Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta-analysis.

PURPOSE: To evaluate the impact of age as a risk factor on the revision rates of anterior cruciate ligament (ACL) primary repair (ACLPR), dynamic intraligamentary stabilization (DIS) and bridge-enhanced ACL restoration (BEAR) compared to ACL reconstruction (ACLR). METHODS: A systematic literature search was performed for comparative studies comparing outcomes for ACLPR, DIS or BEAR to ACLR. A random-effects meta-analysis was performed to assess nondifferentiated and age-differentiated (skeletally mature patients ≤21 and >21 years) ACL revision and reoperation risk, as well as results for subjective outcomes. Methodological study quality was assessed using the Risk of Bias Tool 2.0c and Methodological Index for Nonrandomized Studies tools. RESULTS: A total of 12 studies (n = 1277) were included. ACLR demonstrated a lower nonage-stratified revision risk at 2 years versus ACLPR, DIS and BEAR, but a similar revision risk at 5 years when compared to DIS. However, an age-stratified analysis demonstrated a significantly increased ACLPR revision risk as compared to ACLR in skeletally mature patients ≤21 years of age (risk ratios [RR], 6.33; 95% confidence interval [CI], 1.18-33.87, p = 0.03), while adults (>21 years) showed no significant difference between groups (RR, 1.48; 95% CI, 0.25-8.91, n.s.). Furthermore, DIS reoperation rates were significantly higher than respective ACLR rates (RR, 2.22; 95% CI, 1.35-3.65, p = 0.002), whereas BEAR (RR, 1.07; 95% CI, 0.41-2.75, n.s.) and ACLPR (RR, 0.81; 95% CI, 0.21-3.09, n.s.) showed no differences. IKDC scores were equivalent for all techniques. However, ACLPR exhibited significantly better FJS (mean difference, 11.93; 95% CI, 6.36-17.51, p < 0.0001) and Knee injury and Osteoarthritis Outcome Score Symptoms (mean difference, 3.01; 95% CI, 0.42-5.60, p = 0.02), along with a lower Tegner activity reduction. CONCLUSIONS: ACLPR in skeletally mature patients ≤21 years of age is associated with up to a six-fold risk increase for ACL revision surgery compared to ACLR; however, adults (>21 years) present no significant difference. Based on the current data, age emerges as a crucial risk factor and should be considered when deciding on the appropriate treatment option in proximal ACL tears. LEVEL OF EVIDENCE: Level III.

Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function: A prospective comparative study.

PURPOSE: The aim of this study was to investigate the influence of preoperative anxiety and depression on subjective function, pain and revision rates following total knee arthroplasty (TKA). METHODS: A prospective comparative study was conducted, including 349 patients undergoing TKA surgery between January 2019 and April 2021. Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire preoperatively, and a set of Patient-Reported Outcome Measures (PROMs) preoperatively and at 6, 12 and 24 months postoperatively. Patients were categorized into anxiety and depression groups based on HADS scores. PROMs included the Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS) and NRS-Pain. Differences in PROM scores between the anxiety/depression group and, respectively, nonanxiety/nondepression group were assessed, as well as differences in minimal clinical important difference (MCID) and attainment of Patient Acceptable Symptom State (PASS). Lastly, revision rates were compared. RESULTS: Anxiety and depression groups exhibited inferior subjective function preoperatively and postoperatively compared to nonanxiety and nondepression groups (all p < 0.05), experienced more pain preoperatively (p < 0.001) and also postoperatively for depression patients (all p < 0.05). Significantly fewer patients with anxiety and depression reached the PASS for KOOS-PS, OKS and NRS-Pain (all p < 0.05). There were no differences in the proportion of patients reaching the MCID for all PROMs (all p > 0.060), and revision rates did not differ between groups (both p > 0.96). CONCLUSION: Preoperative anxiety and depression negatively influence subjective function and pain preoperatively and up to 2-year follow-up in patients undergoing TKA. Revision rates did not differ between groups, and there were no relevant differences in clinical improvement of subjective function and pain. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Rates and predictors of reimplantation of matrix-induced autologous chondrocyte implantation following first stage cartilage harvest: A cohort study.

