Eric J. Cotter

Background: Distal clavicle bone loss after failed acromioclavicular (AC) joint stabilization presents a challenging reconstructive problem. Loss of clavicular length and bone stock may compromise both coracoclavicular (CC) and AC stability, limiting the utility of standard revision techniques. Structural graft reconstruction can restore clavicular length, provide cortical support, and create a stable platform for revision ligament reconstruction. Indications: This technique is indicated for patients with symptomatic recurrent AC joint instability and substantial distal clavicular bone loss after a prior failed AC/CC reconstruction or distal clavicular resection. It is particularly useful when residual clavicular deficiency prevents reliable fixation or restoration of stability with soft-tissue reconstruction alone. Technique Description: The patient is positioned supine, and the previous superior clavicular incision is used. After careful dissection, retained suture material and hardware are removed, and the distal clavicle defect is identified. The clavicle is excised to healthy bone, and a fibular strut allograft is prepared to match the segmental defect and restore clavicular length. The graft is secured to the native clavicle using a matching step cut, a lag screw, and an anterior clavicle plate. CA reconstruction with hamstring autograft is then performed to restore vertical stability, followed by clavicle hook plate and AC reconstruction to address horizontal instability. Final fixation is assessed with fluoroscopy to confirm restoration of alignment and stability. Results: This technique is intended to restore clavicular length, improve structural support, and provide a stable foundation for combined AC and CC ligament reconstruction. Previous literature suggests that revision reconstruction can improve pain and stability after failed AC joint procedures. However, persistent dysfunction, recurrent instability, graft-related complications, and reoperation remain important considerations, particularly in the setting of previous distal clavicle excision. In the setting of severe distal clavicle deficiency, structural grafting may expand reconstructive options when standard revision techniques are inadequate. Discussion/Conclusion: Distal clavicle reconstruction with fibular strut allograft combined with revision AC/CC reconstruction is a useful salvage option for recurrent instability with clavicular bone loss. Careful graft preparation, restoration of clavicular length, and attention to both vertical and horizontal stability are critical technical principles. In appropriately selected patients, this technique provides a reproducible method for addressing a challenging form of revision AC joint instability. 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.

Introduction: The aim of this study was to (1) assess the incidence of orthopaedic surgery residency applicants who pursued a dedicated research gap year (RGY) before application over a 10-year time frame at a single academic institution, (2) evaluate differences in applicant characteristics based on RGY participation, and (3) identify factors linked to match success among those who completed a research year. Methods: Applications submitted to a single orthopaedic residency program from the 2014-2015 to the 2023-2024 cycles were reviewed. RGY participation was defined as taking a minimum of 9 months to pursue a dedicated research experience as noted in each ERAS application. MPH, MBA, or PhD programs were excluded. The timing of the RGY was noted, and USMLE scores; sex; number of publications, presentations, and abstracts; medical school location; and Alpha Omega Alpha status were extracted from applications. Results: The percentage of applicants who pursued a RGY increased from 7.4% in 2014-2015 to 14.4% in 2023-2024. A strong positive correlation was noted between the percentage of applicants who participated in a RGY and time (r = 0.95 [95% confidence interval (CI), 0.80 to 0.99], P < 0.0001). Over the study period, 12.2% of applicants had done a RGY, most commonly after their third year of medical school (81.1%). RGY applicants had an average of 31.6 total lines on their CV compared with 9.9 for non-RGY applicants ( P < 0.0001). Among RGY applicants, 71.0% matched into orthopaedics, and 12.7% matched at the same institution where they did their RGY. Discussion: Between 2014 and 2024, the percentage of applicants who completed a RGY doubled. These applicants demonstrated greater academic productivity and a higher-than-average match rate, particularly at the institution hosting the RGY. These findings suggest that RGY opportunities are becoming more sought after and may enhance orthopaedic residency match success, although additional multi-institutional research is warranted.

