Tyler M. Hauer

Background: Transtendinous supraspinatus tears are a rare subset of rotator cuff tears that are characterized by a substantial amount of insertional supraspinatus tendon remaining attached to the greater tuberosity. This can typically be seen in acute, traumatic rotator cuff tears. With this tear pattern, there is often an inability to adequately reduce the medial aspect of the tear to the tuberosity without overtensioning the repair. A side-to-side repair of this transtendinous tear pattern is a good and effective surgical treatment option. Indications: Indications for this procedure include a significant remnant supraspinatus tendon attached to its insertion on the greater tuberosity, where the medial transtendinous nature of the tear may result in overtensioning or inadequate coverage of the tuberosity if the insertional tendon is debrided. Technique Description: After diagnostic arthroscopy and any additional intraarticular procedures, the subacromial space is debrided, and a posterolateral viewing portal is established, as well as a lateral working portal. Two medial row tensionable, all-suture anchors are placed at the medial extent of the greater tuberosity footprint. The repair suture from the anchors is passed medially through the tear. A suture passing device is passed through the supraspinatus remnant laterally on the tuberosity. The repair sutures are shuttled into the anchor, creating a tensionable, knotless side-to-side repair. Fiber tapes from the medial anchors are passed medially and then tensioned into a lateral row, creating a double row repair incorporating the tensionable side-to-side repair of the transtendinous supraspinatus tear. Results: The side-to-side repair technique for rotator cuff repairs yields excellent outcomes comparable to conventionally described rotator cuff repair techniques. This surgical technique describes a knotless, tensionable repair to reduce the risk of overtensioning or undercoverage of the greater tuberosity in transtendinous tears. Discussion/Conclusion: A knotless, tensionable side-to-side repair technique for full-thickness transtendinous supraspinatus tears is a viable option for tears with sufficient lateral insertional tissue at the footprint. This can be performed using a double-row technique, resulting in favorable long-term outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Purpose: To report conversion rates to total hip arthroplasty (THA), patient‐reported outcome measures, and complication rates in adults aged ≥ 40 years undergoing hip arthroscopy since 2016. Methods: MEDLINE, EMBASE, and PubMed were searched from January 2016 to March 2025, and pertinent data were abstracted from eligible studies according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. To provide an updated synthesis without duplicating prior work, this review was limited to studies published from 2016 onward, following a previous systematic review that comprehensively evaluated outcomes of hip arthroscopy in patients aged 40 years and older through 2015. Inclusion criteria were studies involving patients aged ≥ 40 years who underwent hip arthroscopy, published in English, and reporting at least 1 patient‐reported outcome measure or clinical outcome. Exclusion criteria included studies that were not Level I, II, or III studies with nonsurgical treatments or studies with duplicate patient cohorts. Results: Six studies were included (2 Level II cohort studies, 4 Level III cohort studies), encompassing 33,091 patients (30,549 ≥ 40 years; 92.3%). Among 5 studies (n = 2479), the overall THA conversion rate in patients ≥ 40 ranged from 5% to over 21%. The 2‐year THA conversion rate ranged from 9% to 13% in patients aged 40 to 60 years, and the 5‐year conversion rate was as high as 20.2%. Five studies reporting patient‐reported outcome measures showed significant improvements that exceeded the minimal clinically important difference at a follow‐up period of 2 years. Functional outcomes (Modified Harris Hip Score, Hip Outcome Score Activity of Daily Living Scale, Hip Outcome Score Sport Scale, and Nonarthritic Hip Score) were significantly worse in patients > 45 years compared with those < 45 years. Twenty‐one procedure‐related complications occurred among 1807 hips (1.16%) in patients 40 and older, the 2 most common being superficial soft‐tissue injuries (n = 4) and transient neuropraxia/nerve palsy (n = 3). Conclusions: Although hip arthroscopy continues to display statistically and clinically significant postoperative improvements in patients aged 40 and older, the risk of conversion to THA remains substantially higher compared with younger populations. Level of Evidence: Level III, systematic review of Level II and III studies.

Calf injuries are common in athletes and typically result in missed time from sport and activities of daily living. The three individual triceps surae muscles can be injured, with differing described mechanisms. Gastrocnemius or plantaris strains tend to occur during sudden explosive movement of the ankle from a dorsiflexed to a plantarflexed position with the knee in extension. Soleus strains typically occur from repetitive dorsiflexion of the ankle with the knee flexed. Imaging modalities such as magnetic resonance imaging and ultrasonography can be helpful in determining the location and grade of injury, which can aid in treatment and return to play timelines. Classically, these injuries have been graded as grade I, II, or III, with grade I having 10 to 50% muscle fiber disruption, and grade III having 50 to 100% muscle fiber disruption. The mainstay of treatment for most calf strains is nonsurgical, with surgical management being rare but reported in the literature for isolated grade III ruptures of the medial head of the gastrocnemius. Return to sport and activities requires a graduated physical therapy program focused on restoring tissue length without excessive strain. Recent limited evidence has shown promising results with quicker return to activities and decreased pain with platelet-rich plasma injections.

