Leland, Devin P.

Purpose To report the annual incidence of anterior shoulder instability (ASI) diagnosis, injury severity, and surgical stabilization in a U.S. population. Methods An established U.S. geographic database was used to identify patients < 40 years old with diagnoses of ASI from 1994‐2016. Medical records were reviewed to obtain patient demographics, histories, imaging results, and surgical details. Age‐ and sex‐specific incidence rates were calculated and adjusted to the 2010 U.S. population. Poisson regression was performed to examine trends by timeline, sex and age. Results The study population consisted of 652 patients with ASI and a mean age of 21.5 years (range, 3.6‐39.5). Comparing 2015‐2016 to 1994‐1999, we found an increase in the number of dislocations (from 1.0‐1.9; P = 0.016) and total instability events (from 2.3‐3.4; P = 0.041) per patient prior to presentation to a physician. There was a trend in increased diagnosis of bony Bankart and/or Hill‐Sachs on MRI over time, with these lesions documented in 96% of patients undergoing MRI in 2015‐2018 compared to 52.9% in 1994‐1999 ( P < .001). The use of arthroscopic procedures increased and peaked in 2005‐2009 (90% of surgical cases performed). The proportion of open Latarjet procedures increased from 2010‐2014 (14%) and 2015‐2018 (31%). Conclusions The age‐ and sex‐ adjusted incidence of ASI diagnosis in a U.S. population from 1994‐2016 is comparable to that demonstrated in Canadian and European populations. This study demonstrates an increasing number of instability events prior to surgical evaluation, which may correlate with patients’ more commonly presenting with bone loss and requiring more aggressive surgical treatment or that ASI is being more frequently cared for and documented by present‐day orthopedic surgeons. Level of Evidence Level III, cross‐sectional study.

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.

Background: The rate of osteoarthritis (OA) in patients with a history of previous anterior shoulder instability (ASI) varies within the literature, with the majority of studies investigating rates after surgical stabilization. ASI appears to lead to increased rates of OA, although risk factors for developing OA in cohorts treated nonoperatively and operatively are not well-defined. Purpose: To determine the incidence of clinically symptomatic OA and identify potential risk factors for the development of OA in patients younger than 40 years with a known history of ASI. Study Design: Case-control study; Level of evidence, 3. Methods: An established, geographically based database was used to identify patients in the United States who were younger than 40 years and were diagnosed with ASI between 1994 and 2014. Patient information, including demographic, imaging, and surgical details, was collected. Comparative analysis was performed between groups with and without OA at final follow-up as well as between patients who underwent surgical and nonsurgical management. Results: The study population consisted of 154 patients with a mean follow-up of 15.2 years (range, 5.1-29.8 years). The mean age at initial instability event was 20.9 years (95% CI, 19.9-22.0 years). Overall, 22.7% of patients developed clinically symptomatic glenohumeral OA. Multivariate analysis revealed that current or former smokers (odds ratio [OR], 4.3; 95% CI, 1.1-16.5; P = .030), hyperlaxity (OR, 10.1; 95% CI, 1.4-72.4; P = .020), laborer occupation (OR, 6.1; 95% CI, 1.02-36.1; P = .043), body mass index (BMI) (OR, 1.2; 95% CI, 1.03-1.3; P = .012), and age at initial instability (OR, 1.1; 95% CI, 1.02-1.2; P = .013) as potential independent risk factors when accounting for other demographic and clinical variables. Conclusion: In a US geographic population of patients younger than 40 years with ASI, approximately one-fourth of patients developed symptomatic OA at a mean follow-up of 15 years from their first instability event. When accounting for differences in patient demographic and clinical data, we noted a potentially increased risk for the development of OA in patients who are current or former smokers, have hyperlaxity, are laborers, have higher BMI, and have increased age at initial instability event. Smoking status, occupation, and BMI are modifiable factors that could potentially decrease risk for the development of symptomatic OA in these patients.