Background: Multiplug “snowman” osteochondral allograft transplantation (OCA) is an effective treatment method for large, irregularly shaped osteochondral defects of the knee. No existing literature directly compares the effectiveness of this technique with traditional single-plug circular OCA. Purpose: To compare failure rates, reoperation rates, and relevant patient-reported outcome (PRO) scores at 2-year follow-up between patients undergoing snowman OCA and patients undergoing single-plug OCA. Study Design: Case series; Level of evidence, 3. Methods: Patients who underwent snowman or single-plug OCA between 2001 and 2021 with a minimum 2-year follow-up were identified. Propensity score matching at 1:2 was performed based on age, sex, body mass index, defect location, and defect size. The PRO measures assessed included the International Knee Documentation Committee subjective score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score, and 12-Item Short Form Health Survey. Failure was defined as conversion to arthroplasty, revision OCA, or graft degeneration on second-look arthroscopic examination. Additionally, rates of achieving the minimal clinically important difference (MCID) or patient acceptable symptom state (PASS) for PRO measures were determined. Results: There were 26 patients (mean age, 33.3 ± 9.3 years; 65.4% male) who underwent snowman OCA with a mean follow-up of 5.8 ± 4.1 years. No significant differences in baseline variables were identified compared with a matched control group of 52 patients who underwent single-plug OCA. No differences were detected in the rate of achieving the MCID or PASS between the groups for any PRO measure. Overall, 5 patients (19.2%) in the snowman group experienced graft failure at a mean 1.7 ± 1.0 years, while 10 patients (19.2%) in the single-plug group met the criteria for failure at a mean 6.6 ± 3.5 years. No differences were detected in the rate of failure or reoperations between the 2 groups. Conclusion: Multiplug “snowman” and single-plug circular OCA techniques yielded comparable clinical outcomes and graft survivorship for defects of a similar size in a matched cohort analysis. Defect shape, rather than size alone, should guide the selection of a technique. The snowman technique is advantageous for longer or oval-shaped defects not easily treated with a single plug, as it minimizes the removal of healthy cartilage while maintaining optimal outcomes.

Purpose: To compare the clinical outcomes of transosseous tunnel (TO) techniques to suture anchor (SA) techniques for the primary repair of unilateral quadriceps tendon ruptures (QTRs). Methods: A systematic review of the PubMed database was performed for studies containing rerupture and/or patient‐reported outcome measure (PROM) outcome data of primary QTR repairs utilizing TO and/or SA techniques. Included studies were evaluated using the Methodological Index for Nonrandomized Studies scoring system. Results: Twelve studies including 600 patients met inclusion criteria for the systematic review. The level of evidence for these studies ranged from III to IV, with most (n = 10; 83.3%) being retrospective case series. Within included studies, TO repairs accounted for 79.5% of patients (n = 477), while 20.5% (n = 123) underwent repair using SA. All publications using SAs reported placing 2 to 3 anchors for the primary QTR repair. Studies reporting using TO methods mostly placed 3 patellar drill holes, although 1 study only used 2 drill holes, 2 studies used 3 to 4 drill holes, and 3 studies did not report this information. QTR rerupture rates varied between 0% and 16.7% for TO techniques and between 0% and 14.7% for SA techniques. PROM collection varied widely, with limited data to clearly show the superiority of TO or SA techniques. The methodologic quality for noncomparative studies was moderate, with a mean score of 10.2 ± 1.3 (range, 8‐12), and was moderate for comparative studies, with a mean score of 15.7 ± 2.1 (range, 14‐18). Conclusions: Rerupture rates were similar between TO and SA repair methods for primary QTR repairs. Some data indicate that SA techniques might show superior outcomes based on PROMs between SA and TO methods for the primary repair of QTRs, but high‐quality evidence is lacking. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Background: Previous studies have observed promising short-term outcomes after revision osteochondral allograft (OCA) transplantation. However, few studies have examined midterm outcomes after revision OCA transplantation. Purpose: To examine midterm outcomes after revision OCA transplantation of the femoral condyle and evaluate reoperation and survivorship compared with a matched cohort of patients who underwent primary OCA transplantation. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of prospectively collected data identified patients undergoing revision OCA transplantation to the femoral condyle between 1999 and 2018 (minimum 5-year follow-up). A 1:2 cohort of patients who underwent revision OCA transplantation to patients who underwent primary OCA transplantation, matched by defect size, age, sex, and body mass index, was created. Patient-reported outcome measures and the incidence of reoperations or graft failures were collected. Failure was defined as subchondral collapse of the OCA transplantation as confirmed via second-look arthroscopy, revision OCA transplantation, or conversion to knee arthroplasty. Results: Fifteen patients who underwent revision OCA transplantation were matched to 30 patients who underwent primary OCA transplantation. The mean follow-up in the revision OCA transplantation group was 9.3 ± 3.0 years (range, 5.1-14.7 years), with a mean age of 31.4 ± 10.0 years (range, 19.9-52.7 years) and a mean body mass index of 25.9 ± 3.4 (range, 20.8-30.4). Revision OCA transplantation was performed to the lateral condyle in 53% of cases (8/15). A concomitant procedure was performed in 73% of patients (11/15), most commonly involving meniscal allograft transplantation (73% [8/11]), followed by realignment osteotomy (27% [3/11]). The Patient Acceptable Symptom State was achieved by a majority of patients who underwent revision OCA transplantation for all patient-reported outcome measures examined (International Knee Documentation Committee, 70%; Lysholm, 83%; Knee injury and Osteoarthritis Outcome Score [KOOS] Pain, 100%; KOOS Symptoms, 70%, KOOS Sport, 90%; KOOS Activities of Daily Living, 80%; KOOS Quality of Life, 80%), and there was no difference in the proportion of patients the Patient Acceptable Symptom State when compared with those undergoing primary OCA transplantation ( P ≥ .070) (see Table 3). Eight patients (53%) underwent revision OCA transplantation reoperation at a mean time of 3.9 ± 3.7 years (range, 0.6-11.2 years). Failures were observed in 20% (3/15) of patients who underwent revision OCA transplantation at a mean of 4.3 ± 1.9 years (range, 1.7-6.4 years). Graft survivorship free from reoperation ( P = .905; revision 53% [8/15], primary 43% [13/30]) and failure ( P = .577; revision 13% [2/15], primary 20% [6/30]) was not significantly different between revision and primary groups. Conclusion: High rates of Patient Acceptable Symptom State achievement were observed after revision OCA transplantation. Although limited by sample size, no significant difference in graft survivorship free from failure was appreciated between revision versus primary OCA transplantation groups.

