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Restoration of the Knee Medial Collateral Ligament and Complete Soft-tissue Coverage After Medial Open-Wedge High Tibial Osteotomy

Open AccessPublished:September 17, 2022DOI:https://doi.org/10.1016/j.eats.2022.05.013
Restoration of the Knee Medial Collateral Ligament and Complete Soft-tissue Coverage After Medial Open-Wedge High Tibial Osteotomy
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      Abstract

      High tibial osteotomy (HTO) is used in the treatment of knee osteoarthritis. This surgical procedure is indicated in patients with medial osteoarthritis who are relatively young and active and have a good range of motion. In most medial open-wedge HTO cases, the fascia, medial collateral ligament (MCL), and part of the knee joint capsule are carefully separated and moved to expose the osteotomy site, but many patients experience postoperative swelling and pain in the affected limb due to bleeding from the osteotomy site and MCL failure. We have developed a method of osteotomy followed by a restoration of the MCL to its anatomic position and complete soft-tissue coverage of the osteotomy. This Technical Note aims to provide a comprehensive description of the employment of a soft-tissue envelope for the MOW-HTO protection.

      Technique Video

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      A curved oblique skin incision is made from the posteromedial corner of the proximal tibia to the insertion site of the pes anserine tendon. An incision is made in the sartorius fascia. The affected knee is placed in a slightly flexed position to relax the gracilis and semitendinosus tendons. These 2 tendons are then identified and scooped with a Kelly clamp and wet gauze. When the 2 tendons are separated, we can see the shallow layer of the medial collateral ligament (MCL) and the joint capsule. The distal attachments of the 2 tendons are left connected to the proximal tibia, and the boundary between the MCL and the joint capsule is marked with an electrocautery scalpel. A rasp is used at the border between the shallow layer of the MCL and the articular capsule to peel away the matter between the bone and the periosteum, which creates room for expansion. The dissection proceeds toward the posterior surface of the tibia and follows the bone so as not to involve the nerves or blood vessels when the retractor is inserted. At the posterior surface of the tibia, a bent-tip elevators can be used. A retractor is inserted between the MCL and the proximal tibia to protect the neurovascular bundles. At this point, the tip of the first Kirschner wire is inserted between the 2 tendons 4 to 4.5 cm below the medial joint line. The second Kirschner wire is then inserted parallel to the first under fluoroscopy. An anterior ascending osteotomy is then performed at an angle of 110° to the horizontal saw cut, ending behind the patellar tendon insertion. An osteotomy is made toward the fibular head, leaving a hinge. With the spreader inserted into the osteotomy site, the Mikulicz line is checked using a long alignment rod to determine the correction angle. Axial pressure is then applied to the calcaneus to reproduce loading conditions. A β-tricalcium phosphate (β-TCP) block is cut into a trapezoidal shape and inserted considering the amount of correction required at the osteotomy site. Soft-tissue repair is performed before the plate is applied. With a Kocher, the MCL is pulled into its correct anatomical position and sutured to the surrounding tissue. Then, the ST tendon and G tendon are also returned to their usual anatomical positions, ensuring that they cover the MCL. The excised joint tendons and then the sartorius fascia are sutured to completely cover the osteotomy. A TOMOFIX anatomical medial high tibial plate is applied to the medial side of the proximal tibia. (G, gracilis; ST, semitendinosus.)

      Technique Video

      See video under supplementary data.

