Isolated, full-thickness proximal rectus femoris injury in competitive athletes: A systematic review of injury characteristics and return to play

BACKGROUND: Characteristics regarding mechanism of injury, management, and return-to-play (RTP) rate and timing are important when treating and counseling athletes with rectus femoris tears. PURPOSE: To systematically review the literature to better understand the prevalence, sporting activity, injury mechanisms, and treatment of patients with rectus femoris injury and to provide prognostic information regarding the rate and timing of RTP. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we queried PubMed/MEDLINE, Cochrane, OVID, EMBASE, and Google Scholar in March 2022 for studies reporting on athletes sustaining isolated, full-thickness tearing, or bony avulsion injuries to the proximal rectus femoris during sporting activity. Excluded were studies without evidence of full-thickness tearing or avulsion, with athletes sustaining concomitant injuries, or with injuries occurring from nonsporting activities. The percentage of athletes sustaining injuries was calculated based on sport, injury mechanism, and management (nonoperative versus operative). RESULTS: Of 132 studies initially identified, 18 were included, comprising 132 athletes (mean age, 24.0 ± 5.4 years; range, 12-43 years). The most common sporting activities were soccer (70.5%) and rugby (15.2%). The most reported mechanisms of injury were kicking (47.6%) and excessive knee flexion/forced hip extension (42.9%). Avulsion injuries were reported in 86% (n = 114) of athletes. Nonoperative management was reported in 19.7% of athletes, with operative management performed in 80.3%. The mean follow-up time was 21.4 ± 11.4 months (range, 1.5-48 months). The RTP rate was 93.3% (n = 14) in nonoperatively treated and 100% (n = 106) in operatively treated athletes, and the mean RTP time was 11.7 weeks (range, 5.5-15.2 weeks) in nonoperatively treated and 22.1 weeks (range, 14.0-37.6 weeks) in operatively treated athletes. Complications were reported in 7.7% (2/26) of nonoperatively treated and 18% (n = 19/106) of operatively treated athletes. CONCLUSION: Full-thickness proximal rectus femoris injuries occurred most frequently in athletes participating in soccer and rugby secondary to explosive, eccentric contractions involved in kicking and sprinting. Operative management was performed in the majority of cases. Athletes who underwent operative repair had a 100% RTP rate versus 93.3% in athletes treated nonoperatively

Global variation in isolated posterior cruciate ligament reconstruction

PURPOSE: In the setting of persistent instability or failed non-operative management, surgical reconstruction is commonly recommended for isolated posterior cruciate ligament (PCL) tears. The purpose of this study was to systematically review published studies to evaluate regional variation in the epidemiology of and surgical approaches to primary, isolated PCL reconstruction. METHODS: A systematic review was performed in June 2022 to identify studies examining operative techniques during primary, isolated PCL reconstruction. Collected variables consisted of reconstruction technique, graft type, graft source, tibial reconstruction technique, femoral and tibial drilling and fixation methods, and whether the remnant PCL was preserved or debrided. Studies were classified into four global regions: Asia, Europe, North America, and South America. RESULTS: Forty-five studies, consisting of 1461 total patients, were identified. Most of the included studies were from Asia (69%, n = 31/45). Single bundle reconstruction was more commonly reported in studies out of Asia, Europe, and North America. Hamstring autografts were utilized in 51.7% (n = 611/1181) of patients from Asia and 60.8% (n = 124/204) of patients from Europe. Trans-tibial drilling and outside-in femoral drilling were commonly reported in all global regions. The PCL remnant was generally debrided, while remnant preservation was commonly reported in studies from Asia. CONCLUSION: Surgical treatment of isolated PCL injuries varies by region, with the majority of published studies coming from Asia. Single-bundle reconstruction with hamstring autograft through a trans-tibial approach is the most commonly reported technique in the literature, with males reported to undergo isolated reconstruction more often than females. LEVEL OF EVIDENCE: Systematic review, Level IV

Systematic review and meta-analysis of clinical outcomes after management of posterior cruciate ligament tibial avulsion fractures

