Incidence of Femoroacetabular Impingement and Surgical Management Trends Over Time

BACKGROUND

Femoroacetabular impingement (FAI) is a well-known cause of hip pain in adolescents and young adults. However, the incidence in the general population has not been clearly defined.

PURPOSE

To (1) define the population-based incidence of diagnosis of FAI in patients with hip pain, (2) report the trends in diagnosis of FAI over time, and (3) determine the changes in the rate and type of surgical management over time.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A geographic database was used to identify patients who were 14 to 50 years old with hip pain between the years 2000 and 2016. Chart and radiographic review was performed to determine which patients had FAI. To be included, patients had to have a triad of clinical symptoms, physical examination signs, and imaging findings consistent with FAI. Medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Statistical analysis determined the overall age- and sex-adjusted annual incidence of FAI diagnosis and trends over time.

RESULTS

There were 1893 patients evaluated with hip pain, and 716 (38%; 813 hips) had diagnosed FAI. The mean ± SD age was 27.2 ± 8.4 years, and 67% were female. The incidence of FAI diagnosis was 54.4 per 100,000 person-years. Female patients had a higher incidence than male patients (73.2 vs 36.1 per 100,000 person-years; P < .01). Incidence of FAI diagnosis were higher from 2010 to 2016 (72.6 per 100,000 person-years; P < .01) as compared with 2005 to 2009 (45.3) and 2000 to 2004 (40.3). Hip arthroscopy, surgical hip dislocation, and periacetabular osteotomy utilization increased from the 2000-2004 to 2010-2016 periods, respectively: 1 (1%) to 160 (20%; P = .04), 2 (1%) to 37 (5%; P = .01), and 1 (1%) to 22 (3%; P = .58).

CONCLUSION

The overall incidence of FAI diagnosis was 54.4 per 100,000 person-years, and it consistently increased between 2000 and 2016. Female patients had a higher incidence than male patients. The utilization of joint preservation operations, including hip arthroscopy, surgical hip dislocation, and anteverting periacetabular osteotomy, increased over time.

Biomechanical evaluation of the transtibial pull-out technique for posterior medial meniscal root repairs using 1 and 2 transtibial bone tunnels

BACKGROUND

Current methods of the transtibial pull-out meniscal root repair significantly displace under cyclic loading in porcine models but have not been evaluated in human models. One potential explanation for the displacement is that a single transtibial tunnel may not fully restore the attachment of the entire posterior medial meniscal root.

PURPOSE/HYPOTHESIS

The purpose of this study was to biomechanically evaluate the transtibial pull-out technique in a human cadaveric model using either 1 or 2 transtibial bone tunnels. The hypothesis was that a transtibial pull-out technique using 2 transtibial bone tunnels would confer superior biomechanical properties in comparison to an iteration using 1 transtibial bone tunnel.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten matched pairs of male human cadaveric knees (average age, 52.7 years) were randomly assigned (1 each of the pair) to 2 groups consisting of a transtibial pull-out technique using either 1 or 2 transtibial bone tunnels. The knees were cyclically loaded for 1000 cycles from 10 to 30 N at 0.5 Hz, representing the loads experienced during a typical meniscal root repair postoperative rehabilitation program, and then pulled to failure at a rate of 0.5 mm/s.

RESULTS

Differences between 1- and 2-tunnel repair groups were neither statistically nor clinically significant with respect to displacement or ultimate failure load. On average, the 1- and 2-tunnel repair groups resulted in 3.32 mm and 3.23 mm of displacement, respectively, after 1000 testing cycles. At 1, 100, 500, and 1000 testing cycles, displacement was not significantly different between groups (P > .799). The 2-tunnel repair technique resulted in a 10.2% higher ultimate failure load (135 N vs. 123 N); however, this was not significant (P = .333).

CONCLUSIONS

Similar biomechanical properties were seen between transtibial pull-out repairs using either 1 or 2 transtibial bone tunnels in a human cadaveric model. Both repair groups exceeded the 3-mm threshold for nonanatomic displacement.

CLINICAL RELEVANCE

This study indicates that a newly proposed iteration of the transtibial pull-out repair technique using a second transtibial tunnel, which theoretically restores more of the posterior medial meniscal root, was almost identical to the current clinical standard involving a single transtibial tunnel. As the importance of repairing meniscal root tears is increasingly recognized, further studies on new iterations of both techniques are warranted to minimize the risk of displacement caused by early motion in the initial postoperative rehabilitation period.

Investigating the Chronology of Meniscus Root Tears: Do Medial Meniscus Posterior Root Tears Cause Extrusion or the Other Way Around?

Background

Meniscus root tears are increasingly being recognized. Meniscal extrusion has previously been associated with medial root tears; however, the relationship between secondary meniscal restraints, such as the meniscotibial (MT) ligament, extrusion, and root tears has yet to be formally evaluated.

Purpose

To better understand the association between MT ligament competence, medial meniscal extrusion, and medial meniscus posterior root tears (MMPRTs) as well as to determine the progression of meniscal extrusion over time.

Study Design

Case series; Level of evidence, 4.

Methods

Serial magnetic resonance imaging (MRI) scans were reviewed for patients who showed evidence of medial meniscal extrusion and MMPRTs on at least 1 of ≥2 available MRI scans. All patients were symptomatic at the time of diagnosis. All MRI scans were analyzed independently by 2 board-certified musculoskeletal radiologists. MT ligament disruption, medial meniscal extrusion, and MMPRTs were recorded for each MRI scan. The time between MRI scans, presence of insufficiency fractures, and Outerbridge classification for the medial femur and tibia were also evaluated.