      High tibial osteotomy (HTO) is used in the treatment of knee osteoarthritis. It alleviates pain by correcting medial deformity of the tibia, thereby reducing the load on the medial compartment of the knee joint.
      • Amendola A.
      • Bonasia D.E.
      Results of high tibial osteotomy: Review of the literature.
      Int. Orthop. 2010; 34: 155-160
      , 
      • Kumagai K.
      • Akamatsu Y.
      • Kobayashi H.
      • Kusayama Y.
      • Koshino T.
      • Saito T.
      Factors affecting cartilage repair after medial opening-wedge high tibial osteotomy.
      Knee Surg Sports Traumatol Arthrosc. 2017; 25: 779-784
      , 
      • Jildeh T.R.
      • Comfort S.M.
      • Peebles A.M.
      • Powell S.N.
      • Provencher M.T.
      Treatment of malalignment and cartilage injury: High tibial osteotomy with a concomitant osteochondral allograft to the medial femoral condyle and lateral and medial partial meniscectomy.
      Arthrosc Tech. 2022; 11: e623-e630
      This surgical procedure is indicated in patients with medial osteoarthritis who are relatively young and active and have a good range of motion.
      • Amendola A.
      • Bonasia D.E.
      Results of high tibial osteotomy: Review of the literature.
      Int. Orthop. 2010; 34: 155-160
      The HTO may be performed using an open- or closed-wedge method. However, the closed-wedge approach has several disadvantages, including difficulty achieving accurate correction, neurovascular complications, and a risk of accidental osteotomy of the fibula, with potential bone loss.
      • Akiyama T.
      • Okazaki K.
      • Mawatari T.
      • Ikemura S.
      • Nakamura S.
      Autologous osteophyte grafting for open-wedge high tibial osteotomy.
      Arthrosc Tech. 2016; 5: e989-e995
      Medial open-wedge (MOW)-HTO is widely used because it allows intraoperative determination of the osteotomy gap. Fixation using a locking plate allows micromotion and promotes bone healing.
      • Baumgaertel F.
      • Buhl M.
      • Rahn B.A.
      Fracture healing in biological plate osteosynthesis.
      Injury. 1998; 29 (suppl 3): C3-C6
      The osteotomy can be fixed without friction between the bone and the plate, preventing interference with periosteal blood flow. In addition, the use of a long plate increases the screw pull-out strength and provides long-axis stability.
      • Hunt S.B.
      • Buckley R.E.
      Locking plates: A current concepts review of technique and indications for use.
      Acta Chir Orthop Traumatol Cech. 2013; 80: 185-191
      ,
      • Miranda L.L.
      • Guimaraes-Lopes V.P.
      • Altoe L.S.
      • et al.
      Plant extracts in the bone repair process: A systematic review.
      Mediators Inflamm. 2019; 20191296153
      The periosteal blood vessels are especially important postoperatively, as they restore blood flow to the fracture site and facilitate the influx of osteogenic cells.
      • Tomlinson R.E.
      • Silva M.J.
      Skeletal blood flow in bone repair and maintenance.
      Bone Res. 2013; 1: 311-322
      To minimize the MOW-HTO soft-tissue damage, we have developed a technique in which an envelope of soft tissue is used to protect the osteotomy site. This is achieved using a TOMOFIX (DePuy Synthes, Solothurn, Switzerland) anatomical medial high tibial plate. The successful use of this device requires a complete understanding of the technique involved. Hence, this Technical Note aims to provide a comprehensive description of the employment of a soft-tissue envelope for the MOW-HTO protection.

      Surgical Technique (With Video Illustration)