PURPOSE: To assess the reimplantation rate and predictors of patients requiring second-staged matrix-induced autologous chondrocyte implantation (MACI) reimplantation after initial first stage cartilage biopsy. METHODS: A retrospective review was performed from 2018 to 2022 among patients who underwent only phase I MACI biopsy procedure (biopsy group) or both phase I with transition to phase II implantation of chondrocytes (implantation group) at a single tertiary center. Demographic, qualitative, and quantitative measurements were recorded, and univariate and multivariate regression analysis was performed to assess predictors of ultimately requiring second stage MACI implantation. RESULTS: A total of 71 patients (51% female, age 27.7 ± 10.6 years (range 12-50)) were included in this study. Eventually, 25 of 71 patients (35.2%) experienced persistence of symptoms after initial MACI biopsy and other concomitant procedures, requiring second-stage implantation. Univariate analysis showed the implantation group compared to the biopsy group had a greater lesion size (5.2 cm2 ± 3.3 vs. 3.3 cm2 ± 1.4, p = 0.024), a higher proportion patients ≥ 26 years of age (76% vs. 43%, p = 0.009), a medial femoral condyle lesion more commonly (33% vs 11%, p = 0.005), were more often female (72% vs. 39%, p = 0.008), and had less often soft tissue repair at time of biopsy (32% vs. 61%, p = 0.020). Backward multivariate logistic regression analysis revealed that size of the lesion (OR 1.43, p = 0.031) and age ≥ 26 years old at time of biopsy (OR 3.55, p = 0.042) were independent predictors of not responding to initial surgery and requiring implantation surgery. CONCLUSION: This study found that 35% of patients undergoing MACI phase I biopsy harvest eventually required autologous implantation. Independent risk factors for progressing to implantation after failed initial surgery were larger defect size and older age. LEVEL OF EVIDENCE: III, Cohort Study.

Comparison of the early postoperative outcomes of cementless and cemented medial unicompartmental knee arthroplasty.

Aims: The primary objective of this registry-based study was to compare patient-reported outcomes of cementless and cemented medial unicompartmental knee arthroplasty (UKA) during the first postoperative year. The secondary objective was to assess one- and three-year implant survival of both fixation techniques. Methods: We analyzed 10,862 cementless and 7,917 cemented UKA cases enrolled in the Dutch Arthroplasty Registry, operated between 2017 and 2021. Pre- to postoperative change in outcomes at six and 12 months' follow-up were compared using mixed model analyses. Kaplan-Meier and Cox regression models were applied to quantify differences in implant survival. Adjustments were made for patient-specific variables and annual hospital volume. Results: Change from baseline in the Oxford Knee Score (OKS) and activity-related pain was comparable between groups. Adjustment for covariates demonstrated a minimally greater decrease in rest-related pain in the cemented group (ß = -0.09 (95% confidence interval (CI) -0.16 to -0.01)). Cementless fixation was associated with a higher probability of achieving an excellent OKS outcome (> 41 points) (adjusted odds ratio 1.2 (95% CI 1.1 to 1.3)). The likelihood of one-year implant survival was greater for cemented implants (adjusted hazard ratio (HR) 1.35 (95% CI 1.01 to 1.71)), with higher revision rates for periprosthetic fractures of cementless implants. During two to three years' follow-up, the likelihood of implant survival was non-significantly greater for cementless UKA (adjusted HR 0.64 (95% CI 0.40 to 1.04)), primarily due to increased revision rates for tibial loosening of cemented implants. Conclusion: Cementless and cemented medial UKA led to comparable improvement in physical function and pain reduction during the initial postoperative year, albeit with a greater likelihood of achieving excellent OKS outcomes after cementless UKA. Anticipated differences in early physical function and pain should not be a decisive factor in the choice of fixation technique. However, surgeons should consider the differences in short- and long-term implant survival when deciding which implant to use.

Knotless Re-tensionable Direct Fixation of Medial Meniscus Posterior Root Tears.

