Publications by authors named "Justin J Mitchell"

70 Publications

Functional Outcomes and Return to Sport After Cartilage Restoration of the Knee in High-level Athletes.

J Am Acad Orthop Surg 2021 Jul 22. Epub 2021 Jul 22.

From the Department of Orthopaedic Surgery, Kaiser Permanente, Los Angeles, CA (Mehran), the Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance, CA (Singla), the Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Okoroha), and the Orthopaedic Surgery and Sports Medicine, Gundersen Health System, Onalaska, WI (Mitchell).

Articular cartilage injuries of the knee are being observed with increasing frequency in athletes and have proven to be difficult to treat given the limited regenerative ability of cartilage and the potential for progressive joint degeneration. A wide range of surgical treatments such as microfracture, autologous chondrocyte implantation, and osteochondral autograft and allograft have demonstrated promising results in these high-demand individuals. These procedures permit healing of cartilage defects while decreasing pain and restoring function with patient-reported outcomes demonstrating significant improvement at short-, mid-, and long-term follow-up. Most athletes are able to return to play after cartilage restoration of the knee, regardless of the surgical technique used. Although there is a large degree of heterogeneity across the literature and no consensus as to the optimal technique, osteochondral autograft transfer seems to offer the highest rate of return to sport and return to play at preinjury level. However, autologous chondrocyte implantation and osteochondral allograft transplantation are often used for larger defects or salvage after previous procedures, so results may be confounded. In addition, a multitude of factors including patient history, characteristics of the chondral lesion, and postoperative management may affect functional outcomes in athletes.
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http://dx.doi.org/10.5435/JAAOS-D-21-00242DOI Listing
July 2021

Anterior Cruciate Ligament Injury at the Time of Anterior Tibial Spine Fracture in Young Patients: An Observational Cohort Study.

J Pediatr Orthop 2019 Oct;39(9):e668-e673

Department of Orthopaedic Surgery, University of Colorado Hospital.

Background: Anterior tibial spine fractures (ATSF) in the skeletally immature parallel anterior cruciate ligament (ACL) tears in adult patients, yet these injuries are generally regarded as mutually exclusive. Biomechanical analysis suggests that intrinsic ACL damage occurs during ATSF, and long-term clinical studies demonstrate residual anteroposterior knee laxity following ATSF. We aim to describe prevalence, demographics, and characteristics of pediatric patients who sustained ATSF with concomitant ACL injury.

Methods: We included 129 patients with ATSF over a 16-year period. Age, sex, injury mechanism, ATSF type, magnetic resonance imaging (MRI) evaluation, treatment modality, ACL injury, and concomitant meniscal/chondral injuries were analyzed. Concurrent ACL injury was confirmed either from MRI or intraoperatively.

Results: Nineteen percent (n=25) of ATSF patients had concomitant ACL injury, with ACL injury significantly more likely in type II or type III ATSF compared with type I ATSF (P=0.03). Patients with combined ATSF/ACL injury were significantly older (P=0.02) and more likely to be male (P=0.01). Mechanism of ATSF injury was not associated with ACL injury (P=0.83). Preoperative MRI had low sensitivity (0.09) for recognizing ACL injury at the time of ATSF relative to intraoperative assessment. Half of ATSF/ACL-injured patients had additional meniscal or chondral injury, with meniscal repair or debridement required in 37.5% of the type II ATSF/ACL injury.

Conclusions: There are demographic characteristics, such as age (older) and sex (male), associated with a higher risk of concomitant ACL injury at the time of ATSF. Type II and type III ATSF patterns had a higher prevalence of ACL injury. MRI failed to correctly identify ACL injury at the time of ATSF. Concomitant ACL injury at the time of ATSF is highly prevalent in the skeletally immature, occurring in 19.4% of patients with ATSF.

Level Of Evidence: Level IV-case series.
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http://dx.doi.org/10.1097/BPO.0000000000001011DOI Listing
October 2019

Editorial Commentary: Haven't We Seen This Somewhere Before? Laying the Foundation for Cartilage Restoration in Hip Preservation.

Arthroscopy 2019 07;35(7):2048-2050

Since its inception in the early 1980s, the microfracture procedure has been successfully used throughout the body to treat isolated full-thickness cartilage lesions. Although treatment of such injuries can be challenging, and outcomes variable, microfracture has afforded surgeons the ability to treat cartilage lesions in a single-stage fashion at the time of treatment for concomitant injuries. Whereas most research relating to the use of microfracture has focused on managing lesions in the knee, there continues to be interest in applying the same principles in other regions of the body. With the recent enthusiasm and procedural increase in hip arthroscopy and hip preservation procedures, evaluating the use of microfracture in the femoroacetabular joint is the next logical step in establishing treatment principles for cartilage defects in this location. Although we continue to innovate as orthopedic surgeons, and there have been recent declines in ardor for the use of microfracture, this sentiment has arisen only after decades of research and clinical advances. Because of this, continued work will be necessary to understand the limits of the microfracture procedure in hip preservation surgery. Early outcome studies are encouraging and continue to be an important platform on which to lay the foundation for further research and refinement of techniques and indications.
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http://dx.doi.org/10.1016/j.arthro.2019.03.010DOI Listing
July 2019

Meniscal Repair in Pediatric Populations: A Systematic Review of Outcomes.

Orthop J Sports Med 2019 May 13;7(5):2325967119843355. Epub 2019 May 13.

West Virginia University School of Medicine, Morgantown, West Virginia, USA.

Background: Loss of meniscal tissue in the pediatric population can have long-term consequences on joint health, highlighting the importance of meniscal preservation in this group.

Purpose: To systematically review reported knee outcome measures and complication rates after repair of meniscal tears in children and adolescents.

Study Design: Systematic review; Level of evidence, 4.

Methods: A review of the literature regarding the existing evidence for pediatric meniscal tear outcomes was performed through use of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-present), and MEDLINE (1980-present). Included were articles in English that reported the outcomes of meniscal tears in the pediatric population (<18 years old) with a follow-up of more than 12 months. Clinical outcome scores were reviewed.

Results: A total of 1003 total studies were initially retrieved, with 8 meeting the inclusion criteria. The review included 287 patients (165 male, 122 female), mean age 15.1 years (range, 4-18 years), with 301 meniscal tears (reported: 134 medial, 127 lateral, and 32 both medial and lateral, 8 location unspecified). Concomitant anterior cruciate ligament reconstruction was performed in 52% (158/301) of meniscal repairs. The average reported postoperative Lysholm scores ranged from 85.4 to 96.3, and the average reported postoperative Tegner activity scores ranged from 6.2 to 8.