BACKGROUND: There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment. PURPOSE: To systematically review clinical outcomes and complications after management of tibial-sided avulsion fractures of the PCL. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature search of Scopus, PubMed, Medline, and the Cochrane Central Register for Controlled Trials was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies with evidence levels 1 to 4 that reported clinical outcomes after treatment of PCL tibial-sided avulsion fractures in humans. The quality of the included studies was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A meta-analysis was performed for patient-reported outcome measures using random-effects modeling with 95% CIs. RESULTS: A total of 58 studies published between 1999 and 2022 were identified. The mean MINORS score was 9.90 ± 4.12, indicating overall low-quality evidence with high risk of bias. The studies comprised 1440 patients (mean age, 32.59 ± 5.69 years; 75.2% males) with a mean follow-up of 26.9 ± 19.6 months (range, 5.3-126 months). Most patients were treated with open surgery (63.6%), followed by arthroscopic surgery (29.7%) and nonoperative treatment (6.7%). All patients reported significant posttreatment improvement in both subjective and objective outcomes ( CONCLUSION: Although nonoperative and surgical management of PCL tibial avulsion fractures resulted in high rates of fracture union and improvement in functional outcome scores and a low incidence of complications, nonoperative treatment yielded a high side-to-side posterior displacement (\u3e4 mm) with a lower rate of fracture union compared to surgical treatment

Nonoperative management of tibial stress fractures result in higher return to sport rates despite increased failure versus operative management: A systematic review

PURPOSE: To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures. METHODS: 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: 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: 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: Level IV; Systematic Review of level I-IV studies

Clinical outcomes, return to sport, and complications after isolated primary Latarjet versus Latarjet as a revision procedure: A systematic review and meta-analysis

BACKGROUND: The purpose of this review was to compare clinical outcomes, return to sport (RTS), and complications in comparative studies examining patients undergoing primary Latarjet procedure versus Latarjet in the revision setting following soft tissue stabilization. METHODS: A literature search was conducted using PubMed and Scopus databases using Preferred Reporting Items for Systematic Meta-Analyses guidelines. Inclusion criteria consisted of level I to III human clinical studies reporting clinical outcomes (Visual Analogue Pain Scale [VAS]), RTS metrics, and complications in patients following primary versus revision Latarjet procedures. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: A total of seven studies, consisting of 1170 patients (n=1179 shoulders) with a mean age of 26.4 years, consisting of 91.9% males (n=1083/1179 shoulders), were identified. Mean final follow-up was 46.4 (mean range, 7.3-72.2) months. A total of 748 primary and 431 revision Latarjet procedures were analyzed. Complications were reported in 9.6% (range, 0%-24.2%) of patients undergoing primary and 20.2% (range, 0%-40.7%) in patients undergoing revision procedures (p=0.22). There was no significant difference in the RTS rate between patients undergoing primary (87.3%; range, 83.8%-92.1%) versus Latarjet as a revision procedure (78.9%; range, 60%-100%) (p=0.08). Moreover, no significant difference in postoperative VAS was observed in patients undergoing primary versus Latarjet as a revision procedure (p=0.21). Recurrent shoulder subluxation was significantly greater in patients undergoing revision (12.0%; n=31/259 shoulders; range, 0%-20.7%) compared to primary procedures (3.3%; n=27/511 shoulders; range, 0%-9%) (p\u3c0.001). DISCUSSION: Patients undergoing primary and revision Latarjet demonstrated overall similar rates of complications and return to sport. Of clinical importance, Latarjet as a revision procedure possessed a risk of recurrent subluxation 3.6 times higher than primary Latarjet. While effective, patients should be counseled regarding the differing prognosis between Latarjet as a primary or revision procedure. LEVEL OF EVIDENCE: III; Systematic review and meta-analysis

Radiofrequency-based chondroplasty creates a precise area of targeted chondrocyte death with minimal necrosis outside the target zone: A systematic review

PURPOSE: To systematically examine the effects of radiofrequency (RF) ablation or coblation (controlled ablation) on chondrocyte viability following knee chondroplasty in preclinical literature to determine the effectiveness and safety of RF-based techniques. METHODS: A literature search was performed in September 2022 using PubMed and Scopus using the following search terms combined with Boolean operators: chondroplasty, radiofrequency, thermal, knee, chondral defect, articular cartilage, and cartilage. The inclusion criteria consisted of preclinical studies examining the effect of RF ablation or coblation on chondrocytes during knee chondroplasty. Exclusion criteria consisted of studies reporting chondroplasty in joints other than the knee, clinical studies, in vitro studies using animal models, case reports, non-full-text articles, letters to editors, surveys, review articles, and abstracts. The following data were extracted from the included articles: author, year of publication, chondral defect location within the knee and chondral characteristics, RF probe characteristics, cartilage macroscopic description, microscopic chondrocyte description, and extracellular matrix characteristics. RESULTS: A total of 17 articles, consisting of 811 cartilage specimens, were identified. The mean specimen age was 63.4 ± 6.0 (range, 37-89) years. Five studies used monopolar RF devices, 7 studies used bipolar RF devices, whereas 4 studies used both monopolar and bipolar RF devices. Time until cell death during ablation at any power was reported in 5 studies (n = 351 specimens), with a mean time to cell death of 54.4 seconds (mean range, 23.1-64) for bipolar RF and 56.3 seconds (mean range, 12.5-64) for monopolar RF devices. Chondrocyte cell death increased with increased wattage, while treatment time was positively correlated with deeper cell death. CONCLUSIONS: In this systematic review, histologic analysis demonstrated that RF-based chondroplasty creates a precise area of targeted chondrocyte death, with minimal evidence of necrosis outside the target zone. Caution must be exercised when performing RF-based chondroplasty due to the risk of cell death with increased application time and wattage. CLINICAL RELEVANCE: Although RF ablation has demonstrated favorable results in preliminary trials, including smoother cartilage and less damage to the surrounding healthy tissue, the risks versus benefits of the procedure are largely unknown. Caution must be exercised when performing RF-based chondroplasty in the clinical setting due to the risk of cell death with increased application time and wattage