Over the past decade, there has been an increased awareness of the recognition and treatment of medial meniscus posterior root tears. Recent systematic reviews and meta-analyses have shown that surgical repair of medial meniscus posterior root tears is effective in improving patient-reported outcome measures and decreasing the progression of osteoarthritis when compared with nonoperative treatment or meniscectomy. The available techniques currently consist of transosseous suture fixation and direct suture anchor fixation, with transosseous repairs being the most frequently performed. Transosseous fixation relies on indirect fixation on the anterior tibial cortex, which may predispose to gap formation at the repair site. On the other hand, suture anchor fixation is technically demanding with arthroscopic placement of the anchor perpendicular to the tibial plateau at the posterior medial root insertion. Furthermore, re-tensioning of the construct is not possible with the current techniques. In this technical note, we present a knotless re-tensionable direct fixation technique using an anterior tibial tunnel, which has the advantages of direct fixation, a rip-stop suture configuration, a reproducible surgical technique, and the possibility of re-tensioning of the repaired meniscal root.

Management of Bone Loss in Posterior Glenohumeral Shoulder Instability: Current Concepts.

¼ Posterior glenohumeral instability is relatively uncommon compared with anterior instability, but is becoming an increasingly recognized and surgically managed shoulder pathology.¼ Soft-tissue stabilization alone may not be sufficient in patients who present with substantial bone loss to the posterior glenoid and/or the anterior humeral head.¼ For posterior glenoid defects, posterior glenoid osteoarticular augmentation can be used, and posterior glenoid opening wedge osteotomy can be considered in cases of posterior instability with pathologic retroversion.¼ For humeral head lesions, several surgical treatment options are available including subscapularis transposition into the humeral head defect, autograft or allograft reconstruction, humeral rotation osteotomy, and shoulder arthroplasty.

Bioactive and Bioinductive Implants Are Increasingly Used in Orthopaedic Sports Medicine but Adequately Controlled Studies Are Needed: A Scoping Review.

PURPOSE: To describe the currently available literature reporting clinical outcomes for bioactive and bioinductive implants in sports medicine. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of 4 databases was completed to identify eligible studies. Inclusion criteria were studies using bioactive or bioinductive implants in human clinical studies for sports medicine procedures. Data were extracted and reported in narrative form, along with study characteristics. RESULTS: In total, 145 studies were included involving 6,043 patients. The majority of included studies were level IV evidence (65.5%), and only 36 included a control group (24.8%). Bioactive materials are defined as any materials that stimulate an advantageous response from the body upon implantation, whereas bioinductive materials provide a favorable environment for a biological response initiated by the host. Bioactivity can speed healing and improve clinical outcome by improving vascularization, osteointegration, osteoinduction, tendon healing, and soft-tissue regeneration or inducing immunosuppression or preventing infection. The most common implants reported were for knee (67.6%, primarily cartilage [most commonly osteochondral defects], anterior cruciate ligament, and meniscus), shoulder (16.6%, primarily rotator cuff), or ankle (11.7%, primarily Achilles repair). The most common type of implant was synthetic (44.1%), followed by autograft (30.3%), xenograft (16.6%), and allograft (9.0%). In total, 69% of implants were standalone treatments and 31% were augmentation. CONCLUSIONS: The existing bioactive and bioinductive implant literature in sports medicine is largely composed of small, low-level-of-evidence studies lacking a control group. CLINICAL RELEVANCE: Before bioactive implants can be adapted as a new standard of care, larger, comparative clinical outcome studies with long-term follow-up are essential.

Editorial Commentary: Suture-Button Fixation May Have Advantages Over Screw Fixation for Glenoid Bone Grafting Procedures for Shoulder Instability.

Orthopaedic suture buttons have been increasingly used in a variety of procedures, such as syndesmosis stabilization, coracoclavicular ligament repair, anterior cruciate ligament graft fixation, and Lisfranc injury treatment. In many instances, suture-button fixation constructs have shown equivalent, if not superior, outcomes to screw fixation. More recently, suture buttons have been suggested for osseous fixation of the coracoid during the Latarjet procedure, as well as other anterior (or posterior) bone block reconstruction of the glenoid using distal tibial allograft, tricortical iliac crest, or distal clavicle in cases of complex shoulder instability. Suture buttons offer several unique advantages, including the ability to tension and retension graft fixation, smaller driller paths with bone preservation, less osteolysis, lower risk of hardware removal, and greater ease of hardware revision and/or secondary surgery. However, certain disadvantages also exist, such as higher implant costs, less time-zero implant rigidity, technical difficulty, and, potentially, less mediolateral stability of the bone graft. Time will tell if these suture-button constructs will supplant traditional screw fixation for the Latarjet procedure in terms of clinical and cost-effectiveness.