Conclusion: Arthroscopic repair of a meniscal tear in the pediatric and adolescent population is an effective treatment option that has a low failure rate, enhances postoperative clinical outcomes, and preserves meniscal tissues.
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http://dx.doi.org/10.1177/2325967119843355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537073PMC
May 2019

Axial-Oblique Versus Standard Axial 3-T Magnetic Resonance Imaging for the Detection of Trochlear Cartilage Lesions: A Prospective Study.

Orthop J Sports Med 2018 Oct 9;6(10):2325967118801009. Epub 2018 Oct 9.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Imaging of the femoral trochlea has been inherently difficult because of its convex anatomy.

Purpose/hypothesis: The purpose of this study was to compare the diagnostic utility of a standard axial magnetic resonance imaging (MRI) sequence with an axial-oblique MRI sequence of the knee for the detection of trochlear articular cartilage lesions on a high-field 3-T MRI scanner. We hypothesized that axial-oblique MRI scans of the knee obtained along the true axis of the trochlea would significantly improve the detection of high-grade cartilage lesions.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: Patients who underwent MRI and subsequent surgery for any indication were prospectively enrolled into this study between June 2014 and February 2015. The articular cartilage of the trochlea was evaluated independently by 3 raters on axial and axial-oblique MRI and compared with arthroscopic findings (gold standard). The interrater and intrarater reliability of mild (International Cartilage Repair Society [ICRS] grades 1 or 2) and severe (ICRS grades 3 or 4) lesions on MRI were assessed as well as the sensitivity, specificity, positive predictive value, and negative predictive value.

Results: A total of 99 knees in 96 patients were included in the study. Interrater and intrarater agreement for the identification of severe lesions were moderate to good on the proximal trochlea and fair to moderate on the distal trochlea. No significant differences in sensitivity were found between axial and axial-oblique scans for any grade of lesion (55% vs 51%, respectively; = .700) or for severe lesions (61% vs 52%, respectively; = .289). Similarly, specificity for detecting severe lesions was not significantly different between axial and axial-oblique scans (95% vs 87%, respectively; = .219). Last, no significant differences in sensitivity or specificity were found between MRI sequences when separately evaluating proximal and distal trochlear lesions (all > .05).

Conclusion: The axial-oblique sequence was unable to improve the sensitivity of MRI in detecting articular cartilage lesions on the trochlea. Both conventional axial and axial-oblique sequences, reviewed independently of the complete MRI series, had low sensitivity in detecting trochlear articular cartilage lesions. For this reason, clinicians should utilize all MRI planes to evaluate the articular cartilage of the trochlea. Future studies should focus on improving MRI techniques for detecting and characterizing cartilage lesions of the trochlea.
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http://dx.doi.org/10.1177/2325967118801009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6178377PMC
October 2018

Avulsion of the Anterior Lateral Meniscal Root Secondary to Tibial Eminence Fracture.

Am J Orthop (Belle Mead NJ) 2018 May;47(5)

Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO.

The lateral tibial eminence shares a close relationship with the anterior root of the lateral meniscus. Limited studies have reported traumatic injury to the anterior meniscal roots in the setting of tibial eminence fractures, and reported rates of occurrence of concomitant meniscal and chondral injuries vary widely. The purpose of this article is to describe the case of a 28-year-old woman who had a complete avulsion of the anterolateral meniscal root caused by a tibial eminence fracture with resultant malunion and root displacement. The anterolateral meniscal root was anatomically repaired following arthroscopic resection of the malunited fragment.
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http://dx.doi.org/10.12788/ajo.2018.0024DOI Listing
May 2018

Immediate physical therapy without postoperative restrictions following open subpectoral biceps tenodesis: low failure rates and improved outcomes at a minimum 2-year follow-up.

J Shoulder Elbow Surg 2018 Oct 25;27(10):1891-1897. Epub 2018 May 25.

Steadman Philippon Research Institute, Vail, CO, USA; The Steadman Clinic, Vail, CO, USA. Electronic address:

Hypothesis: We aimed to determine patient-reported outcomes in patients undergoing open subpectoral biceps tenodesis with a dual-fixation construct who had no postoperative range-of-motion or weight-bearing restrictions. Our hypothesis was that patients without postoperative restrictions would have low failure rates with improved patient-reported outcomes. We further hypothesized that this technique would allow an earlier return to activity and similar functional outcomes when compared with those reported in the literature.

Methods: In this institutional review board-approved retrospective outcome study, we evaluated 105 patients who underwent primary open subpectoral biceps tenodesis with a bicortical suture button and interference screw construct without postoperative restrictions. The primary outcome measure was failure of the biceps tenodesis. Postoperative outcome scores included the Short Form 12 (SF-12) Physical Component Score; SF-12 Mental Component Score; American Shoulder and Elbow Surgeons total score and subscales; and Disabilities of the Arm, Shoulder and Hand score.

Results: A total of 98 patients (85%) were available for final follow-up at an average of 3.5 years. There were 2 failures (2.2%), at 5 weeks and 9 weeks postoperatively. Four patients underwent additional surgery unrelated to the previous tenodesis procedure. Final outcome scores indicated high levels of function, including the SF-12 Physical Component Score (mean, 51.5; SD, 7.8), SF-12 Mental Component Score (mean, 54.7; SD, 6.7), American Shoulder and Elbow Surgeons total score (mean, 89.4; SD, 14.2), and Disabilities of the Arm, Shoulder and Hand score (mean, 11.3; SD, 13.4).

Conclusion: Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure.
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http://dx.doi.org/10.1016/j.jse.2018.02.061DOI Listing
October 2018

Influence of Meniscal and Chondral Lesions on Patient-Reported Outcomes After Primary Anterior Cruciate Ligament Reconstruction at 2-Year Follow-up.

Orthop J Sports Med 2018 Feb 13;6(2):2325967117754189. Epub 2018 Feb 13.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Meniscal and chondral lesions are commonly associated with anterior cruciate ligament (ACL) tears, and these lesions may play a role in patient outcomes after ACL reconstruction.

Purpose: To determine the effects of the presence and location of meniscal and chondral lesions at the time of ACL reconstruction on patient-reported outcomes at a minimum 2-year follow-up.

Study Design: Cohort study; Level of evidence, 3.