Results

Overall, 27 knees in 26 patients were included in this study, with a total of 63 MRI scans analyzed (21 knees with 2 MRI scans, 3 with 3 MRI scans, and 3 with 4 MRI scans). All patients demonstrated clear medial meniscal extrusion and MT ligament disruption before the subsequent development of MMPRTs (P < .001). Mean extrusion at the time of initial MRI was 3.3 ± 1.1 mm and increased significantly to 5.5 ± 1.8 mm at the time of first imaging with an identified MMPRT (P < .001). The mean time between initial MRI and the first identification of an MMPRT on later MRI was 1.7 ± 1.6 years.

Conclusion

In a sample of 27 symptomatic knees with serial MRI scans both before and after an MMPRT diagnosis, all patients demonstrated MT ligament disruption and associated meniscal extrusion before the development of subsequent medial meniscus root tears. These findings suggest that MT ligament disruption and medial meniscal extrusion represent early and predisposing events contributing to MMPRTs. Therefore, this provides a possible explanation of why meniscal extrusion is not corrected with medial meniscus root repair.

Biomechanical Evaluation of the Medial Stabilizers of the Patella

BACKGROUND

Quantification of the biomechanical properties of each individual medial patellar ligament will facilitate an understanding of injury patterns and enhance anatomic reconstruction techniques by improving the selection of grafts possessing appropriate biomechanical properties for each ligament.

PURPOSE

To determine the ultimate failure load, stiffness, and mechanism of failure of the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), and medial patellomeniscal ligament (MPML) to assist with selection of graft tissue for anatomic reconstructions.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Twenty-two nonpaired, fresh-frozen cadaveric knees were dissected free of all soft tissue structures except for the MPFL, MPTL, and MPML. Two specimens were ultimately excluded because their medial structure fibers were lacerated during dissection. The patella was obliquely cut to test the MPFL and the MPTL-MPML complex separately. To ensure that the common patellar insertion of the MPTL and MPML was not compromised during testing, only one each of the MPML and MPTL were tested per specimen (n = 10 each). Specimens were secured in a dynamic tensile testing machine, and the ultimate load, stiffness, and mechanism of failure of each ligament (MPFL = 20, MPML = 10, and MPTL = 10) were recorded.

RESULTS

The mean ± SD ultimate load of the MPFL (178 ± 46 N) was not significantly greater than that of the MPTL (147 ± 80 N; P = .706) but was significantly greater than that of the MPML (105 ± 62 N; P = .001). The mean ultimate load of the MPTL was not significantly different from that of the MPML ( P = .210). Of the 20 MPFLs tested, 16 failed by midsubstance rupture and 4 by bony avulsion on the femur. Of the 10 MPTLs tested, 9 failed by midsubstance rupture and 1 by bony avulsion on the patella. Finally, of the 10 MPMLs tested, all 10 failed by midsubstance rupture. No significant difference was found in mean stiffness between the MPFL (23 ± 6 N/mm²) and the MPTL (31 ± 21 N/mm²; P = .169), but a significant difference was found between the MPFL and the MPML (14 ± 8 N/mm²; P = .003) and between the MPTL and MPML ( P = .028).

CONCLUSION

The MPFL and MPTL had comparable ultimate loads and stiffness, while the MPML had lower failure loads and stiffness. Midsubstance failure was the most common type of failure; therefore, reconstruction grafts should meet or exceed the values reported herein.

CLINICAL RELEVANCE

For an anatomic medial-sided knee reconstruction, the individual biomechanical contributions of the medial patellar ligamentous structures (MPFL, MPTL, and MPML) need to be characterized to facilitate an optimal reconstruction design.

Lateral Meniscal Oblique Radial Tears Are Common With ACL Injury: A Classification System Based on Arthroscopic Tear Patterns in 600 Consecutive Patients

Background:

Meniscal root tears and ramp lesions have been rigorously characterized in recent literature. However, one of the most common lateral meniscal injuries identified with an acute anterior cruciate ligament (ACL) disruption, a posterior horn lateral meniscal oblique radial tear (LMORT), has not been thoroughly described.

Purpose:

To determine the incidence of all meniscal tears and, more specifically, the incidence of posterior horn LMORTs in a multicenter cohort of consecutive, acute ACL reconstructions. Additionally, the authors aimed to develop a new classification system to help guide treatment of posterior horn LMORTs.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A multicenter retrospective cohort design was used to analyze 200 consecutive cases of acute ACL reconstruction from each of 3 different surgeons, for a total of 600 patients. The operative notes and intraoperative photos were analyzed to determine the incidence and laterality of all meniscal tears. A classification system based on tear characterization was then used to categorize tear patterns into similar groups.

Results:

A total of 396 (66%) of the 600 patients with acute ACL disruption had concomitant meniscal tears. Specifically, 187 (31%) had a lateral meniscal injury, 89 (15%) had a medial meniscal injury, and 122 (20%) had both medial and lateral meniscal injuries. The most common lateral meniscal tear was an LMORT; 71 (18%) patients with meniscal tears had a posterior horn LMORT. Overall, the incidence of ACL injury with a concomitant posterior horn LMORT was 12%. A classification was developed, which included type 1 tear (partial thickness <10 mm from the root attachment), type 2 tear (complete radial oblique tear that extended <10 mm from root), type 3 tear (incomplete LMORT that extended >10 mm from root), and type 4 tear (complete LMORT >10 mm from root).

