validated as a reliable tool for consultations and physical examinations and increases access to care in a cost-efficient manner. Social distancing and avoiding team members who have tested positive are the most effective ways to reduce spread. For screening, daily self-reported symptom checklists and fever monitoring help identify potentially infected athletes who should be instructed to isolate and seek care. Polymerase chain-reaction (PCR) testing for the virus via nasopharyngeal swab is not recommended for screening and should be reserved for symptomatic individuals with fever, cough, or shortness of breath. Face masks and personal protective equipment (PPE) may be beneficial in high-risk settings, but there is little evidence to support use in athletic populations. Median return to play after COVID-19 in elite athletes has been reported as 18 days (range: 12 to 30), with 27% not fully available at 28 days. Chest pain at diagnosis was the only symptom associated with time loss longer than 28 days. Finally, canceled competitions or time loss results in grief, stress, and frustration for athletes, as well as loss of a social support network and routine training regimens. Mental health support services may be indicated.

Qualitative and Quantitative Anatomic Descriptions of the Coracoclavicular and Acromioclavicular Ligaments: A Systematic Review.

Purpose: To summarize the quantitative and qualitative anatomy of the acromioclavicular (AC) and coracoclavicular (CC) ligaments of the AC joint. Methods: A systematic review of the literature evaluating the quantitative and qualitative anatomy of the CC and AC ligaments of the AC joint was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: The conoid ligament (CL) arises from the posterior coracoid precipice and courses with a tapered inferior apex to insert on the conoid tubercle of the posteroinferior clavicle. The trapezoid ligament originates from the anterior-superior coracoid with medially extending fibers anterior to the conoid's C-shaped footprint and runs with the CL to insert along the trapezoid line on the inferior aspect of the anterior clavicle, anterolateral to the conoid tubercle. The AC capsule's superoposterior bundle and the CL are robust stabilizing ligaments characterized by prominent attachment sites to the posteroinferior clavicle. Conclusions: Clear and consistent quantitative and qualitative descriptions of the CC ligaments (CL and trapezoid ligament) have been well defined; however, quantitative data on the capsuloligamentous anatomy of AC ligaments (superoposterior and anteroinferior) ligaments) remain limited. Clinical Relevance: There are high complication and failure rates after AC joint stabilization. To improve patient outcomes, the anatomy of the CC and AC joints needs to be better understood.

Glenoid Bone Loss Directly Affects Hill-Sachs Morphology: An Advanced 3-Dimensional Analysis.

BACKGROUND: While the glenoid track concept presents a useful prediction for recurrent glenohumeral instability, little is known about the humeral head bony architecture as it relates to glenoid erosion in the setting of bipolar bone loss. PURPOSE: To (1) qualitatively and quantitatively analyze the interplay between glenoid bone loss (GBL) and Hill-Sachs lesions (HSLs) in a cohort of patients with anterior instability using 3-dimensional imaging software and (2) assess the relationships between GBL and HSL characteristics. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients were identified who had anterior shoulder instability with a minimum 5% GBL and evidence of HSL confirmed on computed tomography. Unilateral 3-dimensional models of the ipsilateral proximal humeral head and en face sagittal oblique view of the glenoid were reconstructed using MIMICS software (Materialise NV). GBL surface area, width, defect length, and glenoid track width were quantified. The volume, surface area, width, and depth of identified HSLs were quantified with their location (medial, superior, and inferior extent) on the humeral head. Severity of GBL was defined as percentage glenoid bone surface area loss and categorized as low grade (5%-10%), moderate grade (>10% to 20%), high grade (>20% to 30%), and extensive (>30%). Analysis of variance was then computed to determine significance (P < .05) between severity of GBL and associated HSL parameters. RESULTS: In total, 100 patients met inclusion criteria (mean age, 27.9 years; range, 18-43 years), which included 58 right shoulders and 42 left shoulders (84 male, 16 female). Among groups, there were 32 patients with low-grade GBL (mean GBL = 6.1%), 38 with moderate grade (mean GBL = 16.2%), 17 with high grade (mean GBL = 23.7%), and 13 with extensive (mean GBL = 34.0%), with an overall mean GBL of 18.1% (range, 5%-39%). Patients with 5%-10% GBL had significantly narrower HSLs (average and maximum width; P < .03) and deeper HSLs (average depth; P = .002) as compared with all other GBL groups, while greater GBL was associated with wider and shallower HSLs. GBL width, percentage width loss, defect length, and glenoid track width all significantly differed across the 4 GBL groups (P < .05). CONCLUSION: HSLs had significantly different morphological characteristics depending on the severity of GBL, indicating that GBL was directly related to the characteristics of HSLs. Patients presenting with smaller glenoid defects had significantly narrower and deeper HSLs with less humeral head surface area loss, while greater GBL was associated with wider and shallower HSLs.