Methods: Patients with no prior knee surgery who underwent primary ACL reconstruction by a single surgeon between 2010 and 2014 were included in this study. Those meeting inclusion criteria were divided into the following groups based on the arthroscopic diagnosis: patients without concomitant meniscal or chondral lesions, patients with isolated meniscal lesions, patients with isolated chondral lesions, and patients with both chondral and meniscal lesions. Patient-reported outcomes (Short Form-12 [SF-12] physical component summary [PCS] and mental component summary [MCS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Lysholm scale) were assessed at a minimum of 2 years from the index surgery.

Results: A total of 151 patients met the inclusion criteria and were included in the study. The mean age at the time of surgery was 36.2 years (range, 14-73 years), and the mean follow-up was 3.2 years (range, 2.0-5.6 years). At the time of surgery, 33 (22%) patients had no concomitant lesions and served as the control group, 63 (42%) patients had isolated meniscal lesions, 21 (14%) patients had isolated chondral lesions, and 34 (22%) patients had both chondral and meniscal lesions. There was significant improvement in all outcome scores postoperatively for the 3 groups ( < .05 for all outcome scores). The presence of a meniscal tear and laterality of the meniscal lesion did not have a negative effect on any postoperative outcome scores. Patients with isolated chondral lesions had significantly lower postoperative WOMAC scores compared with patients without chondral lesions ( < .05). No significant differences were found for all other scores. Patients with patellofemoral chondral lesions had significantly lower postoperative SF-12 PCS and Lysholm scores than patients with tibiofemoral chondral lesions ( < .05).

Conclusion: Patients with ACL tears achieved improved functional scores at a mean 3.2 years after ACL reconstruction. While meniscal lesions did not affect postoperative outcomes in the short term, chondral lesions were identified as a predictor for worse outcomes.
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http://dx.doi.org/10.1177/2325967117754189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813860PMC
February 2018

Outcomes of Arthroscopic Management of Trochanteric Bursitis in Patients With Femoroacetabular Impingement: A Comparison of Two Matched Patient Groups.

Arthroscopy 2018 05 1;34(5):1455-1460. Epub 2018 Feb 1.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.. Electronic address:

Purpose: To determine the prevalence of chronic trochanteric bursitis (TB) in patient being treated for femoroacetabular impingement (FAI) and determine the effectiveness of arthroscopic bursectomy and iliotibial band lengthening (AB-ITB-L) at the time of hip arthroscopy for FAI.

Methods: Patients diagnosed with primary FAI and chronic TB were included in the study. Patients were included if they underwent hip arthroscopy with labral repair, femoral and/or acetabular osteoplasty, and AB-ITB-L. Patients were matched by age and gender to patients without chronic TB.

Results: The prevalence of chronic TB with FAI was 7% (90/1,278). Females were 5.3 times more likely to have TB compared with males (95% confidence interval: 3.2-8.7). Patients more than 30 years of age were 2.5 times more likely to have TB (95% confidence interval: 1.48-4.4). Of the 90 patients diagnosed with TB, 72 (54 female, 18 male) with an average age of 36.7 years underwent AB-ITB-L at the time of their index hip arthroscopy for FAI. All 72 patients had associated intra-articular pathology consisting of a combined cam and pincer pathology. The TB (average follow-up = 42 ± 9.9 months) and non-TB group (average follow-up = 42 ± 9.1 months) both had significant improvement from preoperative to postoperative scores for Hip Outcome Score Activities Daily Living, Hip Outcome Score Sport, Modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index, Short Form (SF)-12 Physical Component score, and SF-12 Mental Component Score. There was no significant difference between the 2 groups in postoperative patient reported outcome scores.

Conclusions: The occurrence of chronic TB in the FAI population, which did not adequately respond to nonoperative management, for a single surgeon high volume hip arthroscopy practice was 7%, and was more commonly seen in women older than 30 years. Patients who undergo concomitant AB-ITB-L for chronic TB report excellent pain relief, and have equivalent results and outcome scores that are not inferior when compared with patients with primary FAI without chronic TB.

Level Of Evidence: Level III, retrospective matched case control study.
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http://dx.doi.org/10.1016/j.arthro.2017.10.053DOI Listing
May 2018

A Systematic Review of Arthroscopic Versus Open Tenotomy of Iliopsoas Tendonitis After Total Hip Replacement.

Arthroscopy 2018 04 1;34(4):1332-1339. Epub 2018 Feb 1.

VCU Medical Center, Richmond, Virginia, U.S.A.

Purpose: To conduct a systematic review of the literature comparing patient outcomes following arthroscopic and open operative management of iliopsoas tendonitis (IPT) following total hip replacement (THR).

Methods: This review study was conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. Inclusion criteria were as follows: outcome studies following open or arthroscopic iliopsoas tendon release after THR with at least 6 months of follow-up, English language, and human studies. The exclusion criteria included case reports, articles evaluating nonsurgical management or cup revision, and articles without a specific diagnosis of IPT or in which results between open and arthroscopic treatment were reported in conjunction.

Results: A total of 131 studies were initially retrieved, with 7 satisfying all inclusion criteria (4 studies on arthroscopic tenotomy and 3 studies on open tenotomy). The review included a total of 88 patients with IPT-61 patients treated arthroscopically and 27 patients treated with open tenotomy. In total, 77 of the 88 patients demonstrated successful outcomes following surgery. In the group treated with arthroscopy, 91.8% (56/61) of patients had successful outcomes, whereas in those treated with open tenotomy, 77.8% (21/27) of patients had successful outcomes. Of patients with signs of mechanical impingement from acetabular component overhang, those who underwent open tenotomy had complete pain relief in 6/8 patients (75%) compared to arthroscopic tenotomy in which there was relief in 40/43 patients (93%).

Conclusions: Arthroscopic iliopsoas release for management of IPT is suggested to be an effective minimally invasive operative technique that may also yield a lower complication rate in comparison to open tenotomy. Tenotomy, both arthroscopic and open, are successful treatment options for IPT, including those with signs of mechanical impingement, and are recommended prior to cup revision.

Level Of Evidence: Level IV, systematic review of level IV studies.
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http://dx.doi.org/10.1016/j.arthro.2017.10.051DOI Listing
April 2018

Minimally Invasive Anatomical Reconstruction of Posteromedial Corner of Knee: A Cadaveric Study.

Am J Orthop (Belle Mead NJ) 2017 Nov/Dec;46(6):E429-E434

Santa Monica Orthopaedic Group, Santa Monica, CA.