Conclusion:

In 600 consecutive acute ACL reconstructions, the incidence of concomitant ACL injury with meniscal injury was 66%, and posterior horn LMORTs represented a large proportion of all meniscal tears (12%). A classification scheme was developed for posterior horn LMORTs to aid reporting and clinical decision making for these common tears.

The History and Evolution of Elbow Medial Ulnar Collateral Ligament Reconstruction: from Tommy John to 2020

PURPOSE OF REVIEW

The purpose of this review article is to discuss the evolution of surgical reconstruction of the anterior bundle of the UCL, otherwise known as Tommy John surgery, from Dr. Jobe's initial description in 1986 to present day. In particular, the unique changes brought forth by each new surgical technique, and the reasons that these changes were implemented, are highlighted.

RECENT FINDINGS

The incidence of UCL reconstruction surgery continues to increase significantly, particularly in the 15- to 19-year-old age group. New anatomic understanding of the anterior bundle of the UCL, including the importance of the central fibers and the broad and tapered ulnar insertion, may affect optimal UCL reconstruction techniques in the future. Although return to play rates are generally quite high (80-95%), the mean time to return to play (typically 12-18 months for pitchers) is longer than desired. Accordingly, many authors feel that there remains room for improvement in the treatment of this common injury. The Tommy John surgery has evolved in many ways with the development of novel techniques over the last 35 years. Currently, overhead throwing athletes undergoing UCL reconstruction have high return to play and low complication rates. Future modifications to the surgery may aim to further improve outcomes and, more importantly, expedite the length of postoperative rehabilitation.

The Cost of Outpatient Arthroscopic Rotator Cuff Repairs: Hospital Reimbursement Is on the Rise While Surgeon Payments Remain Unchanged

PURPOSE

To better understand the relative increases in rotator cuff charges and to analyze national and regional trends between hospital, anesthesiologist, and surgeon charges and reimbursements for contemporary rotator cuff repairs (RCRs) performed in the United States.

METHODS

A representative Medicare sample was used to capture hospital, surgeon, and anesthesiologist charges and payments for outpatient RCR from 2005 to 2014. The charges and reimbursements were calculated using Current Procedural Terminology codes. Two ratios were calculated to compare surgeon and hospital charges and reimbursements. The charge multiplier (CM) is the ratio of hospital to surgeon charges, and the payment multiplier (PM) is the ratio of hospital to surgeon reimbursements. Trends were evaluated using national and regional charges, reimbursements, Charlson Comorbidity Index, CM, and PM.

RESULTS

In total, 12,617 patients were included in this study. Between 2005 and 2014, hospital charges for RCR significantly increased from $4877 to $11,488 (136% increase; P < .0001), anesthesiologist charges increased from $1319 to $2169 (64% increase; P < .0001), and surgeon charges increased from $7528 to $9979 (33% increase; P < .0001). Reimbursements during the same period significantly increased from $3007 to $6696 (123% increase; P < .0001) for hospitals, from $203 to $239 (17% increase; P = .005) for anesthesiologists. Reimbursements for surgeons remained relatively unchanged (from $1821 to $1885, 3% increase; P = .116). Increases in national CM (P = .003) and PM (P < .0001) were both statistically significant. Charlson Comorbidity Index did not change significantly over the period (P = .1178).

CONCLUSIONS

Although outpatient RCR charges increased significantly for hospitals, surgeons, and anesthesiologists, hospital reimbursements increased substantially relative to surgeon and anesthesiologist reimbursements despite stable patient complexity. In 2005, hospitals were reimbursed 65% more than surgeons. By 2014, hospitals were reimbursed 255% more than surgeons, indicating that hospitals disproportionally drove increases in charges and reimbursements over this period.

LEVEL OF EVIDENCE

Level IV, economic analysis.

Risk Factors for Long-term Hip Osteoarthritis in Patients With Femoroacetabular Impingement Without Surgical Intervention

BACKGROUND

Femoroacetabular impingement (FAI) is a common cause of hip pain and a known risk factor for hip osteoarthritis (OA) and total hip arthroplasty (THA) at a young age. Unfortunately, little is known about the specific factors associated with an increased risk of OA.

PURPOSE

To (1) report the overall rate of symptomatic hip OA and/or THA in patients with FAI without surgical intervention and (2) identify radiographic features and patient characteristics associated with hip OA.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A geographic database was used to identify all patients with hip pain and radiographs between 2000 and 2016. Chart review was performed to identify patients with FAI. Patient medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Kaplan-Meier analysis was used to determine the rate of hip OA. Univariate and multivariate proportional hazard regression models were performed to determine risk factors for OA.

RESULTS

The study included 952 patients (649 female; 303 male; 1104 total hips) with FAI. The majority of hips had mixed type (n = 785; 71.1%), 211 (19.1%) had pincer type, and 108 (9.8%) had cam type. Mean age at time of presentation was 27.6 ± 8.7 years. Mean follow-up time was 24.7 ± 12.5 years. The rate of OA was 13.5%. THA was performed in 4% of patients. Male sex, body mass index (BMI) greater than 29, and increased age were risk factors for OA (male sex: hazard ratio [HR], 2.28; P < .01; BMI >29: HR, 2.11; P < .01; per year of increased age: HR, 1.11; P < .01.). Smoking and diabetes mellitus were not significant risk factors. No radiographic morphological features were found to be significant risk factors for OA.