      This technique can be carried out under local or general anesthesia and does not require a pneumatic tourniquet. The patient is placed in the supine position on a radiolucent table with lateral thigh support. The affected lower limb is sterilized, and standard anterolateral and anteromedial portals are created for a routine arthroscopic evaluation. The concomitant meniscal and chondral injuries are treated. The knee joint line is identified by palpation and a curved oblique skin incision is made, extending from the posteromedial corner of the proximal tibia to the insertion site of the pes anserine tendon. The skin incision is curved rather than straight as this helps to reduce the risk of postoperative infection.
      • Anagnostakos K.
      • Mosser P.
      • Kohn D.
      Infections after high tibial osteotomy.
      Knee Surg Sports Traumatol Arthrosc. 2013; 21: 161-169
      Care is taken to detect all branches of the descending genicular artery. These are cauterized during the separation of subcutaneous tissue and sartorius fascia. The affected knee is placed in a slightly flexed position to maximize the visibility of the lateral joint line. The gracilis and semitendinosus tendons are then identified and scooped with a Kelly clamp and wet gauze. The distal attachments of these 2 tendons are left connected to the proximal tibia. The periosteum and medial collateral ligament (MCL) are partially detached dorsally from the border of the knee joint capsule to preserve them during the osteotomy (Fig 1). They will later be returned before plate fixation. A retractor is inserted between the MCL and the proximal tibia to protect the neurovascular bundles (Fig 2). The tip of the first Kirschner wire is inserted 4 to 4.5 cm below the medial joint line between the 2 tendons (Fig 3). A second Kirschner wire is inserted parallel to the first under fluoroscopic guidance (Fig 4).
      • Lee S.Y.
      • Lim H.C.
      • Bae J.H.
      • et al.
      Sagittal osteotomy inclination in medial open-wedge high tibial osteotomy.
      Knee Surg Sports Traumatol Arthrosc. 2017; 25: 823-831
      To create a lateral bone hinge, a cut is made with a bone saw that is 5 mm less than the depth of the wires. Furthermore, it is important to ensure that there is sufficient cranial space for the locking bolts of the plate fixator. At this point, an anterior ascending osteotomy is performed at an angle of 110° to the horizontal saw cut. The osteotomy ends behind the patellar tendon insertion. The width of the tuberosity segment is set to at least 1.5 cm (Fig 5).
      • Staubli A.E.
      • Jacob H.A.
      Evolution of open-wedge high-tibial osteotomy: experience with a special angular stable device for internal fixation without interposition material.
      Int Orthop. 2010; 34: 167-172
      The horizontal osteotomy is gradually opened to the desired correction angle (Fig 6).
      • Staubli A.E.
      • De Simoni C.
      • Babst R.
      • Lobenhoffer P.
      TomoFix: A new LCP-concept for open wedge osteotomy of the medial proximal tibia—early results in 92 cases.
      Injury. 2003; 34 (suppl 2): B55-62
      To minimize tibial slope alteration, a spreader is inserted as close to the posterior cortex as possible. With the spreader in place, the Mikulicz line is checked using a long alignment rod to determine the correction angle. Axial pressure is applied to the calcaneus to reproduce loading conditions. A β-tricalcium phosphate (β-TCP) block is cut into a trapezoid shape to a size appropriate to the amount of correction needed at the osteotomy site (Fig 7).
      • Yan J.
      • Musahl V.
      • Kay J.
      • Khan M.
      • Simunovic N.
      • Ayeni O.R.
      Outcome reporting following navigated high tibial osteotomy of the knee: A systematic review.
      Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3529-3555
      The detached MCL and the hamstring tendons are replaced in their original anatomical positions. The fascia and hamstring tendons are sutured in place to completely cover the osteotomy site (Fig 8). A TOMOFIX (DePuy Synthes) medial high tibial plate is applied to the medial side of the proximal tibia and the intraoperative mechanical axis of the lower limb is set at 55% and checked using a long alignment rod (Fig 9 and Video 1).
      • Wu K.
      • Zeng J.
      • Han L.
      • Feng W.
      • Lin X.
      • Zeng Y.
      Effect of the amount of correction on posterior tibial slope and patellar height in open-wedge high tibial osteotomy.
      J Orthop Surg (Hong Kong). 2021; 2923094990211049571
      ,
      • Ha J.K.
      • Yeom C.H.
      • Jang H.S.
      • et al.
      Biomechanical analysis of a novel wedge locking plate in a porcine tibial model.
      Clin Orthop Surg. 2016; 8: 373-378
      Finally, each layer of soft tissue and skin is closed. The advantages and disadvantages of this technique are shown in Table 1.
      Figure thumbnail gr1
      Fig 1The patient with left knee osteoarthritis is placed in the supine position on a radiolucent table. After skin incision, the sartorius fascia is unfolded, and the gracilis (G) tendon and semitendinosus (ST) tendon are identified. Wet gauze is applied over the G and ST tendons to expose the shallow layer of the medial collateral ligament (MCL) and the joint capsule. We enter the shallow layer of MCL at the border between the joint capsule and the MCL. White arrows indicate G and ST tendons. Dotted line indicates the border between the joint capsule and the MCL. Yellow arrow indicates entry point. Black arrows indicate MCL and joint capsule.
      Figure thumbnail gr2
      Fig 2Avoiding the shallow layer of the left medial collateral ligament, a retractor is inserted dorsally into the posterior cortex of the left tibia. White arrows indicate G tendon and ST tendon. (G, gracilis; ST, semitendinosus.)
      Figure thumbnail gr3
      Fig 3Under fluoroscopic guidance, a metal ruler is aligned with the joint plane to mark the point 45 mm distal to it. This will be the osteotomy line. White arrow indicates osteotomy point.
      Figure thumbnail gr4
      Fig 4Two Kirschner wires are inserted to fix the guide to the marked osteotomy site. The wire is used to make a hole in the cortical bone to create the osteotomy line. Dotted line indicates osteotomy line.
      Figure thumbnail gr5
      Fig 5The anterior ascending osteotomy line is marked 15 mm posterior to the left tibial ridge. Black dotted line indicates tibial tuberosity. White dotted line indicates anterior ascending osteotomy line.
      Figure thumbnail gr6
      Fig 6The osteotomy is performed proximal to the guide pin. The guide pin is removed before using the bone saw. After confirming by fluoroscopy that the bone saw is correctly placed, the osteotomy is performed carefully. White dotted line indicates osteotomy line.
      Figure thumbnail gr7
      Fig 7After the osteotomy, fluoroscopy was used with a long alignment rod to ensure correct alignment. Two β-TCP blocks of the appropriate size for the amount of correction required were inserted. White arrow indicates β-TCP. (β-TCP, β-tricalcium phosphate.)
      Figure thumbnail gr8
      Fig 8After insertion of the beta-tricalcium phosphate blocks, the left shallow layer of the medial collateral ligament, and then the G tendon and ST tendon, are replaced in their original positions and sutured with absorbable thread. The osteotomy site is then completely covered by the periosteum. White arrow indicates sutured sartorius fascia. (G, gracilis; ST, semitendinosus.)
      Figure thumbnail gr9
      Fig 9A cross-linked plate is placed over the periosteum and fixed with 8 locking screws. The osteotomy site is completely covered by the periosteum, and periosteal blood flow is preserved. White arrow indicates completely covered osteotomy site. Yellow arrow indicates TOMOFIX anatomical medial high tibial plate.
      Table 1Advantages and Disadvantages of Intraoperative Soft-Tissue Envelopment for the Preservation of Medial Open-Wedge High Tibial Osteotomies
      Advantages
      • •
        Allows adequate dissection of the sartorius fascia
      • •
        Separates the shallow and deep layers of the MCL
      • •
        Sutures can be placed with the shallow layer of the MCL pulled up
      • •
        Maintains periosteal blood flow
      • •
        Reduces postoperative wound swelling and pain
      Disadvantages
      • •
        Soft-tissue damage may occur during osteotomy
      • •
        Risk of postoperative MCL insufficiency
      MCL, medial collateral ligament.