We conducted a study to determine if a minimally invasive posteromedial reconstruction technique would return medial knee stability to its intact state. Ten cadaveric knees were tested under 3 state conditions: intact, sectioned, and reconstructed. The medial compartment opening was measured on valgus stress radiographs at full extension and at 20° of flexion with a 10-N valgus load (applied with dynamometer) to assess valgus stability in the intact, sectioned, and reconstructed states. After posteromedial sectioning, mean medial gap was statistically significantly larger (P = .0002) at full extension (11 mm vs 3.3 mm) and at 20° of flexion (12.6 mm vs 3.7 mm). There was no statistically significant difference between the value of the intact state and the value after minimally invasive reconstruction at 0° (P = .56) or 20° (P = .102) of flexion. Interobserver reliability for the measurements was almost perfect (κ = 0.86). Minimally invasive medial knee reconstruction returns medial knee stability almost to normal at full extension and at 20° of flexion. Development of minimally invasive techniques will allow medial ligament reconstruction with minimal disruption of the surrounding tissue, potentially leading to less scarring and easier restoration of knee motion after surgery.
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August 2018

Biomechanical Comparison of 3 Glenoid-Side Fixation Techniques for Superior Capsular Reconstruction.

Am J Sports Med 2018 03 27;46(4):801-808. Epub 2017 Dec 27.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Superior capsular reconstruction (SCR) was recently introduced as a treatment for irreparable superior rotator cuff tears in younger patients. Purpose/Hypothesis: The purpose was to assess the biomechanical strength of 3 methods for fixation of the graft to the glenoid for SCR. It was hypothesized that a 4-anchor technique would provide greater load to failure than 3-anchor techniques.

Study Design: Controlled laboratory study.

Methods: Thirty-six cadaveric specimens were randomized into 3 groups of previously established glenoid-side graft fixation techniques: (1) three 3.5-mm knotless screw-in anchors, (2) three 3.0-mm knotless push-in anchors, and (3) a 4-anchor hybrid construct with two 3.0-mm knotted push-in anchors and two 2.9-mm knotless push-in anchors. The repairs were cyclically loaded at 0.5 Hz from 10 to 200 N, then pulled to failure. Elongation, stiffness, maximum load at failure, and mode of failure were recorded and calculated.

Results: There were no significant differences in graft elongation or stiffness among the 3 techniques ( P > .37 and P > .26, respectively). Maximum load to failure was significantly greater in technique 1 (mean ± SD, 427.85 ± 119.70 N) than technique 3 (319.5 ± 57.60 N) ( P = 0.024). There were no significant differences in load to failure between techniques 1 and 2 or between techniques 2 and 3.

Conclusion: Glenoid-side graft fixation with 3 threaded 3.5-mm suture anchors showed a significant superior pull-out strength when compared with a 4-anchor hybrid technique and thus might be recommended in SCR for patients with irreparable superior rotator cuff tears to achieve maximum stability.

Clinical Relevance: SCR presents a novel alternative for treatment of irreparable superior rotator cuff tears in younger patients. Glenoid fixation is essential to provide adequate fixation of the graft to prevent the humeral head from rising and to restore normal biomechanics.
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http://dx.doi.org/10.1177/0363546517745626DOI Listing
March 2018

Glenoid Erosion Leading to Contact with Retained Metallic Suture Anchors: Bilateral Metallosis After Bilateral Shoulder Hemiarthroplasty: A Case Report.

JBJS Case Connect 2017 Apr-Jun;7(2):e24

Steadman Philippon Research Institute, Steadman Clinic, Vail, Colorado.

Case: Hemiarthroplasty of the shoulder is commonly indicated for younger patients with osteoarthritis who desire to continue recreational and employment activities. In patients who have undergone prior shoulder surgery, metallic suture anchors may be present in the glenoid. We present a case of bilateral shoulder metallosis following bilateral resurfacing hemiarthroplasty for arthropathy in the setting of previous shoulder instability; the prostheses caused eventual glenoid erosion, leading to contact with the retained metal anchors.

Conclusion: Because glenoid erosion is a common complication after shoulder hemiarthroplasty, patients with retained metal anchors are at risk for secondary metallosis due to medial protrusion of the prosthesis in the glenoid, with subsequent erosion of the metal anchors.
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http://dx.doi.org/10.2106/JBJS.CC.16.00161DOI Listing
August 2018

Primary Versus Revision Anterior Cruciate Ligament Reconstruction: Patient Demographics, Radiographic Findings, and Associated Lesions.

Arthroscopy 2018 03 8;34(3):695-703. Epub 2017 Dec 8.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A.. Electronic address:

Purpose: The purpose of this study was to evaluate the differences in intra-articular pathology, demographic characteristics, and radiographic characteristics of the knee associated with primary anterior cruciate ligament reconstruction (ACLR) versus revision ACLR at the time of initial presentation with either a native anterior cruciate ligament tear or an anterior cruciate ligament graft tear. Secondarily, we aimed to investigate risk factors for concomitant medial and lateral meniscal tears and cartilage injuries at the time of ACLR.

Methods: This was a retrospective review of patients who underwent primary or revision ACLR by a single surgeon. The exclusion criteria were as follows: skeletally immature patients; patients with an intra-articular fracture; patients with an ipsilateral knee infection; or patients who underwent an osteotomy, cartilage restoration procedure, or meniscal transplantation either previously or concomitantly with the ACLR. Detailed patient demographic data, radiographic long-standing alignment, tibial slope, and intraoperative findings including articular cartilage injury grade and meniscus integrity were documented at surgery.

Results: There were 487 patients included in this study (363 with primary ACLR and 124 with revision ACLR). There were no significant differences in age (P = .119), sex (P = .917), body mass index (P = .468), allograft versus autograft reconstruction (P = .916), or prevalence of meniscal tears (P = .142) between the primary and revision groups. Patients who underwent revision ACLR had a significantly increased medial tibial slope (P = .048) and a higher prevalence of chondral defects on both the medial (P < .001) and lateral (P = .003) femoral condyles when compared with primary ACLR patients. Logistic regression showed that a decreased tibial slope was correlated with femoral medial-sided chondral injuries and that varus or valgus coronal-plane malalignment was correlated with lateral meniscal tears in both groups.