CONCLUSION

At mean follow-up of 24.7 years, 14% of hips had symptomatic OA and 4% underwent THA. BMI greater than 29, male sex, and increased age at the time of presentation with hip pain were risk factors for hip OA. The cohort consisted of a large percentage of mixed-type FAI morphologies, and no specific radiographic risk factors for OA were identified.

A Strategy for Repair, Augmentation, and Reconstruction of Knee Extensor Mechanism Disruption: A Retrospective Review

Background

The loss of extensor mechanism continuity that occurs with patellar and quadriceps tendon rupture has devastating consequences on patient function.

Purpose

To describe a treatment strategy for extensor mechanism disruption and evaluate the outcomes of 3 techniques: primary repair, repair with semitendinosus tendon autograft augmentation, and reconstruction with Achilles tendon allograft.

Study Design

Case series; Level of evidence, 4.

Methods

The authors reviewed surgeries for extensor mechanism disruption performed by a single surgeon between 1999 and 2019. Patient characteristics, imaging studies, surgical techniques, and outcomes were recorded. Primary ruptures with robust tissue quality were repaired primarily, and first-time ruptures with significant tendinosis or moderate tissue loss were repaired using quadrupled semitendinosus tendon autograft augmentation. Patients with failed previous extensor mechanism repair or reconstruction and poor tissue quality underwent reconstruction with Achilles tendon allograft. The primary outcome was extensor mechanism integrity at a minimum 1-year follow-up, with extensor mechanism lag defined as >5° loss of terminal, active knee extension. Secondary outcomes included postoperative knee range of motion, International Knee Documentation Committee (IKDC) and Tegner activity scores, and the radiographic Caton-Deschamps Index.

Results

Included were 22 patellar tendon and 21 quadriceps tendon surgeries (patients: 82.5% male; mean age, 48.1 years; body mass index, 31). Seventeen (39.5%) cases underwent primary tendon repair, 13 (30.2%) had repair using semitendinosus tendon autograft augmentation, and 13 (30.2%) underwent reconstruction using an Achilles tendon allograft. Seventeen (39.5%) cases had at least 1 prior failed extensor mechanism surgery performed at an outside facility. At the last follow-up, 4 (9.3%) cases had an extensor mechanism lag, no cases required additional extensor mechanism surgery, and all cases were able to achieve >90° of knee flexion. Postoperative IKDC scores were significantly improved with all methods of extensor mechanism surgery, and postoperative Tegner activity scores were significantly improved in patients who underwent primary repair and Achilles tendon allograft reconstruction (P < .05 for all).

Conclusion

Primary repair alone, repair using quadrupled semitendinosus tendon autograft augmentation, and reconstruction using Achilles tendon allograft were all effective methods to restore extensor mechanism and knee function with the proper indications. Persistent knee extensor lag was more common in chronic extensor mechanism injuries after failed surgery, although patients still reported significantly improved postoperative functional outcomes.

Incidence of Hip Dysplasia Diagnosis in Young Patients With Hip Pain: A Geographic Population Cohort Analysis

Background

Hip dysplasia is a common source of hip pain and a known cause of early osteoarthritis of the hip.

Purpose

To (1) define the population-based incidence of hip dysplasia diagnosis in young patients presenting with hip pain in a large geographically defined cohort, (2) analyze trends regarding presentation and diagnosis of hip dysplasia, and (3) report the rate and type of surgical interventions used to treat this population.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A geographic epidemiological database was queried to identify patients aged 14 to 50 years with hip pain between the years 2000 and 2016. Patient medical records were analyzed, and demographic, imaging, clinical, and treatment history were recorded. Incidence trends were examined by use of linear regression with confidence intervals for age and calendar year.

Results

Overall, 1893 patients were included. Of these, 156 patients (196 hips) had a diagnosis of hip dysplasia. The incidence of hip dysplasia diagnosis in patients who reported hip pain was 12.7 per 100,000 person-years. Patients with dysplasia had a mean age of 26.7 ± 9.8 years, while the highest age-adjusted incidence occurred at age 14 to 18 years in both male and female patients. Female patients had double the age-adjusted incidence of male patients (cases per 100,000 person-years: 16.8 [95% CI, 13.9-19.7] vs 8.7 [95% CI, 6.6-10.8]; P < .01). Of the patients who underwent magnetic resonance imaging, 77% had imaging consistent with labral pathology. Patients were treated with physical therapy (67%), intra-articular steroid injection (29%), hip arthroscopy (10%), and periacetabular osteotomy (9%). The use of hip arthroscopy significantly increased over time (P < .01), whereas the use of steroid injection and periacetabular osteotomy did not (P < .28 and P < .08, respectively).

Conclusion

The incidence of hip dysplasia diagnosis in patients presenting with hip pain was 12.7 per 100,000 person-years. Female patients had twice the age-adjusted incidence of male patients, and the highest age-adjusted incidence occurred in the age range of 14 to 18 years in both sexes. The use of hip arthroscopy to treat patients with hip dysplasia significantly increased over time.

A Novel Scoring Instrument to Assess Donor Site Morbidity After Anterior Cruciate Ligament Reconstruction With a Patellar Tendon Autograft at 2-Year Follow-up Using Contemporary Graft-Harvesting Techniques

Background:

Donor site morbidity after anterior cruciate ligament (ACL) reconstruction with a bone–patellar tendon–bone (BTB) autograft is clinically significant, but evidence with contemporary techniques is lacking.