Background: Posterior shoulder instability is a common yet underappreciated condition in elite hockey players. It presents unique treatment dilemmas during both the season and the offseason. Purpose: To investigate treatment trends and decision-making factors among National Hockey League (NHL) team physicians when managing posterior shoulder instability. Study Design: Cross-sectional study. Methods: A 35-item questionnaire addressing treatment decisions, surgical thresholds, bone loss management, and return-to-play (RTP) protocols was sent to all 32 NHL team orthopaedic surgeons. Data were collected on both in-season and offseason preferences and analyzed as descriptive statistics. Results: Of the 32 invited team physicians, a total of 31 (97%) completed all (n = 29) or most (n = 2) of the survey. For first-time in-season posterior shoulder instability, 100% of physicians chose nonoperative management. For recurrent posterior instability, 35% favored in-season surgery if there was no bone loss, and 74% favored in-season surgery when bone loss was ≥15%. Timing within the season did not influence the majority of surgeons. In the offseason, 39% would recommend offseason surgery for first-time injuries and 48% for recurrent instability without bone loss. Arthroscopic stabilization was the preferred procedure in all soft tissue cases; in cases of bone loss ≥15%, 53% would perform a soft tissue only procedure, and 30% would perform augmentation with distal tibial allograft. RTP was guided by full strength, range of motion, absence of pain, and absence of subjective instability. Conclusion: NHL team physicians strongly favor nonoperative management in-season for first-time posterior shoulder instability events. Recommendation of in-season surgery becomes more likely in the presence of injury recurrence or bone loss. Heterogeneity exists among surgeons regarding the amount of combined bone loss that would lead to the recommendation of a bony procedure. Injury timing during the season rarely alters treatment decisions, and arthroscopic repair remains the standard approach.

Background: Posterior shoulder instability has been associated with abnormal acromial and glenoid morphology. However, the role of coracoid morphology in posterior instability remains unclear. Hypothesis: Patients undergoing surgery for posterior shoulder instability will have more inferiorly oriented and lateralized coracoids compared to patients with anterior instability or a noninstability comparison group. Study Design: Cohort study; Level of evidence, 3. Methods: Magnetic resonance imaging measurements were collected for 3 surgical cohorts: posterior instability (n = 41), anterior instability (n = 39), and a comparison group undergoing arthroscopy for snapping scapula (n = 38). Coracoid morphology metrics included: lateral coracoid offset, sagittal coracoid angle, coronal coracoid angle (CCA), transverse coracoid length, coracoacromial length (CAL), coracohumeral distance, and inferior coracoid coverage (ICC). Glenoid version and bone loss were also measured. One-way analysis of variance with Tukey post hoc testing or Kruskal-Wallis with Dunn testing was used as appropriate to compare groups. The P value was set a priori at <.05 to represent statistical significance. Analyses were performed using SPSS Version 30.0 and R Version 4.5.0. Results: The posterior instability group demonstrated a significantly higher CCA (69.4° ± 23.5°) than the anterior (52.8° ± 23.8°; P = .002) and comparison (56.9° ± 17.7°; P = .015) groups. The CAL and ICC were also significantly different in the posterior group (both P < .001). No significant differences in coracoid morphology were found between the anterior and comparison groups. Patients with posterior instability had significantly increased glenoid retroversion (–8.1° ± 3.7°) versus the anterior (–3.1° ± 5.3°) and comparison (–4.2° ± 4.3°) groups (both P < .001). Conclusion: Coracoid morphology differs significantly in patients undergoing posterior shoulder stabilization when compared to patients undergoing surgery for anterior instability or a comparison cohort. Increased CCA, increased CAL, and greater ICC are associated with patients undergoing posterior stabilization surgery. These findings suggest that a lower coracoid with increased inferior coverage of the humeral head may contribute to the pathogenesis of posterior instability.