Lever sign test shows high diagnostic accuracy for anterior cruciate ligament injuries: A systematic review and meta-analysis of 3299 observations.

PURPOSE: Injuries of the anterior cruciate ligament (ACL) are common knee injuries among active and younger patients. The Lever Sign Test (LST) is a relatively newer test, of which the accuracy is disputed in the existing literature. The aim of this study was to assess the accuracy with and without anesthesia of the Lever Sign test in the literature. METHODS: PRISMA guidelines were followed, studies were identified using PubMed, EMBASE and Google Scholar. All studies that reported accuracy of LST performed by a clinical professional were included. Integrity of ACL was confirmed using magnetic resonance imaging or arthroscopy. Sensitivity and specificity were calculated using uni- and bivariate methods. RESULTS: After inclusion, 3299 observations in 2516 patients were included from 23 studies. Mean age was 31.8 years and 64.2% were male. Without anesthesia, sensitivity was 79.2% (95% CI 68.7-86.9) and specificity was 92.0% (95% CI 82.2-96.6). An area under the curve (AUC) of 86.1% was found. With anesthesia, sensitivity was 86.6% (95% CI 68.0-95.2), specificity was 93.4% (95% CI 84.5-97.3) and the AUC was 91.6%. CONCLUSION: The Lever Sign test shows very good to excellent accuracy for ACL injury, and is a useful tool for clinical practice.

Role of Preoperative Intra-Articular Corticosteroid Injections on Periprosthetic Joint Infection in Total Hip Arthroplasty and Its Association With Preoperative Timing: A Single-Center Series of 5,909 Hips.

BACKGROUND: Preoperative intra-articular corticosteroid injections to the hip joint increase the risk of periprosthetic joint infection (PJI) during primary total hip arthroplasty (THA). This study aimed to determine the relationship between preoperative timing of intra-articular corticosteroid injections and PJI risk following THA using data from a single-center hospital. METHODS: This single-center, retrospective cohort study included patients who underwent a THA between 2014 and 2020. Medical records were checked for intra-articular corticosteroid injections and PJI within 1 year of surgery. Patients were categorized into groups based on whether they received "no injection" or "injection 0 to 3 months," "3 to 6 months," and "> 6 months prior to THA." Hazard ratios (HRs) for these groups were calculated using multivariate Cox regression analysis, correcting for potential confounders, and presented with 95% confidence intervals [95% CIs]. RESULTS: In total, 4,507 patients (5,909 THAs) were identified. A total of 1,581 patients (27%) received an injection prior to THA. Without considering the timing factor, no increased risk for PJI following an intra-articular injection was noted (P = .19). Comparing the specified groups using multivariate analysis, corticosteroid injection within 3 months of THA showed an increased risk of PJI (HR 2.63, 95% CI 1.18 to 5.87, P = .018), but this effect was not observed for the "injection 3 to 6 months" group (HR 1.51, 95% CI 0.74 to 3.08, P = .264). CONCLUSIONS: Corticosteroid injections administered up to 3 months prior to THA increased the risk of PJI within 1 year after THA, with an HR of 2.63; however, injections between 3 and 6 months before surgery did not have a significantly higher infection rate.

Editorial Commentary: Lower Trapezius Transfer May Be Indicated for Surgical Management of Massive Irreparable Rotator Cuff Tears in Younger, Non-Arthritic Patients.

Although shoulder rotator cuff repair fixation constructs and suture anchor design have evolved, repair of massive or functionally irreparable tears historically has relied on tendon mobilization and compression, optimizing footprint biology, and attempting a tension-free repair. However, despite these efforts, rates of failure of complete healing may be high, ranging from 20% to 94%. This has led to a search for alternative approaches, including bridging grafts, subacromial balloons, superior capsular reconstructions, biologic tuberoplasties, bursal acromial grafts, and, ultimately, renewed interest in tendon transfers. The latissimus dorsi transfer was traditionally a preferred tendon-transfer technique for posterosuperior massive cuff tears, but inconsistent outcomes have resulted in declining popularity. Recently, the lower trapezius transfer (LTT) has gained acceptance for the treatment of posterosuperior tears, particularly with external rotation weakness and lag signs. The LTT is biomechanically superior to the latissimus dorsi transfer, offering a more native vector of pull and in-phase activation. LTT could be indicated for younger patients with massive cuff tears. However, LTT is relatively contraindicated in patients with cuff tear arthropathy; combined loss of elevation and external rotation; irreparable subscapularis tear; teres minor involvement; and/or those of advanced age or unable to comply with rigid rehabilitation guidelines.