Purpose:

To (1) evaluate donor site morbidity at a single institution using modern techniques of BTB autograft harvest at 2-year follow-up, (2) develop a 10-question donor site morbidity instrument, and (3) compare this instrument against traditional outcome tools.

Study Design:

Case series; Level of evidence, 4.

Methods:

We analyzed the 2-year follow-up outcomes of 200 consecutive patients who underwent ACL reconstruction with a BTB autograft performed by 2 surgeons at a single institution. The surgical technique utilized modern and consistent BTB autograft harvest, including graft sizing, patellar tendon and peritenon closure, and patellar and tibial donor site bone grafting. There were 187 patients included, with 13 patients undergoing revision ACL reconstruction excluded. An original 10-question scoring instrument evaluating donor site morbidity was administered to each patient (score, 0-100) and compared against each patient’s International Knee Documentation Committee (IKDC) and Lysholm scores.

Results:

Overall, 13.9% of patients were noted to have anterior knee pain with activity at 2-year follow-up. Moreover, 3.7% of patients reported an inability to kneel on hard surfaces but had no problems on soft surfaces; 5.9% of patients reported mild discomfort but were able to kneel on all surfaces. Additionally, 75.4% of patients had a perfect (100/100) donor site morbidity score. The mean donor site morbidity score at 2-year follow-up was 98.3 ± 3.4. There was a very strong correlation between the IKDC and Lysholm scores but only a strong and moderate correlation when the donor site morbidity score was compared with the IKDC and Lysholm scores, respectively.

Conclusion:

Donor site morbidity after ACL reconstruction with a BTB autograft was less frequent than reported in the existing literature. Some patients developed anterior knee pain; therefore, an informed discussion is advised. IKDC and Lysholm scores may not capture donor site symptoms after surgery. The 10-question donor site morbidity instrument may provide a more accurate assessment.

Stem Cell Treatment for Ligament Repair and Reconstruction

PURPOSE OF REVIEW

With the rapid and ongoing evolution of regenerative and sports medicine, the use of stem/stromal cells in ligament repair and reconstruction continues to be investigated and grow. The purpose of this review was to assess available methods and formulations for stem/stromal cell augmentation as well as review early pre-clinical and clinical outcomes for these recently emerging techniques.

RECENT FINDINGS

Recent literature demonstrates promising outcomes of stem/stromal cell augmentation for ligament repair and reconstruction. Multiple groups have published animal models suggesting improved healing for partially transected ligaments as well as histologic re-approximation of native bone-tendon interfaces with the use of mesenchymal stem/stromal cells in reconstructive models. Human studies also suggest improved outcomes spanning from higher patient-reported outcome scores to magnetic resonance imaging evidence of ligament healing in the setting of anterior cruciate ligament tears. However, clinical studies are only recently available, relatively few in number, and not necessarily accompanied by standard-of-care controls. There is increasing availability and growing animal and clinical evidence demonstrating potential benefit of stem/stromal cell augmentation for tendon healing. However, to date, there is a relative paucity of high-level human evidence for the routine use of stem/stromal cells for ligament repair and reconstruction in the clinical practice. This field contains substantial promise and merits further, ongoing investigation.

Intramedullary Tibial Nailing Reduces the Attachment Area and Ultimate Load of the Anterior Medial Meniscal Root: A Potential Explanation for Anterior Knee Pain in Female Patients and Smaller Patients

BACKGROUND

Intramedullary (IM) nailing is the treatment of choice among orthopaedic surgeons for tibial shaft fractures. However, because of the close proximity of the nail's insertion site to the anterior medial (AM) meniscal root on the tibial plateau, there is increased risk of iatrogenic injury to the meniscal root during nailing.

PURPOSE

To quantify the area of the AM meniscal root footprint damaged by IM tibial reaming and determine its subsequent effects on the ultimate failure load in female versus male knees.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve matched pairs (6 male and 6 female pairs; average age, 50.2 years) of human cadaveric knees were randomly assigned to native and reamed groups. In the reamed group, knees were reamed within the "safe zone" according to current guidelines for IM tibial nail insertion (3 mm lateral to the center of the tibial tubercle and adjacent to the anterior margin of the tibial plateau). The attachment areas and ultimate failure load were quantified and compared with paired knees in the native group.

RESULTS

Intra-articular reaming within the "safe zone" for IM tibial nail insertion did not significantly decrease the AM root attachment area or ultimate failure load in male specimens, as only 2 of the 6 knees were damaged by reaming. In contrast, all 6 of the AM roots in the female knees were damaged by reaming, and on average, reaming decreased the female AM root attachment area by 19% and significantly decreased ultimate failure load by 37% (P = .028). There was a strong negative correlation (R(2) = 0.77) between reamed tunnel-AM root overlap area and medial-lateral width in female but not in male knees.

CONCLUSION

Standard reaming for an IM tibial nail induced significant damage to the AM meniscal root in smaller, female specimens, whereas larger, male specimens were not affected.

CLINICAL RELEVANCE

These findings may suggest that improvements in current guidelines and surgical techniques are warranted to prevent iatrogenic injury to the AM meniscal root during intramedullary reaming for tibial shaft fractures in females and in smaller patients.

Anterior Shoulder Instability in Throwers and Overhead Athletes: Long-term Outcomes in a Geographic Cohort

BACKGROUND

Athletes of all sports often have shoulder instability, most commonly as anterior shoulder instability (ASI). For overhead athletes (OHAs) and those participating in throwing sports, clinical and surgical decision making can be difficult owing to a lack of long-term outcome studies in this population of athletes.