Purpose: This study introduces the posterior tibial plateau offset (PTO). It was hypothesised that (1) the PTO is reliably quantifiable and (2) correlates with the posterior tibial slope (PTS). Methods: The study involved lateral radiographs of patients who sustained an anterior cruciate ligament (ACL) graft failure and a control group. Exclusion criteria were skeletal immaturity, osteoarthritis (Kellgren and Lawrence grade > I), lateral radiographs with n = 103; control group, n = 43; 45% female, 60% left knees) were included. Mean overall PTO was 82% ± 7% (1%–35%), and mean PTS was 12° ± 3 (7–20). The PTS and PTO showed a moderate positive correlation in the overall collective ( r = 0.5; p < 0.001), ACL graft failure group ( r = 0.49; p < 0.001), and control group ( r = 0.69; p < 0.001), indicating a higher slope corresponded to a greater PTO. There was no statistical difference in PTO between the ACL failure and the control group (82% vs. 83%, p < 0.05). ICC between three raters was (0.8–0.9; p < 0.05). Conclusion: The PTO is a simple and repeatable measurement. A higher PTS is associated with a greater PTO, and the variability of the PTO across the patients with ACL graft failure and the control group was high. When planning osteotomy levels in the highly sloped proximal tibia, the PTO may be considered to optimise individualised planning for patients with failed ACL reconstruction. Level of Evidence: Level V.

Background: Massive rotator cuff tears (MRCTs) involving the rotator cable are associated with increased tendon retraction, fatty infiltration, and high retear rates after repair. Biceps anterior cable reconstruction (ACR) is a surgical technique that augments rotator cuff repair by reconstructing the anterior cable with the long head of the biceps tendon (LHBT), improving greater tuberosity coverage and biomechanical stability. Indications: Biceps ACR is indicated for full-thickness MRCTs with anterior cable involvement in patients with an intact LHBT and no advanced glenohumeral arthritis. Risk factors for repair failure, including the full-thickness retracted pattern of a tear, patient age, and activity level, are considered when deciding to add a concomitant ACR. Technique Description: A knotless repair stitch from an anchor at the anteromedial footprint of the greater tuberosity is passed circumferentially around the proximal LHBT. The biceps is left attached to the glenoid, and the repair stitch is tightened, which reduces the biceps tendon to the anterior aspect of the greater tuberosity. This allows the biceps tendon to slide and find its optimal tension, tenodeses the biceps tendon to the greater tuberosity, and reconstructs the anterior cable. This provides greater tuberosity coverage and reduces the tear distance. The remaining sutures from the anteromedial anchor can be passed through the rotator cuff. The remaining rotator cuff can be repaired using a variety of standard techniques. Simple side-to-side stitches can be placed in the biceps tendon and rotator cuff as needed. Results: Biceps ACR improves greater tuberosity coverage and enhances biomechanical stability by decreasing superior translation and subacromial contact pressure. Clinical studies have demonstrated excellent patient-reported outcomes and lower retear rates when biceps ACR is added to arthroscopic rotator cuff repair. Discussion/Conclusion: Biceps ACR is a viable option for MRCTs with anterior cable involvement and a high risk for failure. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: The meniscus-deficient knee, especially in the lateral compartment, is prone to early degeneration, cartilage loss, and pain. Meniscus allograft transplantation (MAT) with an all-soft tissue graft and centralization is a technique used to treat unicompartmental pain and improve outcomes. Indications: Isolated lateral MAT with centralization is indicated for unicompartmental pain in a meniscus-deficient knee without significant articular cartilage loss, limb malalignment, or ligamentous instability. Technique Description: For MAT preparation, an osteotome is used to remove the anterior and posterior meniscus roots with small wafers of bone to preserve the entire meniscus length, and the meniscus is transected at the meniscus-capsule junction. Sutures are passed through the anterior and posterior roots for later transtibial fixation. Knee arthroscopy is performed, and the lateral meniscus is debrided to a stable rim. A suture is passed through the lateral capsule, just anterior to the popliteus, for centralization. A targeting guide is used to drill a tunnel from the anteromedial tibia to the lateral edge of the lateral plateau, and the centralization suture is retrieved into the tunnel. Then the posterior root insertion is prepared, and an anatomic tunnel is drilled. MAT is delivered into the joint via the posterior root suture through our previously established portal. Meniscus repair all-inside devices are used to fixate the MAT to the capsule in a vertical mattress configuration. Then the anterior root tunnel is prepared and drilled. MAT anterior root is shuttled into the tunnel. The centralization suture is first tied down over a button on the anteromedial tibia, followed by the posterior root over a separate button, and the anterior root over a third button at 60° of knee flexion. Results: MAT relieves pain and restores meniscal function in a meniscus-deficient knee. Clinical studies have demonstrated good long-term survivorship rates with improvements in functional and patient-reported outcomes after MAT. Centralization is used to decrease the size of the lateral compartment, improving MAT compartment fit and decreasing extrusion. Discussion/Conclusion: All-soft tissue MAT with centralization is a viable option for the treatment of the meniscus-deficient knee with isolated lateral compartment pain without ligamentous instability, malalignment, or focal cartilage loss. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.