      Postoperative Rehabilitation

      Subsequent to this procedure, a postoperative rehabilitation protocol must be instigated. This begins with muscle-strengthening exercises, including quadriceps settings and straight leg lifts. These are begun immediately and gradually increased over time. Range-of-motion exercises are allowed a day after surgery. Partial weight-bearing is allowed at 2 weeks and full weight-bearing without crutches 4 weeks postoperatively. Jogging is permitted after 12 weeks. Squatting and sporting activities are not permitted until at least 6 months after surgery.

      Discussion

      In this Technical Note, we have described a MOW-HTO technique in which the osteotomy site is enveloped in soft tissue. This is achieved by separating the shallow layer of the MCL before osteotomy, protecting it while the osteotomy is performed, and then suturing the MCL back into position, covering the osteotomy site.
      The HTO is an effective surgical treatment for relatively young patients with knee osteoarthritis. The procedure uses osteotomy of the tibia to correct the Mikulicz line. This reduces medial compartment pressure on the knee joint and alleviates pain. In most MOW-HTO cases, the fascia, MCL, and part of the knee joint capsule are carefully separated and moved to expose the osteotomy site. Releasing or resecting the shallow layer of the MCL allows alignment to be corrected.
      • Kim J.H.
      • Ryu D.J.
      • Lee S.S.
      • et al.
      Does transection of the superficial MCL during HTO result in progressive valgus instability? [Formula: see text].
      Am J Sports Med. 2022; 50: 142-151
      Yet, despite the advantages, many patients experience postoperative swelling and pain in the affected limb due to bleeding from the osteotomy site. There have also been cases reported in which excessive intraoperative release of the MCL has resulted in postoperative MCL insufficiency and external deformity due to altered collateral ligament balance.
      • Song S.J.
      • Bae D.K.
      • Kim K.I.
      • Lee C.H.
      Conversion total knee arthroplasty after failed high tibial osteotomy.
      Knee Surg Relat Res. 2016; 28: 89-98
      Sasaki et al.
      • Sasaki A.
      • Sugita T.
      • Itaya N.
      • et al.
      A right angle guide for distal tuberosity osteotomy with medial open wedge high tibial osteotomy for varus knee osteoarthritis.
      Arthrosc Tech. 2021; 10: e1007-e1016
      have described a similar technique in which the osteotomy site is covered using the deep fascia. Our surgical technique involves repairing not only the deep fascia, but also the pes anserinus and the shallow MCL layer. Maximum possible soft-tissue repair reduces postoperative swelling of the affected limb and promotes long-term bone healing by preventing bleeding from the osteotomy site. This also helps to maintain periosteal blood flow.
      • Grundnes O.
      • Reikeras O.
      Blood flow and mechanical properties of healing bone. Femoral osteotomies studied in rats.
      Acta Orthop Scand. 1992; 63: 487-491
      ,
      • Smith S.R.
      • Bronk J.T.
      • Kelly P.J.
      Effect of fracture fixation on cortical bone blood flow.
      J Orthop Res. 1990; 8: 471-478
      This method cannot be used in cases in which the soft tissue around the pes anserinus is severely damaged intraoperatively or the correction angle is great. In future research, we hope to determine the maximum correction angle at which soft tissue repair and full coverage are possible.