Sternoclavicular Joint Instability and Reconstruction.

Chronic instability or degenerative arthritis of the sternoclavicular (SC) joint may occur after traumatic or spontaneous dislocation of the SC joint. Most commonly, chronic instability of the SC joint occurs anteriorly; however, posterior instability has an increased risk of serious complications because of proximity to mediastinal structures. Although chronic anterior instability of the SC joint does not resolve with nonsurgical treatment, patients often have mild symptoms that do not impair activities of daily living; however, chronic anterior SC joint instability may be functionally limiting in more active individuals. In these cases, surgical treatment with either (1) SC joint reconstruction or (2) medial clavicle resection, or both, can be done. Recurrent posterior instability of the SC joint also requires surgical treatment due to risk of injury to mediastinal structures. Recent literature describes various reconstruction techniques which generally show improved patient-reported outcomes and low complication rates.

Improved Accuracy of Coronal Alignment Can Be Attained Using 3D-Printed Patient-Specific Instrumentation for Knee Osteotomies: A Systematic Review of Level III and IV Studies.

PURPOSE: To evaluate the accuracy and precision of postoperative coronal plane alignment using 3D-printed patient-specific instrumentation (PSI) in the setting of proximal tibial or distal femoral osteotomies. METHODS: A systematic review evaluating the accuracy of 3D-printed PSI for coronal plane alignment correcting knee osteotomies was performed. The primary outcomes were accuracy of coronal plane limb alignment correction and number of correction outliers. Secondary variables were duration of surgery, number of intraoperative fluoroscopic images, complications, cost, and clinical outcomes (as applicable). RESULTS: Ninety-three studies were identified, and 14 were included in the final analysis. Overall, mean postoperative deviation from target correction ranged from 0.3° to 1° for all studies using hip-knee angle measurements and 2.3% to 4.9% for all studies using weight-bearing line measurements. The incidence of correction outliers was assessed in 8 total studies and ranged from 0 to 25% (total n = 10 knees) of patients corrected with 3D-printed PSI. Osteotomies performed with 3D-printed cutting guides or wedges demonstrated significantly shorter operative times (P < .05) and fewer intraoperative fluoroscopic images (P < .05) than control groups in four case control studies. CONCLUSION: Patients undergoing distal femoral osteotomy or proximal tibial osteotomy procedures with 3D-printed patient-specific cutting guides and wedges had highly accurate coronal plane alignment with a low rate of outliers. Patients treated with 3D printed PSI also demonstrated significantly shorter operative times and decreased intraoperative fluoroscopy when compared to conventional techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Biomechanical Analysis of Segmental Medial Meniscal Transplantation in a Human Cadaveric Model.