Purpose To compare the (1) rates of complications and reoperations, (2) rate of anterior cruciate ligament (ACL) graft failure, and (3) patient‐reported outcomes (PROs) among patients after hamstring autograft ACL reconstruction (ACLR) with and without independent suture tape reinforcement at a minimum 2‐year clinical follow‐up. Methods We performed a 1:2 matched‐cohort comparison of patients who underwent hamstring autograft ACLR with and without independent suture tape reinforcement between July 2011 and July 2017. Patients were matched according to age, sex, body mass index, preinjury Tegner activity score, and concomitant meniscal injury. Medical records were reviewed for demographic characteristics, additional injuries, and concomitant procedures. PRO scores (including Tegner activity, Lysholm, and International Knee Documentation Committee scores) and physical examination findings were collected both preoperatively and at a minimum of 2 years postoperatively. Results Overall, 108 patients who underwent ACLR were included: 36 patients (mean age, 25.3 years; range, 13‐44 years) with independent suture tape reinforcement and 72 patients (mean age, 24.9 years; range, 13‐54 years) without suture tape reinforcement. Overall, 5 of 36 suture tape patients (14%) and 10 of 72 control patients (14%) underwent reoperations. At an average follow‐up of 26.1 months in the suture tape cohort and 31.3 months in the control cohort, 1 patient in the suture tape cohort and 4 patients in the control cohort experienced graft failure. There were no statistically significant differences between the suture tape and control groups regarding return‐to‐sport rate (89% and 88%, respectively), postoperative International Knee Documentation Committee score (94.4 and 93.8, respectively), and postoperative Lysholm score (95.6 and 94, respectively). There was a statistically significant difference between the suture tape and control groups in postoperative Tegner activity score, at 7.1 (95% confidence interval, 6.5‐7.6) and 6.4 (95% confidence interval, 6.2‐6.6), respectively ( P = .026). Conclusions ACLR with hamstring autograft and independent suture tape reinforcement was performed safely with low rates of complications, graft failure, and reoperations with similar PROs, function, and return‐to‐sport rates when compared with hamstring autograft ACLR without suture tape reinforcement at a minimum 2‐year follow‐up. Level of Evidence Level III, retrospective comparative study.

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.

Objectives: There remains a paucity of data describing the efficacy of non-operative treatment following an index anterior instability event. The purpose of this study was to describe the long-term outcomes of non-operative treatment following index anterior instability event, define the success rate of initial non-operative treatment for anterior shoulder instability, and describe factors that predict conversion to surgery after initial non-operative management to help guide surgical decision making in these patients. Methods: An established geographic database was utilized to identify patients under the age of 40 treated for anterior shoulder instability between 1994 and 2016. Patient demographics, comorbidities, injury characteristics, instability history, activity level, x-rays, advanced imaging, treatment course, and outcomes were evaluated. Patients treated non-operatively for the first 6 months following index instability event were analyzed to determine long-term outcomes, success rate of continued non-operative treatment, and factors associated with conversion to surgery. Results: 739 patients met criteria with an average follow-up of 190 months (range 0.13 to 490 months). Average age was 23.8, mean BMI was 25.6, 9.1% had a history of hyperlaxity, and 83.9% of instability events were due to trauma. 29.7% of patients had a Hill-Sachs lesion on index x-ray, and 6.3% had a bony Bankart. 198 shoulders went on to operative treatment (26.8%) with a mean time to surgery of 62.7 months following initial instability event. At final follow-up, 24.0% reported mild pain, 6.2% as moderate, 0.2% as severe. 13.8% of patients had evidence of glenohumeral arthritis on final follow-up x-rays compared to 1.6% on initial radiographs. Factors associated with conversion to surgery included 2 or more dislocations prior to first clinical evaluation (OR=1.75, p<0.001), labor intense occupation (OR=1.49, p=0.031), Hill Sachs lesion on index x-ray (OR=1.31, p=0.034), and MRI findings including: anteroinferior labral tear (OR=2.15, p<0.001), posteroinferior labral tear (OR=1.38, p=0.049), SLAP tear (OR=1.29, p=0.054), Hill-Sachs lesion (OR=1.85, p<0.001), and glenohumeral cartilage injury (OR=1.26, p=0.041). Conclusion: The majority of patients less than 40 can be definitively treated non-operatively after an initial 6 month episode of non-operative treatment. A small proportion will report pain over the long-term and/or develop glenohumeral arthritis. Multiple factors upon initial evaluation were associated with future conversion to surgery including: increasing number of prior instability events, occupation, and degree of soft tissue injury on MRI.