Conclusions: The findings of this study show that patients undergoing a revision ACLR have significantly more chondral lesions, as well as higher-grade chondral lesions, at the time of presentation. Furthermore, coronal malalignment and a decreased tibial slope may contribute to injury patterns of the lateral meniscus and medial compartment cartilage, respectively. LEVEL OF EVIDENCE: Level III, retrospective case-control study.
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http://dx.doi.org/10.1016/j.arthro.2017.08.305DOI Listing
March 2018

Concomitant Reverse Hill-Sachs Lesion and Posterior Humeral Avulsion of the Glenohumeral Ligament: Treatment With Fresh Talus Osteochondral Allograft and Arthroscopic Posterior Humeral Avulsion of the Glenohumeral Ligament and Labrum Repair.

Arthrosc Tech 2017 Aug 10;6(4):e987-e995. Epub 2017 Jul 10.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Chronic posterior glenohumeral joint instability can be a challenging clinical entity for patients and surgeons alike. In the setting of a posterior dislocation, a large anterior humeral impaction injury (reverse Hill-Sachs [HS]) may occur, leading to engagement of the humerus with the posterior glenoid bone, especially during internal rotation of the joint. A reverse HS is especially debilitating because of the significant portion of affected humeral head cartilage, and is made worse in the setting of ligamentous disruption such as a posterior humeral avulsion of the glenohumeral ligament (HAGL) lesions. Although several nonanatomic procedures to address these defects have been previously described, recent interest in anatomic reconstructions capable of restoring the cartilage surface of the humeral head has led to the use of bone grafts (autografts and allografts) to restore the articular contour of the humeral head in conjunction with anatomic repair of associated soft tissue injuries. We present our preferred technique for an anatomic repair of a posterior HAGL lesion in combination with reconstruction of an engaging reverse HS lesion using an unmatched hemitalar allograft.
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http://dx.doi.org/10.1016/j.eats.2017.03.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5621160PMC
August 2017

Epidemiology of Anterior Tibial Spine Fractures in Young Patients: A Retrospective Cohort Study of 122 Cases.

J Pediatr Orthop 2019 Feb;39(2):e87-e90

Department of Orthopaedic Surgery, University of Colorado Hospital.

Background: Historically, bicycle accidents were described as the most common mechanism for pediatric anterior tibial spine fractures (ATSFs). There is a paucity of current literature examining the demographic factors associated with these injuries. The purpose of this cohort study was to characterize the epidemiology of ATSFs presenting to a single tertiary referral pediatric hospital.

Methods: A consecutive cohort of 122 pediatric patients with ATSFs between 1996 and 2014 were reviewed. Radiographic variables, classification of fractures (Meyers and McKeever type), age, sex, height, weight, body mass index, and mechanism of injury were retrieved. Categories of mechanism of injury included organized sports (football, soccer, basketball, lacrosse, wrestling, and gymnastics), bicycling, outdoor sports (skiing, skateboarding, and sledding), fall, motor vehicle collision/pedestrian versus motor vehicle, and trampoline.

Results: Organized sports-related injuries represented the most common cause of ATSFs (36%). Other common mechanisms of injury included bicycle accidents (25%), outdoor sports (18%), and falls (11%). There was a higher proportion of males (69%) compared with females (31%). Males (mean age, 11.6 y) were significantly older than females (mean age, 9.8 y) (P=0.004). Younger patients (aged 11.5 y and below) were more likely to have displaced fractures (type III), whereas type I and type II were more common in patients above 11.5 years (P=0.02). Patients with fracture type I were significantly taller than patients with fracture type III. No other variables were found to differ significantly according to fracture severity, including sex, weight, and body mass index.

Conclusions: To our knowledge, our study represents both the largest (n=122) and most up-to-date epidemiological ATSF study in pediatric patients. A higher rate of ATSF occurs due to organized sports rather than bicycling or motor vehicle collision. This 18-year data collection represents a change in the paradigm, and is likely multifactorial, including increased participation in youth sports and early sport specialization.

Level Of Evidence: Level IV-retrospective, cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000001080DOI Listing
February 2019

Single-Bundle and Double-Bundle Posterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis of 441 Patients at a Minimum 2 Years' Follow-up.

Arthroscopy 2017 Nov 31;33(11):2066-2080. Epub 2017 Aug 31.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A.. Electronic address:

Purpose: To perform a systematic review on the techniques and a meta-analysis on the functional and objective outcomes after single-bundle (SB) versus double-bundle (DB) posterior cruciate ligament (PCL) reconstructions.

Methods: A systematic review of the techniques, as well as functional and objective outcomes of clinical studies comparing SB versus DB PCL reconstruction with a mean follow-up of at least 24 months and minimum level of evidence of III were performed. After review of the literature, a quality analysis of the studies (Detsky score) and a meta-analysis comparing raw mean differences in data between SB and DB PCL groups were performed. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC] scores) and objective measurements (arthrometer and stress radiographs).

Results: The systematic search identified 11 studies (441 patients). Three studies were prospective randomized controlled trials and the other 8 studies were case-control studies. Two hundred thirty-two patients were treated with SB PCL reconstruction, whereas 209 were treated with DB PCL reconstruction. Only 4 studies satisfied the threshold for a satisfactory level of methodologic quality (>75%). There were no significant differences between SB and DB PCL reconstructions in postoperative Lysholm (P = .6, 95% confidence interval [CI], -0.98, 2.18) or Tegner scores (P = .37, 95% CI, -0.19, 0.92). DB PCL reconstruction provided significantly better objective posterior tibial translation stability than the SB technique using the Telos technique at 90° (P = -.58, 95% CI, -1.06, -0.10).

Conclusions: Improved patient-reported outcomes and knee stability were achieved with both SB and DB PCL reconstruction surgery. DB PCL reconstruction provided significantly improved objective posterior tibial stability and objective IKDC scores when compared with SB PCL reconstruction in randomized clinical trials. No significant difference was found for the other patient-reported outcomes.

Level Of Evidence: Level III, systematic review and meta-analysis of Level II and III studies.
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http://dx.doi.org/10.1016/j.arthro.2017.06.049DOI Listing
November 2017

Axillary Nerve Palsy and Deltoid Muscle Atony.

JBJS Rev 2017 07;5(7):e1

Department of Orthopaedic Surgery, Division of Sports Medicine and Shoulder Surgery, University of Colorado, Aurora, Colorado.

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http://dx.doi.org/10.2106/JBJS.RVW.16.00061DOI Listing
July 2017

Return to running after arthroscopic hip surgery: literature review and proposal of a physical therapy protocol.