The phenotypic diversity of anteromedial osteoarthritis before and after treatment with medial unicompartmental knee arthroplasty: A radiographic analysis of 1000 knees.

PURPOSE: This study aimed to assess phenotypic variation in the coronal plane of knees with anteromedial osteoarthritis using the functional knee phenotype classification, before and after treatment with medial unicompartmental knee arthroplasty (UKA). METHODS: The study comprised 1000 knees of 835 patients (45% females, 55% males, 90% Caucasian) who underwent medial UKA for anteromedial osteoarthritis. Pre and postoperative alignment was evaluated through the hip-knee-ankle angle (HKA), femoral mechanical angle (FMA), and tibial mechanical angle (TMA). Knees were classified according to the functional knee phenotype system which combines limb phenotype (HKA), and femoral and tibial knee phenotypes (FMA and TMA, respectively). Restoration of prearthritic coronal alignment following medial UKA was evaluated by phenotype. RESULTS: Preoperatively, 76 distinct and 25 relevant (prevalence ≥1%) functional knee phenotypes were identified, of which VARHKA 6°VARFMA 3°NEUTMA 0° was the most common (9.4% of knees). The most prevalent limb phenotype, VARHKA 6°, comprised 15 distinct knee phenotypes (FMA and TMA combinations). Postoperatively, 58 distinct and 17 relevant functional knee phenotypes were observed, of which VARHKA 3°NEUFMA 0°NEUTMA 0° had the highest prevalence at 18.3%. Knees with combined tibial and femoral deformities were associated with a lower probability of restoration of prearthritic coronal alignment following medial UKA, compared to knees without extra-articular deformity, or knees with an isolated tibial or femoral deformity. CONCLUSION: Phenotype analysis using the functional knee phenotype system demonstrated a wide diversity of coronal alignment phenotypes among knees with anteromedial osteoarthritis in a predominantly Caucasian population. Following medial UKA, a reduction from 25 preoperative to 17 postoperative relevant phenotypes was observed. Consideration of phenotypic variation can be of importance when aiming to restore prearthritic coronal alignment during medial UKA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Early Anterior Cruciate Ligament Treatment Might Be Crucial for Acute Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Systematic Review of the Various Treatment Strategies.

PURPOSE: To assess the outcomes of acute, combined, complete anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in the literature. METHODS: A literature search using PubMed, Embase, Scopus, and Cochrane Reviews was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria were studies reporting outcomes of complete ACL-MCL injuries at a minimum of 12 months' follow-up. Data were presented as ranges. RESULTS: Twenty-seven studies with 821 patients were included (mean age, 29 years; 61% male patients; mean follow-up period, 27 months). There were 4 randomized trials, 10 Level III studies, and 13 Level IV studies. Nine different strategies were noted, of which nonoperative MCL treatment with acute ACL reconstruction and acute MCL repair with acute ACL reconstruction were most commonly performed. Nonoperative MCL-ACL treatment and acute MCL repair with nonoperative ACL treatment led to low rates of valgus stability at 30° of flexion (27%-68% and 36%-77%, respectively) compared with acute ACL reconstruction with either nonoperative MCL treatment (80%-100%), acute MCL repair (65%-100%), or acute MCL reconstruction (81%-100%). Lysholm scores were not different between the strategies. CONCLUSIONS: Outcomes in this systematic review suggest that ACL stabilization in the acute setting might result in the lowest rates of residual valgus laxity, whereas there is no clear difference between the different MCL treatments along with acute ACL reconstruction. Nonoperative MCL treatment with either nonoperative or delayed ACL reconstruction, as well as acute MCL repair with either nonoperative or delayed ACL reconstruction, leads to higher rates of valgus laxity. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Editorial Commentary: Meniscal Allograft Transplantation Is Effective for Adolescents With Meniscal Insufficiency, Although Outcomes May Decline Over Time.