PURPOSE/HYPOTHESIS

To report presentation characteristics, pathology, treatment strategies, and outcomes of ASI in OHAs and throwers in a geographic cohort. We hypothesized that OHAs and throwers would have similar presenting characteristics, management strategies, and clinical outcomes but lower rates of return to play (RTP) when compared with non-OHAs (NOHAs) and nonthrowers, respectively.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

An established geographic medical record system was used to identify OHAs diagnosed with ASI in the dominant shoulder. An overall 57 OHAs with ASI were matched 1:2 with 114 NOHAs with ASI. Of the OHAs, 40 were throwers. Sports considered overhead were volleyball, swimming, racquet sports, baseball, and softball, while baseball and softball composed the thrower subgroup. Records were reviewed for patient characteristics, type of sport, imaging findings, treatment strategies, and surgical details. Patients were contacted to collect Western Ontario Shoulder Instability index (WOSI) scores and RTP data. Statistical analysis compared throwers with nonthrowers and OHAs with NOHAs.

RESULTS

Four patients, 3 NOHAs and 1 thrower, were lost to follow-up at 6 months. Clinical follow-up for the remaining 167 patients (98%) was 11.9 ± 7.2 years (mean ± SD). Of the 171 patients included, an overall 41 (36%) NOHAs, 29 (51%) OHAs, and 22 (55%) throwers were able to be contacted for WOSI scores and RTP data. OHAs were more likely to initially present with subluxations (56%; P = .030). NOHAs were more likely to have dislocations (80%; P = .018). The number of instability events at presentation was similar. OHAs were more likely to undergo initial operative management. Differences in rates of recurrent instability were not significant after initial nonoperative management (NOHAs, 37.1% vs OHAs, 28.6% [P = .331] and throwers, 21.2% [P = .094]) and surgery (NOHAs, 20.5% vs OHAs, 13.0% [P = .516] and throwers, 9.1% [P = .662]). Rates of revision surgery were similar (NOHAs, 18.0% vs OHAs, 8.7% [P = .464] and throwers, 18.2% [P > .999]). RTP rates were 80.5% in NOHAs, as compared with 71.4% in OHAs (P = .381) and 63.6% in throwers (P = .143). Median WOSI scores were 40 for NOHAs, as compared with 28 in OHAs (P = .425) and 28 in throwers (P = .615).

CONCLUSION

In a 1:2 matched comparison of general population athletes, throwers and OHAs were more likely to have more subtle instability, as evidenced by higher rates of subluxations rather than frank dislocations, when compared with NOHAs. Despite differences in presentation and the unique sport demands of OHAs, rates of recurrent instability and revision surgery were similar across groups. Similar outcomes in terms of RTP, level of RTP, and WOSI scores were achieved for OHAs and NOHAs, but these results must be interpreted with caution given the limited sample size.

Surgical Treatment of Isolated Meniscal Tears in Competitive Male Wrestlers: Reoperations, Outcomes, and Return to Sport

Background:

Wrestlers are highly active, young athletes prone to meniscal injuries that often require surgery. However, there is a lack of data evaluating the results of meniscal repair or partial meniscectomy in this cohort.

Purpose:

To describe the outcomes (subjective function, return to play, complications, reoperation rates, and progression of osteoarthritis) for treatment (meniscectomy or repair) of meniscal injuries in a cohort of competitive wrestlers.

Study Design:

Case series; Level of evidence, 4.

Methods:

All competitive wrestlers (high school, collegiate, or professional leagues) with a history of a meniscal injury and isolated meniscal surgery at a single institution between 2001 and 2017 were retrospectively identified. Failure was defined as a reinjury of the operative meniscus by clinical or advanced imaging examination, reoperation, or any additional surgical treatment of the meniscus after the index procedure. All patients were contacted for determination of reinjury rates, current sport status, and International Knee Documentation Committee and Tegner activity scores.

Results:

Of 85 male wrestlers with isolated meniscal tears, 34% underwent a meniscal repair, and 66% received a partial meniscectomy. Index surgery failed for 9.4% of the cohort. Among wrestlers treated with initial meniscal repair, 21% required a subsequent partial meniscectomy at a mean 2.2 years, and of those treated with partial meniscectomy, 3% underwent a second operation (P < .001). All secondary operations were revision partial meniscectomies occurring at a mean 3.2 years (95% CI, 0.01-6.4 years) after the index procedure. At final follow-up, 89% of patients were able to return to sport, with 65% returning to wrestling competition. There was significant improvement in the Tegner score from a mean 6.5 (95% CI, 5.9-7.2) preoperatively to 8.3 (95% CI 8.0-8.6) postoperatively (P < .001).

Conclusion:

The reoperation rate after meniscal surgery in wrestlers was quite low, but only 65% returned to competitive wrestling. Meniscal repair and partial meniscectomy improved patient-reported outcomes and activity levels at short-term follow-up. However, 21% of wrestlers treated with initial meniscal repair required a subsequent partial meniscectomy at a mean 2.2 years.

Analysis of Charges and Payments for Outpatient Arthroscopic Meniscectomy From 2005 to 2014: Hospital Reimbursement Increased Steadily as Surgeon Payments Declined

Background:

Charge and reimbursement trends for arthroscopic partial meniscectomies among orthopaedic surgeons, anesthesiologists, and hospital/surgery centers have not been formally analyzed, even though meniscectomies are the most commonly performed orthopaedic surgery.