BACKGROUND: Meniscal deficiency has been reported to increase contact pressures in the affected tibiofemoral joint, possibly leading to degenerative changes. Current surgical options include meniscal allograft transplantation and insertion of segmental meniscal scaffolds. Little is known about segmental meniscal allograft transplantation. PURPOSE: To evaluate the effectiveness of segmental medial meniscal allograft transplantation in the setting of partial medial meniscectomy in restoring native knee loading characteristics. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen human cadaveric knees underwent central midbody medial meniscectomy and subsequent segmental medial meniscal allograft transplantation. Knees were loaded in a dynamic tensile testing machine to 1000 N for 20 seconds at 0°, 30°, 60°, and 90° of flexion. Four conditions were tested: (1) intact medial meniscus, (2) deficient medial meniscus, (3) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures, and (4) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures and 1 suture fixed through 2 bone tunnels. Submeniscal medial and lateral pressure-mapping sensors assessed mean contact pressure, peak contact pressure, mean contact area, and pressure mapping. Two-factor random-intercepts linear mixed effects models compared pressure and contact area measurements among experimental conditions. RESULTS: The meniscal-deficient state demonstrated a significantly higher mean contact pressure than all other testing conditions (mean difference, ≥0.35 MPa; P < .001 for all comparisons) and a significantly smaller total contact area as compared with all other testing conditions (mean difference, ≤140 mm2; P < .001 for all comparisons). There were no significant differences in mean contact pressure or total contact area among the intact, transplant, or transplant-with-tunnel groups or in any outcome measure across all comparisons in the lateral compartment. No significant differences existed in center of pressure and relative pressure distribution across testing conditions. CONCLUSION: Segmental medial meniscal allograft transplantation restored the medial compartment mean contact pressure and mean contact area to values measured in the intact medial compartment. CLINICAL RELEVANCE: Segmental medial meniscal transplantation may provide an alternative to full meniscal transplantation by addressing only the deficient portion of the meniscus with transplanted tissue. Additional work is required to validate long-term fixation strength and biologic integration.

The Impact of COVID-19 on the Orthopaedic Sports Medicine Fellowship Application Process.

Over the last year, coronavirus disease 2019 (COVID-19) has spread across the world as a global pandemic, bringing unprecedented changes to the healthcare landscape for patients and physicians. Medical trainees have been similarly affected, as medical schools throughout the United States have implemented remote learning-based curriculums and withdrawn third- and fourth-year students from in-hospital clerkships. Of particular importance is the impact of COVID-19 on current orthopaedic surgery residents applying to subspecialty fellowship programs. Because of the highly transmissible nature of the virus and current social distancing restrictions, orthopaedic sports medicine fellowship interviews are being held virtually during the 2020-2021 application cycle. This transition to videoconference interviewing may de-emphasize an applicant's unique personality or interpersonal interactions that are traditionally captured in a variety of settings during the interview day. In turn, this may lead to increased prioritization of various aspects of the application, such as the applicant's residency program, letters of recommendation, and research productivity. Matching to a sports medicine fellowship program is an inherently competitive process and the COVID-19 pandemic presents novel challenges to orthopaedic residents in their efforts to successfully match. The purpose of this review is to describe the changes made to the orthopaedic sports medicine fellowship interview process resulting from COVID-19 during the 2020-2021 application cycle and discuss how these changes may impact the future fellowship application process. This review discusses the changes made to the orthopaedic sports medicine fellowship interview process caused by COVID-19 during the 2020-2021 application cycle. This review also assesses how such changes may impact the future application process and proposes potential adaptations to the current virtual interview format if it should become the new standard moving forward.

Pullout Strength of All-Suture and Metallic Anchors in Repair of Lateral Collateral Ligament Injuries of the Elbow.