Adverse events and complications after primary ACL reconstruction with quadriceps tendon autograft: A systematic review

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) surgery with quadriceps tendon (QT) grafts, both with and without a patellar bone plug, have gained popularity in recent years in the primary and revision settings. Postoperative complications occur with the use of QT autografts. PURPOSE: To systematically review the incidence of postoperative complications after primary ACLR QT autograft and compare complication rates in patients undergoing all-soft tissue QT grafts versus QT grafts with a patellar bone plug (QTPB). STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature search using the 2020 PRISMA guidelines was performed by querying PubMed, Embase, and Scopus databases from database inception through August 2022. Included were evidence level 1 to 4 human clinical studies in English that reported complications after primary ACLR with QT autograft. The incidence of complications within the included studies was extracted. Differences in the incidence of postoperative complications between ACLR with QT with and without a patellar bone plug were calculated. RESULTS: A total of 20 studies from 2004 to 2022, comprised of 2381 patients (2389 knees; 68.3% male) with a mean age of 27 years (range, 12-58 years), were identified. The mean follow-up was 28.5 months (range, 6-47 months). The total incidence of complications was 10.3%, with persistent postoperative knee pain being the most common (10.8%). Patients who underwent ACLR with all-soft tissue QT grafts had a 2.7-times increased incidence of anterior knee pain (23.3% vs 8.6%) and reoperations (5.9% vs 3.2%) when compared with QTPB grafts ( CONCLUSION: Complications after primary ACLR using QT autograft were recorded in 10.5% of knees, with anterior knee pain being the most common. No difference was reported in the overall incidence of complications with the use of the QT versus QTPB grafts; however, anterior knee pain was 2.7 times greater with use of a soft tissue quadriceps graft

Arthroscopic Viewing Position Affects Anterior Cruciate Ligament Reconstruction Femoral Tunnel Length Measurements

PurposeTo purpose of this study was to compare arthroscopic anterior cruciate ligament (ACL) reconstruction femoral tunnel length measurements from the anterolateral portal between the standard notch view using a 30° arthroscope versus a “top-down” view utilizing a 70° arthroscope to visual the far side of the femoral tunnel aperture.MethodsArthroscopic femoral tunnel length measurements using calibrated reamers from the standard notch versus the “top-down” view were obtained and reviewed in 54 skeletally mature patients undergoing ACL reconstruction with no prior bony knee surgery. Patient age, height, weight, sex, and surgery laterality were also recorded. Measurements of femoral tunnel length were repeated using both views for inter-observer and intra-observer correlation.ResultsInter-observer and intra-observer intra-class correlation coefficients for the standard notch view and “top-down” views were excellent, with higher reliability values appreciated using the “top down” view. Mean overall femoral tunnel length measurements obtained using the standard notch view were significantly longer than measurements from the “top-down” view (p < 0.001).ConclusionsThe standard notch view provides significantly longer femoral tunnel length measurements in comparison to the “top-down” view

Diagnosis of Biceps Incarceration: Observations on the Biceps Incarceration Maneuver

Instability of the long head of the biceps brachii tendon is a recognized source of shoulder pain. However, this diagnosis is usually associated with concomitant pathology including subscapularis tendon tears. The appropriate diagnosis of biceps incarceration or instability remains challenging, with failure to address instability being likely to result in persistent pain and disability despite arthroscopic management of concomitant shoulder pathology. The objective of this article is to (1) describe a dynamic test performed both preoperatively and intraoperatively, termed the “biceps incarceration maneuver,” to help identify biceps instability; (2) reinforce the concept that biceps instability must be ruled out in young patients presenting with anterior shoulder pain; and (3) report that with proper diagnosis and treatment, patients with biceps instability will experience rapid symptomatic resolution after management