      Supplementary Data

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        Video 1

        A curved oblique skin incision is made from the posteromedial corner of the proximal tibia to the insertion site of the pes anserine tendon. An incision is made in the sartorius fascia. The affected knee is placed in a slightly flexed position to relax the gracilis and semitendinosus tendons. These 2 tendons are then identified and scooped with a Kelly clamp and wet gauze. When the 2 tendons are separated, we can see the shallow layer of the medial collateral ligament (MCL) and the joint capsule. The distal attachments of the 2 tendons are left connected to the proximal tibia, and the boundary between the MCL and the joint capsule is marked with an electrocautery scalpel. A rasp is used at the border between the shallow layer of the MCL and the articular capsule to peel away the matter between the bone and the periosteum, which creates room for expansion. The dissection proceeds toward the posterior surface of the tibia and follows the bone so as not to involve the nerves or blood vessels when the retractor is inserted. At the posterior surface of the tibia, a bent-tip elevators can be used. A retractor is inserted between the MCL and the proximal tibia to protect the neurovascular bundles. At this point, the tip of the first Kirschner wire is inserted between the 2 tendons 4 to 4.5 cm below the medial joint line. The second Kirschner wire is then inserted parallel to the first under fluoroscopy. An anterior ascending osteotomy is then performed at an angle of 110° to the horizontal saw cut, ending behind the patellar tendon insertion. An osteotomy is made toward the fibular head, leaving a hinge. With the spreader inserted into the osteotomy site, the Mikulicz line is checked using a long alignment rod to determine the correction angle. Axial pressure is then applied to the calcaneus to reproduce loading conditions. A β-tricalcium phosphate (β-TCP) block is cut into a trapezoidal shape and inserted considering the amount of correction required at the osteotomy site. Soft-tissue repair is performed before the plate is applied. With a Kocher, the MCL is pulled into its correct anatomical position and sutured to the surrounding tissue. Then, the ST tendon and G tendon are also returned to their usual anatomical positions, ensuring that they cover the MCL. The excised joint tendons and then the sartorius fascia are sutured to completely cover the osteotomy. A TOMOFIX anatomical medial high tibial plate is applied to the medial side of the proximal tibia. (G, gracilis; ST, semitendinosus.)

