Faculty Bibliography

PURPOSE/UNASSIGNED:To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures. METHODS/UNASSIGNED:A literature search was conducted per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using EMBASE, PubMed, and Scopus computerized data from database inception to February 2023. Studies evaluating RTS sport rates and complications after nonoperative or operative management of tibial stress fractures were included. Failure was defined as defined by persistent stress fracture line seen on radiographic imaging. Study quality was assessed using the Modified Coleman Methodology Score. RESULTS/UNASSIGNED:Twenty-two studies consisting of 341 patients were identified. The overall RTS rate ranged from 91.2% to 100% in the nonoperative group and 75.5% to 100% in the operative group. Failures rates ranged from 0% to 25% in the nonoperative groups and 0% to 6% in the operative group. Reoperations were reported in 0% to 6.1% of patients in the operative group, whereas 0% to 12.5% of patients initially managed nonoperatively eventually required operative treatment. CONCLUSIONS/UNASSIGNED:Patients can expect high RTS rates after appropriate nonoperative and operative management of tibial stress fractures. Treatment failure rates were greater in patients undergoing nonoperative management, with up to 12.5% initially treated nonoperatively later undergoing operative treatment. LEVEL OF EVIDENCE/UNASSIGNED:Level IV; Systematic Review of level I-IV studies.

Hip labral "width" should be defined as the distance from the chondrolabral junction to the tip of the labrum in triangular cross-section. "Height" should refer to the distance from the joint surface to the perilabral recess (perpendicular to the width). "Length" is the distance from the anterior end of the labrum, adjacent to the anterior transverse acetabular ligament (TAL), to the posterior end of the labrum, adjacent to the posterior TAL (as may be relevant in reconstructions). Most studies of labral size focus on width, as it is thought to most contribute to the suction seal effect and hip stability. Magnetic resonance imaging most accurately measures labral width. Labral width at the time of surgery should be considered its maximal size; the labrum is reduced in size after repair. Hypoplastic labrums may result in worse outcomes after hip arthroscopy, and hyperplastic labrums may result in higher scores than normoplastic labrums in patients with primary femoroacetabular impingement syndrome. Diminutive labral width is a relative indication for labral reconstruction.

BACKGROUND/UNASSIGNED:Medial meniscus posterior root (MMPR) tears are recognized as a substantial cause of disability and morbidity. However, meniscus root repair, regardless of technique, is not without potential complications. PURPOSE/UNASSIGNED:To evaluate the reported incidence of complications and adverse events after isolated MMPR repair. STUDY DESIGN/UNASSIGNED:Systematic review; Level of evidence, 4. METHODS/UNASSIGNED:A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using Embase, PubMed, and Scopus databases with the following search terms combined with Boolean operators: "meniscus,""root," and "repair." Inclusion criteria consisted of level 1 to 4 human clinical studies in English or English-language translation reporting complications and adverse events after isolated posterior medial meniscus root repairs. The overall incidence of specific complications was estimated from the pooled sample of the included studies. RESULTS/UNASSIGNED:Eleven studies with a total pooled sample of 442 patients were identified. The mean patient age was 58.1 years, while the mean final follow-up time was 37.2 months (range, 12-84.8 months). The overall incidence of complications was 9.7% (n = 43/442), with the most commonly reported complication being progressive degenerative changes within the knee (10.4%; n = 25/240; n = 5 studies). A total of 1.25% (n = 3/240) of patients who experienced degenerative changes required conversion to total knee arthroplasty. Repair failures were reported in 3.1% (n = 10/327; n = 8 studies) of patients. CONCLUSION/UNASSIGNED:Repairing MMPR tears is critical in preventing accelerated progression of knee osteoarthritis in patients without significant knee osteoarthritis preoperatively. While this repair is still recommended and necessary in appropriate patients, this review found that the incidence of complications after isolated posterior medial meniscus root repair was 9.7%, primarily involving the presence of progressive degeneration, while repair failure was reported in 3% of patients.

The use of intraoperative fluoroscopy is standard among hip arthroscopist to evaluate and confirm the adequacy of cam resection in patients with femoroacetabular impingement syndrome. However, given the inherent limitations of fluoroscopy, additional intraoperative imaging, such as ultrasound, should be pursued. We offer a technique to measure alpha angles intraoperatively using ultrasound to determine adequate cam resection.

PURPOSE:To review the incidence of complications following primary medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. METHODS:A literature search was conducted by querying PubMed and Scopus databases from database inception through August 2022 according to the 2020 Preferred Reporting Items for Systematic Review and Meta-analysis guidelines using the terms "Medial Patellofemoral Ligament," "MPFL," "reconstruction," "patellar," and "instability." Inclusion criteria included studies reporting complications following primary MPFL reconstruction for recurrent patellar instability. Exclusion criteria consisted of studies reporting on patients undergoing concurrent osteotomy procedures, revision reconstruction, and biomechanical or anatomic studies. The incidence of specific complications was aggregated from the included studies. RESULTS:Twenty-eight studies, consisting of 1,478 patients (n = 1521 knees), with a mean age of 23.3 years (mean range, 19-34.3 years) were identified. The overall incidence of complications ranged from 0% to 32.3% of knees. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures occurred in 0% to 8.3% of knees, primarily in patients treated with full-length transverse tunnel or 2-tunnel techniques. All patellar fractures occurred in patients with patellar tunnels ranging from 4.5 to 6.0 mm in diameter. The incidence of postoperative knee stiffness/range of motion deficit ranged from 0% to 20%. Persistent anterior knee pain, ranged from 0% to 32.3%. CONCLUSIONS:Complications following primary MPFL reconstruction ranged from 0% to 32.3% of knees, primarily consisting of residual anterior knee pain. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures were reported in 0% to 8.3% of knees. Fractures primarily occurred with a full-length transverse tunnel or 2-tunnel techniques, whereas all fractures occurred with patellar tunnels ranging from 4.5 mm to 6.0 mm in diameter. LEVEL OF EVIDENCE:IV; Systematic Review of Level I-IV studies.