Purpose:

To analyze Medicare charge and reimbursement trends for surgeons, anesthesiologists, and hospital/surgery centers for outpatient arthroscopic partial meniscectomies performed in the United States.

Study Design:

Economic and decision analysis; Level of evidence, 4.

Methods:

We analyzed trends in surgeon, anesthesiologist, and hospital charges and reimbursements for outpatient isolated arthroscopic partial meniscectomies from 2005 to 2014. Current Procedural Terminology codes were used to capture charge and reimbursement information using the nationally representative 5% Medicare sample. National and regional trends for charge, reimbursement, and Charlson Comorbidity Index (CCI) were evaluated using linear regression analysis.

Results:

A total of 31,717 patients were analyzed in this study. Charges across all groups increased significantly (P < .001) during the 10-year study period, with an increase of 18.4% ($2754-$3262) for surgeons, 85.5% ($802-$1480) for anesthesiologists, and 116.8% ($2743-$5947) for hospitals. Surgeon reimbursements declined by 15.5% ($504-$426; P = .072) during this period. Anesthesiologist and hospital reimbursements increased significantly during by 36.5% ($133-$182; P < .001) and 28.9% ($1540-$1984; P < .001) during the 10-year study period, respectively. The annual incidence of partial meniscectomies per 10,000 database patients decreased significantly from 18.3 to 15.6 over the course of the study (14.8% decrease; P = .009), while the CCI did not change significantly (P = .798).

Conclusion:

Hospital and anesthesiologist Medicare reimbursements for outpatient arthroscopic partial meniscectomies increased significantly, while surgeon reimbursements decreased. In 2005, hospitals were reimbursed 205% more ($1540 vs $504) than surgeons, and by 2014, they were reimbursed 365% more ($1984 vs $426), indicating that the gap between hospital and surgeon reimbursement is rising. Improved understanding of charge and reimbursement trends represents an opportunity for key stakeholders to improve financial alignment across the field of orthopaedics.

Arthritic progression secondary to meniscus root tear treated with knee arthroplasty demonstrates similar outcomes to primary osteoarthritis: a matched case-control comparison

PURPOSE

There is limited data comparing the outcomes of knee arthroplasty for arthritis secondary to meniscus root tear versus primary osteoarthritis. The aim of this 2:1 matched case control series was to compare outcomes in patients who underwent arthroplasty for arthritis following a meniscus root tear (root tear cohort-"RTC") with a control group of patients with primary osteoarthritis (primary osteoarthritis-"controls"). The authors hypothesized that the meniscus root tear patients would have similar clinical outcomes, return to activity, complication and reoperation rates as their matched controls.

METHODS

A consecutive series of patients who had a clinically and radiographically confirmed meniscus root tear between 2002 and 2017 at a mean 4.8 year follow-up that developed secondary arthritis were matched 2:1 by laterality, surgery, age at surgery, date of surgery, sex, and surgeon to a control group of patients with primary osteoarthritis, without a root tear, who underwent arthroplasty. No patients were lost to follow-up. Patient demographics, Kellgren-Lawrence grades at the time of surgery, pre- and post-operative Knee Society Score pain and function scores, Tegner score, complications, and survival free of reoperation were analyzed between groups.

RESULTS

A total of 225 subjects were identified, including 75 root tear cohort patients (13 UKA, 62 TKA) and 150 control patients. The root tear cohort had significantly lower Kellgren-Lawrence grades than the control group at the time of arthroplasty (p ≤ 0.001), but similar baseline pre-operative Knee Society Score pain, Knee Society Score function, and Tegner activity scale score. Post-operatively, Knee Society Score pain scores were comparable, and root tear cohort Knee Society Score function scores statistically significantly improved (p ≤ 0.007). Complication rates and survival free of reoperation at final follow-up were not statistically significantly different between groups.

CONCLUSION

Patients treated with arthroplasty for secondary arthritis after a meniscus root tear demonstrated less severe radiographic arthritis, but similar pre-operative pain levels compared to matched controls with primary osteoarthritis. The root tear cohort patients demonstrated improved outcomes with respect to function, and similar outcomes with respect to pain, activity level, complication rates, and reoperation rates. The authors conclude that arthroplasty can be a reliable option for selected patients with an irreparable root tear and ongoing pain and dysfunction refractory to non-operative management, even in the setting of less advanced osteoarthritis on X-ray.

LEVEL OF EVIDENCE

III.

Small Cartilage Defect Management

Cartilage defects in the knee are common resulting in significant pain and morbidity over time. These defects can arise in isolation or concurrently with other associated injuries to the knee. The treatment of small (< 2-3 cm²) cartilage deficiencies has changed as our basic science knowledge of tissue healing has improved. Advancements have led to the development of new and more effective treatment modalities. It is important to address any associated knee injuries and limb malalignment. Surgical options are considered when nonoperative treatment fails. The specific procedure depends on individual patient characteristics, lesion size, and location. Debridement/chondroplasty, microfracture, marrow stimulation plus techniques, fixation of unstable osteochondral fragments, osteochondral autograft transfer, and osteochondral allograft transplantation, all have roles in the treatment of small cartilage defects.