PURPOSE: To compare the biomechanical properties of metallic anchor (MA) and all-suture anchor (ASA) constructs in the anatomic reattachment of the lateral ulnar collateral ligament complex to its humeral insertion. METHODS: Twenty paired male human cadaveric elbows with a mean age of 46.3 years (range: 33-58 years) were used in this study. Each pair was randomly allocated across 2 groups of either MA or ASA. A single 3.5-mm MA or 2.6-mm ASA was then inserted flush into the lateral epicondyle. A dynamic tensile testing machine was used to perform cyclic loading followed by a load to failure test. During the cyclic loading phase, the anchors were sinusoidally tensioned from 10 N to 100 N for 1,000 cycles at a frequency of 0.5 Hz. In the load to failure test, the anchors were pulled at a rate of 3 mm/s. Load at 1-mm and 2-mm displacement, as well as load to ultimate failure were assessed. Clinical failure was defined as displacement of more than 2 mm. Normality of data was assessed with the Shapiro-Wilk test. Continuous data are presented as medians and compared with the Mann-Whitney U test and categorical data was compared with the χ2 test or Fisher exact test. RESULTS: Displacement was significantly greater for the ASA group during cyclic loading starting from the tenth cycle (P < .05). Displacement of more than 5 mm within the first 100 cycles was observed in 2 anchors in the ASA group. No difference was observed in loads required to displace 1 mm (MA: 146 N [6-169] vs ASA: 144 N [2-153]; P = .53) and 2 mm (MA: 171 N [13-202] vs ASA: 161 N [9-191]; P = .97), but there was a statistically significant difference between ultimate loads in favor of ASA in the load to failure test (MA: 297 N [84-343] vs 463 N [176-620]; P < .01). CONCLUSIONS: In the cyclic test, no difference in clinical failure defined as pull-out of more than 2 mm was observed between 3.5 mm MAs and 2.6 mm ASAs. In the ultimate load to failure analysis, no difference was observed between groups in force causing 1 and 2 mm of displacement, but there was a significant difference in favor of ASA in the pull to ultimate failure test. CLINICAL RELEVANCE: Potential benefits of all-suture anchors include preservation of bone stock, reduced radiographic artifacts, and easier revisions. Although their use has been investigated thoroughly in the shoulder, there remains a paucity of literature regarding displacement and pull-out strength in the elbow.

Postoperative Stiffness and Pain After Arthroscopic Labral Stabilization: Consider Anchor Arthropathy.

PURPOSE: To describe the key clinical, imaging, and arthroscopic characteristics of anchor arthropathy after arthroscopic shoulder stabilization procedures and, secondarily, to define risk factors for the development of anchor-induced arthropathy. METHODS: A total of 23 patients who underwent revision arthroscopic shoulder surgery and were diagnosed with glenohumeral arthropathy were retrospectively identified from prospectively collected data registries between January 2000 and May 2018. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, and examination findings before revision surgery. Pre-revision imaging was used to assess presence of glenohumeral osteoarthritis and chondromalacia, anchors/sutures, loose bodies, and labral pathology. The same parameters were recorded intraoperatively during revision surgery. Descriptive statistics were performed for demographic data and means with standard deviations were calculated for continuous data. A McNemar-Bowker test was used to analyze marginal homogeneity between preoperative imaging and intraoperative findings. RESULTS: Mean age at presentation was 33.4 ± 11.7 years (range 16-59, 17 male patients; 6 female patients). More than one half (13/23) developed symptoms within 10 months after index arthroscopic procedure (mean 32.2 ± 59.9 months, range <1 to 165.2 months) with 87% presenting with pain and 100% presenting with loss of motion on examination. Plain radiographs demonstrated humeral osteoarthritis in 57% (13/23) of patients, magnetic resonance imaging (MRI) revealed recurrent labral pathology in 19 of 23 (83%) patients, potential proud implants in 12 of 23 (52%), and loose bodies in 12 of 23 (52%). Intraoperatively, all had evidence of osteoarthritis; 22 of 23 (96%) had prominent implants. Humeral head chondromalacia was present in 21 of 23 patients (91%), the majority of which was linear stripe wear, and 6 of 23 (26%) had severe global glenohumeral osteoarthritis. Statistical analysis revealed a 54.5% (95% confidence interval 0.327-0.749) sensitivity of MRI identification of proud implants with a specificity of 100% (95% confidence interval 0.055-1). The ability of MRI to accurately assess chondromalacia of the humeral head (P = .342) or glenoid (P = .685) was not statistically significant. CONCLUSIONS: Anchor arthropathy is characterized by symptoms of pain and stiffness on examination and in many cases develops early after stabilization surgery (<10 months). Implants were implicated in the majority of cases of humeral head chondromalacia. MRI scans may produce false-negative identification of proud implants and can be a poor predictor of the severity of chondromalacia and intra-articular pathology; thus, a high index of clinical suspicion is necessary in patients with motion loss and pain postoperatively. LEVEL OF EVIDENCE: Level IV, case series.