J Hip Preserv Surg 2017 Jul 11;4(2):121-130. Epub 2017 Apr 11.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO 80045, USA.

The number of hip arthroscopy procedures has significantly increased in the last several years, thereby necessitating individualized rehabilitation protocols for patients following hip arthroscopy. The purpose of this article is to review the literature on rehabilitation protocols for patients following hip arthroscopy and to describe a new protocol specifically designed for patients to return to running following hip arthroscopy. A search of PubMed was performed through October 2016 to locate studies of rehabilitation protocols for patients wishing to return to sport/general activity following hip arthroscopy. Patients at our institution who desired to return to running following hip arthroscopy underwent a set of return to running guidelines which are based on goal achievement within a three-phase system that begins with a walking program and finishes with return to distance running. Rehabilitation protocols for patients following hip arthroscopy frequently use a four-phase system in which Phase I focuses on regaining hip range of motion and protection of surgically repaired tissues, and Phase IV involves a pain-free return to sports. Rehabilitation protocols vary in timing in that some include a timeline with each phase taking a certain number of weeks while others are based on goal achievement. There is an overall lack of published outcomes based on patients adhering to various post-hip arthroscopy rehabilitation protocols.
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http://dx.doi.org/10.1093/jhps/hnx012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467407PMC
July 2017

Multiligament Reconstruction of the Knee in the Setting of Knee Dislocation With a Medial-Sided Injury.

Arthrosc Tech 2017 Apr 20;6(2):e341-e350. Epub 2017 Mar 20.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Multiple ligament knee injuries are complex pathologies that often result from traumatic knee dislocations. Both a high level of suspicion and a thorough clinical and radiographic examination are mandatory to diagnose and identify all injured structures. Reconstruction of all injured ligaments is recommended to aid in early mobilization and to avoid joint stiffness or graft failure. For knee dislocations involving injury to the anterior cruciate ligament, posterior cruciate ligament, and medial-sided structures, a repair and augmentation of the medial collateral ligament, together with an anatomic reconstruction of the anterior cruciate ligament and double-bundle posterior cruciate ligament, is recommended. In the setting of these complex reconstructions, there are several technical aspects that require consideration to ensure concise and efficient treatment of these injuries. Graft choice, sequence of reconstruction, tunnel position and orientation, and graft tensioning all pose surgical challenges, and require dedicated preoperative preparation and planning. The purpose of this Technical Note is to report a safe, effective, and reproducible surgical technique for treatment of multiligament injuries in the setting of a knee dislocation with a medial-sided component (classified as KD-III-M in the Schenck classification system).
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http://dx.doi.org/10.1016/j.eats.2016.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5442403PMC
April 2017

Repair of Proximal Hamstring Tears: A Surgical Technique.

Arthrosc Tech 2017 Apr 13;6(2):e311-e317. Epub 2017 Mar 13.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Proximal hamstring tears are among the most common sports-related injuries. These injuries often occur as strains or partial tears at the proximal muscle belly or the musculotendinous junction, with avulsion injuries of the proximal attachment occurring less frequently. Regardless of the mechanism, they produce functional impairment and negatively affect an athlete's performance. Various classifications for these injuries are reported in the literature. Early surgical treatment is recommended for patients with either a 2-tendon tear/avulsion with more than 2 cm retraction or those with complete 3-tendon tears. Surgery can be performed in the chronic phase but it is technically demanding because of scar formation and tendon retraction. This Technical Note describes a biomechanically validated surgical technique for repair of the proximal hamstring tears.
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http://dx.doi.org/10.1016/j.eats.2016.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5442402PMC
April 2017

Outcomes After 1-Stage Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2017 Jul 18;45(8):1790-1798. Epub 2017 Apr 18.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Revision anterior cruciate ligament reconstruction (ACLR) is becoming increasingly common as the number of primary ACLR cases continues to rise. Despite this, there are limited data on the outcomes of revision ACLR and even less information specifically addressing the differences in 1-stage revision reconstruction versus those performed in a 2-stage fashion after primary reconstruction.

Purpose: To compare the outcomes, patient satisfaction, and failure rates of 1-stage versus 2-stage revision ACLR.

Study Design: Cohort study; Level of evidence, 3.

Methods: All patients who underwent revision ACLR between 2010 and 2014 by a single surgeon were collected, and skeletally mature patients over the age of 17 years were included. Patients were excluded if they were skeletally immature; had a previous intra-articular infection in the ipsilateral knee; underwent a prior alignment correction procedure, cartilage repair or transplant procedure, or meniscal allograft transplantation; or had an intra-articular fracture. An ipsilateral or contralateral bone-patellar tendon-bone (BPTB) autograft was the graft of choice. A BPTB allograft was considered for patients aged ≥50 years, for any patient with an insufficient ipsilateral or contralateral patellar tendon, or for those who chose not to have the contralateral patellar tendon graft harvested. Patients completed a subjective questionnaire preoperatively and at a minimum of 2 years postoperatively. Magnetic resonance imaging and computed tomography of all knees were performed preoperatively to assess for associated injuries and to evaluate the ACLR tunnel size and location. Patients with malpositioned tunnels that would critically overlap with an anatomically placed tunnel or those with tunnels ≥14 mm in size underwent bone grafting.

Results: A total of 88 patients met the inclusion criteria for this study. There were 39 patients in the 1-stage revision surgery group (19 male, 20 female) and 49 patients in the 2-stage revision surgery group who underwent tunnel bone grafting first (27 male, 22 female). In both groups, the 12-item Short Form Health Survey (SF-12) Physical Component Summary, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner activity scale scores significantly improved from preoperatively to postoperatively. There was no significant difference in the SF-12 Mental Component Summary score before and after surgery in either group. Furthermore, there was no significant difference in failure rates or other demographic data between the groups. We observed 4 failures in the 1-stage reconstruction group (10.3%) and 3 failures in the 2-stage reconstruction group (6.1%).

Conclusion: In this study, objective outcomes and subjective patient scores and satisfaction were not significantly different between 1-stage and 2-stage revision ACLRs. Both groups had significantly improved objective outcomes and patient subjective outcomes without notable differences in failure rates. Further longitudinal studies comparing 1-stage and 2-stage revision ACLRs over a longer time frame are recommended.
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http://dx.doi.org/10.1177/0363546517698684DOI Listing
July 2017

Outcomes of Inside-out Meniscal Repair in the Setting of Multiligament Reconstruction in the Knee.

