David L. Bernholt

Patellar tendon rupture and chronic extensor mechanism deficiency present significant reconstructive challenges, particularly in revision settings or when native tissue quality is poor. We describe a reproducible surgical technique for patellar tendon reconstruction using an Achilles allograft with traversing suprapatellar cerclage limbs. This construct helps facilitate controlled restoration of patellar height, immediate continuity of the extensor mechanism, and load sharing across the reconstruction during early healing.

Background: Hyperlipidemia (HLD) impairs tendon healing and is associated with increased revision risk following arthroscopic rotator cuff repair (ARCR). While statins may partially mitigate this effect, residual dyslipidemia may impair healing. Ezetimibe, through inhibition of intestinal cholesterol absorption, has demonstrated favorable effects on tendon healing in preclinical studies. Objectives: This study evaluated whether perioperative statin–ezetimibe therapy is associated with improved postoperative outcomes following ARCR compared with statin monotherapy and patients without HLD. Methods: A retrospective cohort study was conducted using the TriNetX Research Network. Adult patients undergoing ARCR were stratified into three cohorts based on HLD status and perioperative (± 6 months) lipid-lowering therapy: (1) documented HLD treated with statin–ezetimibe prescriptions, (2) patients without documented HLD or lipid-lowering therapy prescriptions, and (3) documented HLD treated with statin monotherapy prescriptions. Primary comparisons were predefined between cohort 1 and cohorts 2 and 3. Propensity score matching (1:1) adjusted for demographics and comorbidities. Tear size and presence of fatty atrophy and fatty infiltration were not adjusted for. Outcomes occurring within 5 years included revision rotator cuff repair (RCR), conversion to shoulder arthroplasty, and secondary shoulder arthroscopy. Results: After matching, 1,066 patients were included in cohorts 1 and 2 and 1,114 patients in cohorts 1 and 3. Compared with patients without HLD, statin–ezetimibe therapy demonstrated similar rates of revision RCR (5.4% vs. 6.4%; RR 0.853; p = 0.358), conversion to shoulder arthroplasty (RR 1.227; p = 0.470), and secondary arthroscopy (RR 0.846; p = 0.260). Compared with statin monotherapy, statin–ezetimibe therapy was associated with lower rates of revision RCR (5.6% vs. 8.0%; RR 0.697; p = 0.023) and secondary shoulder arthroscopy (7.3% vs. 9.6%; RR 0.757; p = 0.048), while arthroplasty rates remained similar (RR 1.261; p = 0.400). Conclusion: Among patients with HLD undergoing ARCR, perioperative statin–ezetimibe therapy was associated with lower reoperation rates compared with statin monotherapy and postoperative outcomes comparable to patients without HLD. These findings support further investigation of intensified lipid-lowering therapy, while accounting for tear size and fatty infiltration.

Rotator cuff tears are common, and although surgical repair is frequently performed, re-tear and complication rates remain substantial. The impact of selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) on postoperative outcomes after rotator cuff repair is not well understood. Using the TriNetX Research Network, adult patients undergoing arthroscopic rotator cuff repair were identified and stratified into SSRI/SNRI users (at least one prescription within 3 months preoperatively and continued use within 2 years postoperatively) and non-users. Propensity score matching was performed for demographic and medical comorbidities, yielding 2457 patients in each cohort. At 1-year follow-up, SSRI/SNRI users demonstrated lower rates of adhesive capsulitis compared with controls (3.1% vs. 5.8%; RR 0.53; 95% CI 0.41–0.70; p < 0.001), with similar revision rotator cuff repair rates. This pattern persisted at 2 years (3.6% vs. 6.1%; RR 0.58; 95% CI 0.45–0.75; p < 0.001), with comparable revision rates between groups. There were no differences in 30-day emergency department visits, readmissions, or 90-day postoperative infections. SSRI/SNRI users had lower early opioid use (21.0% vs. 29.5%; RR 0.71; p < 0.001) but higher prolonged (17.2% vs. 14.1%; RR 1.22; p = 0.003) and chronic opioid use (16.7% vs. 9.1%; RR 1.84; p < 0.001). In this large national cohort, SSRI/SNRI use was associated with lower rates of adhesive capsulitis and differences in postoperative opioid utilization, without differences in revision rotator cuff repair or short-term complications. These findings reflect associations rather than causation and highlight the need for further studies to clarify underlying mechanisms and clinical implications.