Risk factors for long-term hip osteoarthritis in patients with hip dysplasia without surgical intervention

Hip dysplasia is a common cause of hip pain and a known risk factor for hip osteoarthritis (OA) and early total hip arthroplasty (THA). Unfortunately, little is known about the specific factors associated with an increased risk of OA. The purpose was (i) to report the overall rate of symptomatic hip OA and THA and (ii) to identify radiographic features and patient characteristics associated with the development of symptomatic hip OA. A geographic database was used to identify all patients aged 14–50 years old diagnosed with symptomatic hip dysplasia between 2000 and 2016. Kaplan–Meier analysis was used to determine the rate of symptomatic hip OA, defined as a Tönnis grade of ≥1 on hip radiograph. Univariate and multivariate proportional hazard regression models were performed to determine risk factors for OA. One hundred and fifty-nine hips (144 patients) with hip dysplasia (52 F:107 M) out of 1893 patients with hip pain were included. Of these, 45 (28%) had severe hip dysplasia with a lateral center-edge angle ≤18°. Mean age at time of presentation was 26.1 (±10.1) years. Mean follow-up time was 8.2 (±5) years. The rate of OA was 20%. THA was performed in 11% of patients. Body mass index >29 (P = 0.03) and increased age (P < 0.01) were risk factors for OA. Patients with symptomatic hip dysplasia are at significant risk of developing hip OA. Body mass index >29 and age ≥35 years at the time of presentation with hip pain were risk factors for hip OA.

Although Surgical Techniques Differ, Similar Outcomes Can Be Obtained When Operating After Single Versus Multiple Anterior Shoulder Dislocations

Purpose

To compare the differences in preoperative pathology, surgical technique, and overall outcomes between patients treated surgically after a single anterior glenohumeral joint dislocation and those undergoing surgery after multiple dislocations.

Methods

An epidemiologic database was used to identify all patients younger than 40 years undergoing surgery for anterior shoulder instability between January 1, 1994, and July 31, 2016, in a defined geographic area. Patient medical records were reviewed to obtain demographic information, patient history, physical examination findings, imaging findings, clinical progression, surgical details, and outcomes. Comparative analysis was performed between patients who underwent surgery after a single dislocation and those who underwent surgery after multiple preoperative dislocations.

Results

The study population consisted of 187 patients who had a single anterior shoulder dislocation (n = 55) or multiple anterior shoulder dislocations (n = 132) prior to surgery. The mean follow-up period was 103.3 months (range, 0.3-328.4 months). Demographic characteristics were not significantly different between groups. Although the presence of Hill-Sachs lesions on radiographs was more common in the multiple-dislocation group (42.1%) than in the single-dislocation group (18.8%, P = .005), there were no other significant differences in concomitant pathology between groups. Latarjet procedures were more commonly performed in the multiple-dislocation group (12.5% vs 2.1% in the single-dislocation group, P = .04). There were no other significant differences in surgical techniques and characteristics between groups. Rates of survival free from recurrent instability (P = .790), revision surgery (P = .726), and progression to symptomatic osteoarthritis (P = .588) were not significantly different between groups.

Conclusions

Although patients with multiple dislocations prior to surgery were more likely to show radiographic evidence of Hill-Sachs lesions and undergo the Latarjet procedure than those who received surgery after a single dislocation, no significant differences in outcomes with respect to recurrent instability, revision surgery, or progression to symptomatic osteoarthritis were found between these 2 groups at long-term follow-up.

Level of Evidence

Level III, retrospective comparative study.

Hip Arthroscopy and Its Impact on Performance in National Hockey League Players Using Team-Based Advanced Performance Statistics

Background

Ice hockey players have a high rate of hip pathology, which can lead to hip arthroscopy. Previous studies have not utilized team-based advanced performance statistics in the setting of hip arthroscopy in National Hockey League (NHL) players.

Purpose/Hypothesis

The purpose of this study was to use team-based advanced performance statistics to evaluate postoperative performance after hip arthroscopy in NHL players in comparison with their preoperative performance and matched controls of uninjured skaters. It was hypothesized that there would be no significant difference between preoperative and postoperative performance after hip arthroscopy in NHL players, as well as no difference when compared with matched controls of uninjured players.

Study Design

Descriptive epidemiology study.

Methods

There were 56 eligible NHL players found through public records who underwent hip arthroscopy over 12 seasons. Team-based advanced performance statistics including icetime, Corsi, Fenwick, goal, and expected goal percentages were recorded for the preinjury season, index season, and first 2 years after return to play (RTP). Relative percentages of each statistic were collected to allow for intrateam comparisons. A control group of NHL players without injury was collected and matched 1:2 by age, years of play, and draft round.

Results

The RTP rate after hip arthroscopy at the NHL level was 89% for 1 season and 70% for 2 seasons. There were no significant decreases in performance in any advanced statistics after RTP after hip arthroscopy in comparison with the preinjury season or versus a matched control group of uninjured players. There was a significant decrease in games played in the injury season and the first year after RTP versus the preinjury season and versus a matched control group without differences thereafter.

Conclusion

The RTP rate after hip arthroscopy at the NHL level was 89% for 1 season and 70% for 2 seasons. There were no significant decreases in team-based advanced performance statistics after RTP from hip arthroscopy for NHL players versus their preinjury levels or versus a matched control group of uninjured players. This indicates that NHL players who RTP at the NHL level are likely able to return to their previous level of performance, albeit playing in fewer games the first season after surgery.

Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021

BACKGROUND

Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR.

PURPOSE/HYPOTHESIS

The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score <44.

RESULTS

The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score <44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P < .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL <44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07).

CONCLUSION

Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.