Anchor Arthropathy of the Shoulder Joint After Instability Repair: Outcomes Improve With Revision Surgery.

PURPOSE: To report clinical and patient-reported outcome measures (PROMs) in patients undergoing revision surgery after diagnosis of anchor-induced arthropathy. METHODS: Patients who underwent revision arthroscopic shoulder surgery and were diagnosed with post-instability glenohumeral arthropathy performed from January 2006 to May 2018 were included in the current study. Patients were excluded if they underwent prior open shoulder procedures, if glenoid bone loss was present, or if prerevision imaging and records were incomplete or not available. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, exam findings before revision surgery, and surgical intervention. PROMs were prospectively collected before surgery and at minimum 2-year follow-up. RESULTS: Fourteen patients were included with a mean (± standard deviation) age at presentation of 35.2 ± 12.1 years (range 16 to 59). The follow-up rate was 86%, with a mean follow-up of 3.8 years (range 1.1 to 10.6). Mean time to development of arthropathy symptoms was 48.2 months (range <1 month to 13.8 years), all presenting with pain and decreased range of motion on exam. At time of revision surgery, all patients underwent either open or arthroscopic removal of previous implants, including anchors and suture material. Six patients underwent additional revision stabilization procedures, 1 underwent total shoulder arthroplasty, and 7 underwent arthroscopic intraarticular debridement, capsular release, and chondroplasty with or without microfracture. Pain significantly improved in 79% of patients (P = .05). Significant improvements in all PROMs were observed, including 12-item Short Form (43.8 to 54.8, P < .01); Disabilities of the Arm, Shoulder, and Hand, shortened version (31.8 to 8.4, P < .01); Single Assessment Numeric Evaluation (47.0 to 84.5, P < .05); and American Shoulder and Elbow Surgeons (61.6 to 92.1, P < .01). Average external rotation significantly improved, from 31° ± 22° to 52° ± 24° (P = .02). CONCLUSION: Rapid intervention after diagnosis, through either revision arthroscopic or open debridement and stabilization, can lead to significant improvement in range of motion, pain, and overall patient function and satisfaction. LEVEL OF EVIDENCE: IV, retrospective case series.

Surgical Treatment of Medial Gastrocnemius Tear.

Medial gastrocnemius tears typically occur with forced dorsiflexion while the knee is extended. Myotendinous injuries occur most commonly, which are almost always treated without surgery. If a tendinous injury or avulsion occurs, nonoperative treatment should first be attempted. However, in patients where forceful plantar flexion is required for their desired activities or occupation, surgical fixation is an important treatment option. Postoperative bracing should be used to protect the repair with a graduated therapy progression, including range of motion followed by strengthening and return to activities. This technical note describes the technique for a safe and reliable medial gastrocnemius tendinous repair using two suture anchors.

Multidirectional Shoulder Instability With Circumferential Labral Tear and Bony Reverse Hill Sachs: Treatment with 270° Labral Repair and Fresh Talus Osteochondral Allograft to the Humeral Head.