Am J Sports Med 2017 Jul 27;45(9):2098-2104. Epub 2017 Mar 27.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Limited evidence exists for meniscal repair outcomes in a multiligament reconstruction setting. Purpose/Hypothesis: The purpose of this study was to assess outcomes and failure rates of meniscal repair in patients who underwent multiligament reconstruction compared with patients who underwent multiligament reconstruction but lacked meniscal tears. The authors hypothesized that the outcomes of meniscal repair associated with concomitant multiligament reconstruction would significantly improve from preoperatively to postoperatively at a minimum of 2 years after the index surgery. Secondarily, they hypothesized that this cohort would demonstrate similar outcomes and failure rates compared with the cohort that did not have meniscal lesions at the time of multiligament reconstruction.

Study Design: Cohort study; Level of evidence, 3.

Methods: Inclusion criteria for the study included radiographically confirmed skeletally mature patients of at least 16 years of age who underwent multiligamentous reconstruction of the knee without previous ipsilateral osteotomy, intra-articular infections, or intra-articular fractures. Patients were included in the experimental group if they underwent inside-out meniscal suture repair with concurrent multiligament reconstruction. Those included in the control group (multiligament reconstruction without a meniscal tear) underwent multiligament reconstruction but did not undergo any type of meniscal surgery. Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-12 physical component summary and mental component summary, Tegner activity scale, and patient satisfaction scores were recorded preoperatively and postoperatively. The failure of meniscal repair was defined as a retear of the meniscus that was confirmed arthroscopically.

Results: There were 43 patients (16 female, 27 male) in the meniscal repair group and 62 patients (25 female, 37 male) in the control group. Follow-up was obtained in 93% of patients with a mean of 3.0 years (range, 2.0-4.7 years). There was a significant improvement between all preoperative and postoperative outcome scores ( P < .05) for both groups. The meniscal repair group had significantly lower preoperative Lysholm and Tegner scores ( P = .009 and P = .02, respectively). There were no significant differences between any other outcome scores preoperatively. The failure rate of the meniscal repair group was 2.7%, consisting of 1 symptomatic meniscal retear. There was no significant difference in any postoperative outcome score at a minimum 2-year follow-up between the 2 groups.

Conclusion: Good to excellent patient-reported outcomes were reported for both groups with no significant differences in outcomes between the cohorts. Additionally, the failure rate for inside-out meniscal repair with concomitant multiligament reconstruction was low, regardless of meniscus laterality and tear characteristics. The use of multiple vertical mattress sutures and the biological augmentation resulting from intra-articular cruciate ligament reconstruction tunnel reaming may be partially responsible for the stability of the meniscal repair construct and thereby contribute to the overall improved outcomes and the low failure rate of meniscal repair, despite lower preoperative Lysholm and Tegner scores in the meniscal repair group.
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http://dx.doi.org/10.1177/0363546517698944DOI Listing
July 2017

Outcomes After Biologically Augmented Isolated Meniscal Repair With Marrow Venting Are Comparable With Those After Meniscal Repair With Concomitant Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2017 May 1;45(6):1341-1348. Epub 2017 Feb 1.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Meniscal repair in the setting of anterior cruciate ligament (ACL) reconstruction has demonstrated superior outcomes compared with isolated meniscal repair. Limited evidence exists for the effects of biological augmentation in isolated meniscal repair, particularly as compared with meniscal repair with concomitant ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to compare the outcomes and survivorship of meniscal repair in 2 cohorts of patients: meniscal repair with biological augmentation using a marrow venting procedure (MVP) of the intercondylar notch, and meniscal repair with concomitant ACL reconstruction. We hypothesized that the clinical outcomes and survivorship of meniscal repair with concomitant ACL reconstruction would be improved compared with meniscal repair with biological augmentation.

Study Design: Cohort study; Level of evidence, 3.

Methods: Inclusion criteria were skeletally mature patients aged ≥16 years who underwent inside-out meniscal repair and either a concomitant MVP of the intercondylar notch or ACL reconstruction. Patients were excluded from this study if they were skeletally immature, underwent meniscus root or radial tear repair, or underwent meniscal repair with concurrent ligamentous reconstruction not limited to the ACL. At the preoperative evaluation and a minimum 2 years after the index meniscal repair procedure, patients were administered a subjective questionnaire. Differences in outcome scores, survivorship, and failure rates between the cohorts were assessed. Failure was defined as reoperation with meniscectomy or revision meniscal repair.

Results: There were 109 patients (52 female, 57 male) who met the inclusion criteria for this study. There were 37 knees in cohort 1 (isolated meniscal repair plus MVP) and 72 knees in cohort 2 (meniscal repair plus ACL reconstruction). The failure status was known in 95 patients, and patient-reported outcome scores were obtained in 89 (82%) patients. Both cohorts demonstrated a significant improvement in all outcome scores, and there was no significant difference in any of the preoperative or postoperative outcome measures. The overall failure rate was 9.5% (9/95). There were 4 (12.9%) failures in cohort 1 and 5 failures (7.8%) in cohort 2, with no significant difference in failures between the cohorts ( P = .429). There was a significant association between failure and female sex ( P = .001).

Conclusion: The most important finding in this study was that there was no difference in outcomes in meniscal repair performed with biological augmentation using an MVP versus that performed concomitantly with ACL reconstruction. The similar outcomes reported for meniscal repair with an MVP and meniscal repair with ACL reconstruction may be partly attributed to biological augmentation.
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http://dx.doi.org/10.1177/0363546516686968DOI Listing
May 2017

Endoscopic Trochanteric Bursectomy and Iliotibial Band Release for Persistent Trochanteric Bursitis.

Arthrosc Tech 2016 Oct 17;5(5):e1185-e1189. Epub 2016 Oct 17.

The Steadman Clinic, Vail, Colorado, U.S.A.; Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Lateral hip pain associated with trochanteric bursitis is a common orthopedic condition, and can be debilitating in chronic or recalcitrant situations. Conservative management is the most common initial treatment and often results in resolution of symptoms and improved patient outcomes. These modalities include rest, activity modification, physical therapy, anti-inflammatory medication, or corticosteroid injections. However, there is a subset of patients in which symptoms persist despite exhaustive conservative modalities. For these patients, trochanteric bursectomy is a surgical option to address persistent pathology. Previous literature indicates that both open and arthroscopic surgical techniques can be used to address the inflamed bursa and results in good patient outcomes. However, recent advances in hip arthroscopy have allowed for improvements in minimally invasive techniques to address intracapsular and extracapsular pathology of the hip, including recalcitrant trochanteric bursitis. The purpose of this manuscript is to describe our technique for a minimally invasive arthroscopic trochanteric bursectomy.
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http://dx.doi.org/10.1016/j.eats.2016.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310191PMC
October 2016

Arthroscopic Fixation of Os Acetabuli Technique: When to Resect and When to Fix.