      References

        • Amendola A.
        • Bonasia D.E.
        Results of high tibial osteotomy: Review of the literature.
        Int. Orthop. 2010; 34: 155-160
        View in Article
        • Kumagai K.
        • Akamatsu Y.
        • Kobayashi H.
        • Kusayama Y.
        • Koshino T.
        • Saito T.
        Factors affecting cartilage repair after medial opening-wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 779-784
        View in Article
        • Jildeh T.R.
        • Comfort S.M.
        • Peebles A.M.
        • Powell S.N.
        • Provencher M.T.
        Treatment of malalignment and cartilage injury: High tibial osteotomy with a concomitant osteochondral allograft to the medial femoral condyle and lateral and medial partial meniscectomy.
        Arthrosc Tech. 2022; 11: e623-e630
        View in Article
        • Akiyama T.
        • Okazaki K.
        • Mawatari T.
        • Ikemura S.
        • Nakamura S.
        Autologous osteophyte grafting for open-wedge high tibial osteotomy.
        Arthrosc Tech. 2016; 5: e989-e995
        View in Article
        • Baumgaertel F.
        • Buhl M.
        • Rahn B.A.
        Fracture healing in biological plate osteosynthesis.
        Injury. 1998; 29 (suppl 3): C3-C6
        View in Article
        • Hunt S.B.
        • Buckley R.E.
        Locking plates: A current concepts review of technique and indications for use.
        Acta Chir Orthop Traumatol Cech. 2013; 80: 185-191
        View in Article
        • Miranda L.L.
        • Guimaraes-Lopes V.P.
        • Altoe L.S.
        • et al.
        Plant extracts in the bone repair process: A systematic review.
        Mediators Inflamm. 2019; 20191296153
        View in Article
        • Tomlinson R.E.
        • Silva M.J.
        Skeletal blood flow in bone repair and maintenance.
        Bone Res. 2013; 1: 311-322
        View in Article
        • Anagnostakos K.
        • Mosser P.
        • Kohn D.
        Infections after high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 161-169
        View in Article
        • Lee S.Y.
        • Lim H.C.
        • Bae J.H.
        • et al.
        Sagittal osteotomy inclination in medial open-wedge high tibial osteotomy.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 823-831
        View in Article
        • Staubli A.E.
        • Jacob H.A.
        Evolution of open-wedge high-tibial osteotomy: experience with a special angular stable device for internal fixation without interposition material.
        Int Orthop. 2010; 34: 167-172
        View in Article
        • Staubli A.E.
        • De Simoni C.
        • Babst R.
        • Lobenhoffer P.
        TomoFix: A new LCP-concept for open wedge osteotomy of the medial proximal tibia—early results in 92 cases.
        Injury. 2003; 34 (suppl 2): B55-62
        View in Article
        • Yan J.
        • Musahl V.
        • Kay J.
        • Khan M.
        • Simunovic N.
        • Ayeni O.R.
        Outcome reporting following navigated high tibial osteotomy of the knee: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3529-3555
        View in Article
        • Wu K.
        • Zeng J.
        • Han L.
        • Feng W.
        • Lin X.
        • Zeng Y.
        Effect of the amount of correction on posterior tibial slope and patellar height in open-wedge high tibial osteotomy.
        J Orthop Surg (Hong Kong). 2021; 2923094990211049571
        View in Article
        • Ha J.K.
        • Yeom C.H.
        • Jang H.S.
        • et al.
        Biomechanical analysis of a novel wedge locking plate in a porcine tibial model.
        Clin Orthop Surg. 2016; 8: 373-378
        View in Article
        • Kim J.H.
        • Ryu D.J.
        • Lee S.S.
        • et al.
        Does transection of the superficial MCL during HTO result in progressive valgus instability? [Formula: see text].
        Am J Sports Med. 2022; 50: 142-151
        View in Article
        • Song S.J.
        • Bae D.K.
        • Kim K.I.
        • Lee C.H.
        Conversion total knee arthroplasty after failed high tibial osteotomy.
        Knee Surg Relat Res. 2016; 28: 89-98
        View in Article
        • Sasaki A.
        • Sugita T.
        • Itaya N.
        • et al.
        A right angle guide for distal tuberosity osteotomy with medial open wedge high tibial osteotomy for varus knee osteoarthritis.
        Arthrosc Tech. 2021; 10: e1007-e1016
        View in Article
        • Grundnes O.
        • Reikeras O.
        Blood flow and mechanical properties of healing bone. Femoral osteotomies studied in rats.
        Acta Orthop Scand. 1992; 63: 487-491
        View in Article
        • Smith S.R.
        • Bronk J.T.
        • Kelly P.J.
        Effect of fracture fixation on cortical bone blood flow.
        J Orthop Res. 1990; 8: 471-478
        View in Article

      Article Info

      Publication History

      Published online: September 17, 2022
      Accepted: May 24, 2022
      Received: March 30, 2022

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      In Press Corrected Proof

      Footnotes

      The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

      Identification

      DOI: https://doi.org/10.1016/j.eats.2022.05.013

      Copyright

      © 2022 The Authors. Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.

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