Over the last several years, there has been a shift from arthroscopic partial meniscectomy to meniscal repair, especially in the younger patient. In case of a necessary partial meniscectomy, some patients have unremittent symptoms of pain and effusion corresponding to the postmeniscectomy syndrome. In these patients without large coronal malalignment, meniscal allograft transplantation is a valuable option to restore contact pressures, promote a chondroprotective microenvironment, and potentially delay secondary surgical interventions symptoms. In the adolescent population, meniscal allograft transplantation has been shown to effectively improve patient-reported outcomes with a low conversion to arthroplasty. However, these treatments are far from ideal, and prevention is certainly better than the cure: timely diagnosis of meniscus injuries, appropriate treatment with meniscus repair rather than partial meniscectomy, even in the complex tear patterns, and consideration of corrective osteotomy for milder cases of malalignment.

Low Recurrence of Instability and Satisfying Patient-Reported Outcomes Following Various Surgical Treatments of Reverse Hill-Sachs Lesions in the Setting of Posterior Instability: A Systematic Review.

PURPOSE: To systematically review the literature and report the outcomes of various surgical treatments for reverse Hill-Sachs lesions (RHSL) in the setting of posterior shoulder instability. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. All studies assessing outcomes of surgical treatment of RHSL from inception to January 2023 were identified in PubMed, Embase, and Cochrane Library. Inclusion criteria consisted of studies reporting outcomes, minimum mean 1-year follow-up, and minimum Level IV evidence. Outcomes were assessed using Forest plots with random effects models using R software. RESULTS: A total of 29 studies consisting of 291 patients were included with a mean age of 42 years (range 16-88 years), 87% male gender, and mean follow-up of 4.5 years. The mean size of impacted or affected cartilage was 35%, and time from injury to surgery was mean 15 weeks. Nearly all studies were Level IV evidence, and quality of studies was low. Random effect models were performed, and data are presented as range. A low incidence of instability was noted for all surgical techniques with good patient-reported outcome measures. Most studies reported outcomes of the modified McLaughlin procedure (13 studies, 126 patients) with overall Constant-Murley Score of 65 to 92. Trends were seen towards better Constant-Murley Score and external rotation with a shorter delay between injury, and when arthroscopic and joint preserving treatments were performed. CONCLUSIONS: This systematic review showed low rates of instability recurrence, reproducible range of motion, and favorable patient-reported outcome measures were reported following all treatments for RHSLs with posterior instability. There was a significant association between better outcomes and a shorter delay between injury and surgery. The level of evidence is limited, given the small and retrospective studies which can be explained by the rarity of these injuries. LEVEL OF EVIDENCE: Level IV; systematic review of Level III and IV studies.

Magnitude of Change in Leg Length and Clinical Impact Following Medial Unicompartmental Knee Arthroplasty.

BACKGROUND: Change in leg length and leg-length discrepancy (LLD) are common concerns among patients undergoing medial unicompartmental knee arthroplasty (UKA). This study aimed to quantify the magnitude of leg-length change, prevalence of postoperative LLD, and their clinical implications following medial UKA. METHODS: Leg length and mechanical hip-knee-ankle angle (mHKA) were retrospectively measured in 332 patients following unilateral robotic-arm assisted medial UKA for medial compartment osteoarthritis, using calibrated long-leg radiographs. The Knee Injury and Osteoarthritis Otcome Score for Joint Replacement and patient satisfaction were analyzed to assess impact of leg-length change and LLD on outcomes. RESULTS: Following medial UKA, median leg-length change was 2.0 mm (interquartile range, -1.0 to 5.0 mm; P < .001) with a mean correction in mHKA of 4.4° ± 2.7 (P < .001). A total of 158 patients (48%) had a leg-length increase by 0 to 5 mm, 64 (19%) by 6 to 10 mm, and 11 (3%) by >10 mm. Leg-length change was positively correlated with mHKA correction (R = 0.44, P < .001). Postoperatively, moderate (5 to 10 mm) and substantial LLD (≥10 mm) were present in 49% and 17% of patients, respectively. Four-year Knee Injury and Osteoarthritis Outcome Score for Joint Replacement were comparable between patients with and without substantial postoperative LLD (P = .976). Proportions of satisfied patients were similar between groups (P = .687). CONCLUSION: Following medial UKA, the majority of patients had a moderate increase in leg length, the magnitude of which was positively correlated to the correction in mechanical alignment. Postoperative substantial LLD was not uncommon (17% prevalence); however, it had no significant impact on patient-reported outcomes or satisfaction at 4 years follow-up.