Two-incision anterior cruciate ligament reconstruction (ACLR) is a well-established technique used to perform an arthroscopically assisted ACLR. Historically, this approach to ACLR was once considered the benchmark; however, with evolving arthroscopic technology and the rise of more minimally invasive techniques, this approach to ACLR has become less popular. The two-incision technique still has notable clinical utility because it can (1) increase the surgeon's ability to perform a single-stage revision ACLR and (2) help avoid graft-tunnel mismatch in primary ACLR with a patellar tendon autograft when encountering a long tendon. This technique, when coupled with metal screws and an autograft tendon, is also the lowest cost ACLR technique that allows independent femoral tunnel positioning and thus should be considered as an option for primary ACLR by surgeons prioritizing cost containment without compromising surgical outcomes.

Background: Health literacy can be an important predictor of a patient’s health status. We aimed to validate a new shoulder-specific health-literacy test, entitled CASE (Campbell’s Assessment of Shoulder Education), and use it to investigate associations with shoulder literacy and outcomes after rotator cuff surgery. We hypothesized that lower literacy would lead to worse outcomes. Methods: Sixty-five patients completed the Literacy in Musculoskeletal Problems (LiMP) and CASE assessments, then the scores were evaluated using a contingency table, sensitivity/specificity, and Spearman’s correlation coefficients. Once CASE was validated, 110 patients who underwent rotator cuff surgery completed the assessment. Range of motion, American Shoulder and Elbow Surgeons standardized shoulder scores, Single Assessment Numeric Evaluation scores, and Visual Analog Scale pain scores were acquired before and after surgery. Results: When using LiMP to validate the CASE assessment, the sensitivity was 75.7%, specificity was 62.5%, positive predictive value was 67.5%, and negative predictive value was 71.4%. Spearman rank-order correlation results showed a strong positive association between LiMP and CASE scores with r = 0.572 with a P-value < .0001, meeting thresholds for validation. Of the 110 patients who completed CASE after undergoing rotator cuff surgery, 67 had higher literacy (CASE score > 4) and the remaining 43 had lower literacy (CASE score < 4). Patients with lower literacy demonstrated worse pre-operative forward elevation and internal rotation; however, literacy levels did not predict post-operative range of motion. Conclusions: CASE’s sensitivity, specificity, and Spearman correlation compared with the LiMP indicated that it is reliable in evaluating shoulder-specific health literacy. Our hypothesis was refuted: lower shoulder-health literacy was correlated with worse pre-operative shoulder ROM, but CASE was not predictive of global (90 day) post-operative motion or patient-reported outcomes, as there was no difference in these outcomes based on the CASE score. This suggested that although there are initial differences pre-operatively based upon health literacy, with appropriate care and rehabilitation, patients can achieve excellent outcomes regardless of their health literacy. Level of Evidence: Level 2. Prospective Cohort Study

Hamstring injuries are a common injury sustained by athletes with most injuries occurring as strain injuries within the muscle belly or at the proximal musculotendinous junction. Distal hamstring pathology is relatively uncommon but comprises a collection of both acute and chronic diagnoses that can manifest with symptoms either on the medial or lateral side of the knee based on which hamstring tendons are involved. Pes anserinus bursitis is the most common of these distal hamstring pathologies with other chronic diagnoses, including snapping medial hamstrings or snapping biceps femoris. Acute biceps femoris ruptures can occur in an isolated fashion but most often occur in the setting of concomitant posterolateral corner injury as a result of high-energy trauma. Isolated semitendinosus ruptures can occur with lower-energy acute events, commonly with track and field events. Most distal hamstring pathology can be treated without surgery and do well with conservative treatment. However, acute avulsion injuries often require surgical intervention, as can chronic problems that do not adequately respond to prolonged conservative treatment. Treatment algorithms for distal hamstring injuries are less well-developed than more proximal injuries owing to their lower incidence. This review focuses on distal hamstring injuries, the state of current literature, and treatment strategies.

Graft‐tunnel mismatch (GTM) is a known technical challenge that can occur with anterior cruciate ligament reconstruction when using a patellar tendon autograft. Two‐incision anterior cruciate ligament reconstruction is a well‐established technique with excellent outcomes and can serve as an excellent tool to prevent GTM. Traditionally, 2‐incision femoral tunnel drilling has been performed using an over‐the‐top guide through a lateral incision, but more modern retrograde reamer guides can allow this to be done percutaneously. We detail how a minimally invasive 2‐incision femoral tunnel drilling technique can be used in patients with patellar tendon lengths that are longer than average to avoid GTM. Technique Video: video See video under supplementary data.