Arthrosc Tech 2016 Oct 10;5(5):e1155-e1160. Epub 2016 Oct 10.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Acetabular rim fractures, or os acetabuli, are hypothesized to occur as a result of an unfused ossification center or a stress fracture from repetitive impingement of an abnormally shaped femoral neck against the acetabular rim. When treated surgically, these fragments are typically excised as part of the correction for femoroacetabular impingement. However, in some patients, removal of these fragments can create symptoms of gross instability or microinstability of the hip. In these cases, internal fixation of the fragment is necessary. The purpose of this technical note is to describe indications, the arthroscopic technique, and postoperative care for fixation of acetabular rim fractures.
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http://dx.doi.org/10.1016/j.eats.2016.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310184PMC
October 2016

Anterior Horn Meniscal Repair Using an Outside-In Suture Technique.

Arthrosc Tech 2016 Oct 30;5(5):e1111-e1116. Epub 2016 Sep 30.

The Steadman Clinic, Vail, Colorado, U.S.A.; Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

The menisci are important structures within the knee that play a critical role in maintaining proper stability, load distribution, and joint lubrication. Injury to the menisci has been found to significantly alter the complex biomechanics of the knee, and thus affect the health and longevity of the native joint. Tears involving the anterior horn are increasingly recognized as an important pathology. Although early treatment of meniscal tears focused primarily on removal of the injured tissue, recent attention on the long-term consequences of partial or total meniscectomy has led to increased attempts at meniscus repair whenever possible. Because of the location of anterior horn tears and the technical difficulty in accessing this location arthroscopically, an outside-in repair technique is ideal for treatment of these lesions. This technical note details our surgical technique of outside-in repair of anterior horn meniscal tears.
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http://dx.doi.org/10.1016/j.eats.2016.06.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310193PMC
October 2016

Biologic Approaches for the Treatment of Partial Tears of the Anterior Cruciate Ligament: A Current Concepts Review.

Orthop J Sports Med 2017 Jan 25;5(1):2325967116681724. Epub 2017 Jan 25.

The Steadman Philippon Research Institute, Vail, Colorado, USA.; The Steadman Clinic, Vail, CO, USA.

Background: Anterior cruciate ligament reconstruction (ACLR) has been established as the gold standard for treatment of complete ruptures of the anterior cruciate ligament (ACL) in active, symptomatic individuals. In contrast, treatment of partial tears of the ACL remains controversial. Biologically augmented ACL-repair techniques are expanding in an attempt to regenerate and improve healing and outcomes of both the native ACL and the reconstructed graft tissue.

Purpose: To review the biologic treatment options for partial tears of the ACL.

Study Design: Review.

Methods: A literature review was performed that included searches of PubMed, Medline, and Cochrane databases using the following keywords: partial tear of the ACL, ACL repair, bone marrow concentrate, growth factors/healing enhancement, platelet-rich plasma (PRP), stem cell therapy.

Results: The use of novel biologic ACL repair techniques, including growth factors, PRP, stem cells, and bioscaffolds, have been reported to result in promising preclinical and short-term clinical outcomes.

Conclusion: The potential benefits of these biological augmentation approaches for partial ACL tears are improved healing, better proprioception, and a faster return to sport and activities of daily living when compared with standard reconstruction procedures. However, long-term studies with larger cohorts of patients and with technique validation are necessary to assess the real effect of these approaches.
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http://dx.doi.org/10.1177/2325967116681724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298533PMC
January 2017

Intra-articular Implantation of Mesenchymal Stem Cells, Part 1: A Review of the Literature for Prevention of Postmeniscectomy Osteoarthritis.

Orthop J Sports Med 2017 Jan 19;5(1):2325967116680815. Epub 2017 Jan 19.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Osteoarthritis (OA) after a partial or total meniscectomy procedure is a common pathology. Because of the high incidence of meniscectomy in the general population, as well as the significant burden of knee OA, there is increasing interest in determining methods for delaying postmeniscectomy OA. Biological therapies, including mesenchymal stem cells (MSCs), induced pluripotent stem cells (iPSCs), and platelet-rich plasma (PRP), have been proposed as possible therapies that could delay OA in this and other settings. Several studies in various animal models have evaluated the effect of injecting MSCs into the knee joints of animals with OA induced either by meniscal excision with or without anterior cruciate ligament transection. When compared with control groups receiving injections without progenitor cells, short-term benefits in the experimental groups have been reported. In human subjects, there are limited data to determine the effect of biological therapies for use in delaying or preventing the onset of OA after a meniscectomy procedure. The purpose of this review is to highlight the findings in the presently available literature on the use of intra-articular implantation of MSCs postmeniscectomy and to offer suggestions for future research with the goal of delaying or treating early OA postmeniscectomy with MSCs.
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http://dx.doi.org/10.1177/2325967116680815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298518PMC
January 2017

Intra-articular Implantation of Mesenchymal Stem Cells, Part 2: A Review of the Literature for Meniscal Regeneration.

Orthop J Sports Med 2017 Jan 19;5(1):2325967116680814. Epub 2017 Jan 19.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA.

Knee osteoarthritis (OA) after partial or total meniscectomy is a prevalent issue that patients must face. Various methods of replacing meniscal tissue have been studied to avoid this progression, including meniscal allograft transplantation, meniscal scaffolds, and synthetic meniscus replacement. Studies have shown that meniscal scaffolds may improve symptoms but have not been shown to prevent progression of OA. Recently, mesenchymal stem cells (MSCs) have been proposed as a possible biological therapy for meniscal regeneration. Several animal studies and 1 human study have evaluated the effect of transplanting MSCs into the knee joint after partial meniscectomy. The purpose of this review was to assess the outcomes of intra-articular transplantation of MSCs on meniscal regeneration in animals and humans after partial meniscectomy. Limited results from animal studies suggest that there is some potential for intra-articular injection of MSCs for the regeneration of meniscal tissue. However, further studies are necessary to determine the quality of regenerated meniscal tissue through histological and biomechanical testing.
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http://dx.doi.org/10.1177/2325967116680814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298485PMC
January 2017
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