Traumatic posterior dislocations of the shoulder can result in bony defects, labral tears, and cartilage injuries of the glenohumeral joint. Although traditional Hill-Sachs lesions from anterior dislocations are more commonly identified, reverse Hill-Sachs lesions caused by posterior dislocation often leads to recurrent engagement of the humeral head with the glenoid and significantly greater damage to the humeral chondral surface. In severe traumatic cases, concomitant damage of the capsulolabral soft tissues, such as circumferential labral lesions, can lead to chronic shoulder instability and residual glenoid bone loss. These lesions further add to the complexity of managing patients with posterior dislocations of the shoulder because of the challenges of achieving adequate anatomic reduction and tensioning of the capsulolabral junction, while also using a combination of arthroscopic and open-labral repair techniques. In the setting of reverse Hill-Sachs lesions treatment, it is important to address the bony and cartilage defect. The purpose of this Technical Note is to describe our preferred technique for arthroscopic repair of circumferential lesions of the glenoid labrum causing multidirectional instability with concomitant reverse Hill-Sachs Lesion treatment with fresh talus osteochondral allograft.

Limited Predictive Value of the Instability Severity Index Score: Evaluation of 217 Consecutive Cases of Recurrent Anterior Shoulder Instability.

PURPOSE: To review the existing variables and their ability to predict recurrence of shoulder instability as it relates to the Instability Severity Index Score (ISIS), as well as evaluate any other pertinent imaging and patient history variables that may impact risk of recurrent anterior instability after arthroscopic Bankart repair. METHODS: All consecutive patients with recurrent anterior shoulder instability and who had arthroscopic instability repair were identified. Exclusion criteria were prior surgery on the shoulder, posterior or multidirectional instability, instability caused by seizure disorder, or a rotator cuff tear. All ISIS variables were recorded (age <20 years, sport type and level, hyperlaxity, Hill-Sachs on anteroposterior external rotation radiograph, loss of glenoid contour on anteroposterior radiograph), as well as additional variables: (1) number of instability events; (2) total time of instability; (3) glenoid bone loss (GBL) percent; and (4) Hill-Sachs measures (H/L/W/D/Volume). Postoperative outcomes were assessed based on the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons (ASES) scores, and recurrent anterior instability. Regression analysis was used to determine preoperative variables that predicted outcomes and failures. RESULTS: There were 217 consecutive patients (209 male patients [96.5%], 8 female patients [3.5%]) who met the inclusion criteria and were all treated with a primary arthroscopic shoulder stabilization during a 3.5-year period (2007-2011), with a mean follow-up time of 42 months (range, 26-58). The mean age at first instability event was 23.9 years (range, 16-48 years) and the mean cumulative ISIS score for the overall group was 3.6 (range, 1-6). Outcomes were improved from mean preoperative (WOSI = 1,050/2,100; ASES = 61.0; SANE = 52.5) to postoperative (WOSI = 305/2,100; ASES = 93.5; SANE = 95.5). A total of 11.5% (25/217) of patients had evidence of recurrent instability (subluxation or dislocation). Additionally, all 25 patients who failed postoperatively also had consistently inferior ASES, SANE, and WOSI outcome scores when compared with successfully treated patients. Factors associated with failure were GBL greater than 14.5% (P < .001), total time of instability symptoms greater than 3 months (P = .03), Hill-Sachs volume greater than 1.3 cm3 (P = .02), contact sports participation (P = .05), and age 20 years or younger (P < .01). There was no correlation in outcomes with Hill-Sachs on presence of glenoid contour loss on radiograph (P = .07), participation sports, or ISIS (mean = 3.4 success vs 3.9 failure, P > .05). CONCLUSIONS: At a mean follow-up of 42 months was an 11.5% failure rate after arthroscopic Bankart stabilization surgery. This study shows no correlation between treatment outcome and the ISIS measure, given a mean score of 3.4 for the overall cohort with little difference identified in those who failed. However, several important parameters previously unidentified were detected including, GBL greater than 14.5%, Hill-Sachs volume greater than 1.3 cm3, and duration of instability symptoms (>3 months). The ISIS may need to be redesigned to incorporate variables that more accurately portray the actual risk of failure after arthroscopic stabilization, including quantification of both glenoid and humeral head bone loss. LEVEL OF EVIDENCE: III (Retrospective Case Series).