Purpose: To report midterm outcomes after primary medial and lateral meniscal allograft transplantation (MAT) with fresh‐frozen allografts implanted with the bridge‐in‐slot technique in the adolescent patient population. Methods: Adolescent patients less than 18 years old at the time of primary MAT from 1999 to 2016 were retrospectively identified. International Knee Documentation Committee (IKDC) subjective form, Lysholm, and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales scores were collected before surgery and at 1‐year, 2‐year, and a minimum 5‐year follow‐up. Thresholds for achieving clinically significant outcomes were calculated, and the proportion of patients achieving minimal clinically important difference (MCID), patient‐acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) was determined. Meniscus reoperation (partial, subtotal, or total meniscectomy, repair, or failure) and failure (revision MAT or conversion to arthroplasty) rates were determined. Results: Forty‐four (female n = 33; male n = 11) of 62 identified patients met inclusion criteria and were followed for a mean of 9.5 ± 3.8 years (range, 5.0‐17.7). Lateral MAT was performed in most patients (n = 35/44 [80%]). Isolated MAT was performed in 27 (61%) patients. Common concomitant procedures included osteochondral allograft transplantation (32%), autologous chondrocyte implantation (18%), and anterior cruciate ligament reconstruction (14%). MCID, PASS, and SCB were achieved by patients at a minimum 5‐year follow‐up for IKDC (62%; 76%; 31%), Lysholm (62%; 79%; 23%), and KOOS questionnaires (Pain [65%; 81%; 41%], Symptoms [58%; 81%; 47%], Activities of Daily Living [53%; 77%; 35%], Sport [86%; 75%; 50%], and Quality of Life [59%; 81%; 59%]), respectively. Fourteen patients (32%) underwent reoperation at an average of 5.0 ± 4.3 years (range, 0.8‐14.0) after MAT. Three (7%) patients met criteria for failure, requiring revision MAT an average of 3.8 ± 1.1 years (range, 2.8‐4.9) after transplantation. No patients underwent arthroplasty. Overall survival free from failure at 1, 2, 5, and 10 years was 100%, 100%, 93%, and 93%, respectively. At the time of final follow‐up, 80% of patients reported satisfaction with their current physical status. Conclusions: Primary MAT in adolescent patients resulted in significant and durable functional improvements at mid‐ to long‐term follow‐up. At an average of 9.5 years after surgery, meniscal reoperation rate was 32% whereas graft survival free of revision MAT was 93%. Adolescents undergoing MAT demonstrated similar functional outcomes and graft survivability when compared to available adult MAT literature. Level of Evidence: Level IV, retrospective case series.