PURPOSE:To compare clinical and radiologic outcomes following superior capsular reconstruction (SCR) using dermal allograft versus tensor fascia lata (TFL) autograft for massive rotator cuff tears with a minimum 2-year follow-up. METHODS:A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through September 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies evaluating clinical and radiologic outcomes, as well as complications following SCR for the treatment of massive rotator cuff tears were included. Study quality was assessed via the Newcastle-Ottawa Scale and the National Institutes of Health Quality Assessment. The mean change from preoperative to postoperative values (delta) was calculated for each outcome. RESULTS:Seventeen studies, consisting of 519 patients were identified. Mean duration of follow-up ranged from 24 to 60 months. Mean reduction in visual analog scale pain score ranged from 2.9 to 5.9 points following use of dermal allograft, and 3.4 to 7.0 points following TFL autograft reconstruction. Mean improvements in American Shoulder and Elbow Surgeons score were similar between groups (dermal allograft: 28.0-61.6; TFL autograft: 24.7-59.3). The mean increase in forward flexion ranged from 31° to 38° with dermal allograft, versus 19° to 69° with TFL autograft. Average improvement in active external rotation with dermal allograft ranged from -0.4° to 11° and from 2° to 22.4° using TFL autograft. A similar change in acromiohumeral distance following SCR (dermal allograft: 0.9-3.2 mm; TFL autograft: 0.3-3.6 mm) was appreciated. The rate of complications within the dermal allograft group ranged from 4.5% to 38.2% versus 13.3% to 86.4% following TFL autograft. Failure rate ranged from 4.5 to 38.2% following dermal allograft versus 4.5 to 86.4% with TFL autograft. CONCLUSIONS:Acellular dermal allograft versus TFL autograft for SCR both demonstrate improved VAS and American Shoulder and Elbow Surgeons scores, with increased values in flexion and external rotation, and increased visual analog scale, although with high variability. Both grafts demonstrate high rates of complications and failures at minimum 2-year follow-up. LEVEL OF EVIDENCE:IV; systematic review of level II-IV studies.

PURPOSE OF REVIEW/OBJECTIVE:This review provides a historical perspective on the approach to radial tears and collates the currently available evidence on repair techniques, rehabilitation, and outcomes following the treatment of meniscus radial tears. RECENT FINDINGS/RESULTS:Recent literature shows that the repair of meniscus radial tears reports improved patient-reported outcome scores with high return to function and activity. However, no single technique nor construct was proven better than the other. Various methods of repairing radial tears can be employed, with biomechanical research supporting all-inside double vertical sutures, the addition of vertical "rip-stop" mattress sutures, and transtibial pullout augmentation. To ensure proper healing before undergoing physical therapy, it is crucial to abstain from weight-bearing and deep knee flexion for the first 6 weeks after surgery. Despite considerable heterogeneity in surgical techniques and rehabilitation protocols found in the current literature, studies reporting on radial repairs report positive results, with high healing rates and improved patient-reported outcomes.

BACKGROUND Stress fractures of the patella are rare, may result from overuse, and can be difficult to detect on imaging. Furthermore, the differential diagnosis of the anterior knee pain associated with most patellar stress fractures is broad, making it difficult to quickly reach the diagnosis. This report is of an 18-year-old female athlete presenting with knee pain after playing basketball and diagnosed with bilateral patellar stress fractures. CASE REPORT An 18-year-old female athlete with a history of bilateral anterior knee pain presented with left knee pain and swelling following a basketball game. X-ray images and magnetic resonance imaging (MRI) revealed a displaced inferior pole fracture of the left patella. The patient underwent surgical fixation of the patella. Approximately 4 months following surgical fixation of the left patella, right anterior knee pain persisted, and imaging demonstrated a stress reaction in the inferior pole of the right patella. The patient was ultimately treated with surgical fixation of the right patella as well. CONCLUSIONS This report demonstrates that, although stress fractures of the patella are rare, and bilateral stress fractures of the patella are even more rare, this condition may present with pain and usually with a history of high-impact exercise. Challenges remain in identifying patellar stress fractures early in their progression and determining the best course of treatment.

The anterior cruciate ligament (ACL) is the primary restraint to tibial internal rotation and is supported by secondary stabilizers, including the iliotibial band (ITB), anterolateral ligament (ALL), anterolateral capsule, and lateral meniscus, which provide additional rotational control. Combined injury to primary and secondary rotational stabilizers can lead to anterolateral rotatory instability. This can best be demonstrated in patients with large pivot-shifts. Biomechanical studies have demonstrated that ACL reconstruction (ACLR) alone does not restore native kinematics in the setting of a combined injury. Concomitant anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET) techniques have been evaluated as a possible solution. Both the LET and ALLR may help restore rotational control, with the LET being slightly more powerful due to its more horizontal force vector based on biomechanical studies. However, there may be a slight risk of overconstraint with both techniques, more pronounced with the LET. Clinical studies evaluating the techniques for both primary and revision ACLR have generally found both to be safe and effective, leading to decreased rates of re-rupture and improved outcome scores. Either technique is a reasonable addition to ACLR when additional rotational control is indicated, though the LET may be more reproducible.

PURPOSE:To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes. METHODS:A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated. RESULTS:Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery. CONCLUSIONS:Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure. LEVEL OF EVIDENCE:IV; Systematic Review of Level III and IV studies.