Humeral Head Reconstruction of Reverse Hill-Sachs Lesions.

Compared with anterior instability, posterior shoulder dislocations are a rare entity and are often missed at presentation. A concomitant anteromedial impression fracture of the humeral head, or a reverse Hill-Sachs lesion, is commonly present with these dislocations and is more pronounced with a longer timeline to reduction. Treatment of these defects ranges from nonsurgical treatment to soft-tissue procedures, bony reconstruction, and arthroplasty. Management may be dictated by various factors, such as patient demands, defect size and location, concomitant injuries, and underlying etiology. Small reverse Hill-Sachs defects without engagement can generally be treated nonsurgically or with benign neglect, whereas larger defects (>20%) often require surgery. The most reported surgical techniques are the (arthroscopic) McLaughlin and modified McLaughlin procedure, disimpaction and bone grafting, or reconstruction of the defect with autograft or with fresh (or fresh-frozen) osteochondral allograft. Finally, arthroplasty is generally required for large defects, where more than 45% to 50% of the articular cartilage is involved. Overall, reported outcomes generally reflect patient satisfaction for most patients, with a low incidence of secondary instability or posttraumatic arthritis, although better results are achieved when recognizing and treating these injuries in the more acute setting.

Prospective Comparison of Postoperative Pain and Opioid Consumption Between Primary Repair and Reconstruction of the Anterior Cruciate Ligament.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with postoperative pain and necessitates using perioperative nerve blocks and multimodal analgesic plans. Purpose: To assess postoperative pain and daily opioid use after ACL repair versus ACLR and to assess whether ACL repair could be performed successfully without using long-acting nerve blocks. Study Design: Cohort study; Level of evidence, 2. Methods: All eligible patients who underwent ACL surgery between 2019 and 2022 were prospectively enrolled. Patients were treated with primary repair if proximal tears with sufficient tissue quality were present; otherwise, they underwent single-bundle ACLR with either hamstring tendon or quadriceps tendon autograft. The patients were divided into 3 groups: ACLR with adductor canal nerve block (up to 20 mL of 0.25% bupivacaine with 2 mg dexamethasone), primary repair with nerve block, and primary repair without nerve block. Pain visual analog scale and number of opioids used were recorded during the first 14 postoperative days (PODs). Furthermore, patients completed the Quality of Recovery-15 (QoR-15) survey, and range of motion was assessed. Group differences were compared using Mann-Whitney U test and chi-square test. Results: Seventy-eight patients were included: 30 (39%) underwent ACLR, 19 (24%) ACL repair with nerve block, and 29 (37%) ACL repair without nerve block. Overall, the ACL repair group used significantly fewer opioids than the ACLR group on POD 1 (1 vs 3, P = .027) and POD 2 (1 vs 3, P = .014) while also using fewer opioids in total (3 vs 8, P = .038). This difference was even more marked when only analyzing those patients who received postoperative nerve blocks (1 vs 8, P = .029). Repair patients had significantly higher QoR-15 scores throughout the first postoperative week, and they had greater range of motion (all P < .05). There were no significant differences in pain scores, opioid usage, or QoR-15 scores between patients who underwent repair with versus without nerve block. Conclusion: The ACL repair group experienced less postoperative pain during the first 2 weeks after surgery and used significantly fewer opioids than the ACLR group. Furthermore, they had improved knee function and higher recovery quality than patients who underwent ACLR during the initial postoperative period. Postoperative nerve blocks may not be necessary after ACL repair.

Acute Percutaneous Repair of Medial Collateral Ligament With Suture Augmentation in the Multiligamentous Injured Knee Results in Good Stability and Low Rates of Postoperative Stiffness.

Purpose: To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up. Methods: A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years' postoperatively). Continuous variables were reported in median with interquartile range (IQR). Results: A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n = 13) or bicruciate (KDIII-M; n = 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n = 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n = 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0). Conclusions: In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up. Level of Evidence: Level IV, therapeutic case series.