Objectives: The rate of osteoarthritis (OA) in patients with anterior shoulder instability (ASI) varies within the literature, with the majority of studies investigating rates after surgical stabilization. ASI appears to lead to increased rates of OA, although risk factors for developing OA in non-operative and operative cohorts are not well defined. The purpose of this study was to determine the incidence of clinically symptomatic OA and identify potential risk factors for the development of OA following ASI in a U.S. geographic population of patients under the age of 40. Methods: An established geographic database was used to identify patients less than 40 years old diagnosed with anterior should instability between 1994 and 2016. Patient information, including demographics, imaging and surgical details, was collected and comparative analysis was performed between groups with and without OA at final follow-up, as well as patients who underwent surgical and non-surgical management. Results: The study population consisted of 154 patients with a mean follow-up of 15.2 years (range 5.1-29.8). Overall, 22.7% of patients developed clinically symptomatic glenohumeral OA. Twenty-eight percent of patients who underwent at least 1 surgical intervention and 17% of patients who underwent non-operative management of anterior shoulder instability developed glenohumeral OA (p=0.176). Patients who developed arthritis were older at initial instability event (p=0.002) and had higher BMI (p=0.007). Additionally, patients with OA were more likely to be current or former smokers (p=0.004), have a seizure disorder (p=0.033), and be manual laborers (p=0.044). Risk factors for developing OA included seizure disorders (RR 2.61, 95 % CI 1.34-5.07), cartilage injury on initial MRI (RR 2.48, (1.00-6.13), current or former smoker (RR 2.46, 95% CI 1.37-4.42), laborer occupation (RR 2.14, 95% CI 1.14-4.01), and age at initial instability event (OR 1.09 per year, 95% 1.03-1.17). Athletes (RR 0.51, 95% CI 1.08-3.54), specifically contact athletes at the time of initial instability (RR 0.45, 95% CI 0.21-0.97), were less likely to develop OA. There was no difference in the number of dislocations or number of instability events in patients with and without symptomatic osteoarthritis. Conclusions: In a U.S. geographic population of patients less than 40 years old with ASI, approximately one-fourth of patients developed symptomatic OA at a mean follow-up of 15 years from their first instability event. When accounting for differences in patient demographics, there was no significant difference in the rates of OA in patients who underwent surgical and non-surgical management. Overall, there was an increased risk for the development of OA in patients with seizure disorders, cartilage injury on initial MRI, current or former smokers, laborer occupation and increased age at the initial instability event.

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.

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.

Purpose To systematically evaluate the outcomes and complications of osteochondral autograft transfer (OAT) and osteochondral allograft transplantation (OCA) for the surgical treatment of capitellar osteochondritis dissecans (OCD). Methods A literature search was conducted across 3 databases (PubMed, Cochrane, and CINAHL [Cumulative Index to Nursing and Allied Health Literature]) from database inception through December 2019 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) guidelines. Individual study quality was assessed using the Methodological Index for Non‐randomized Studies scale. Studies were published between 2005 and 2019. Results Eighteen studies consisting of 446 elbow OCD lesions treated with OAT surgery were included. There was a single OCA study eligible for inclusion. Patient ages ranged from 10 to 45 years. Of the OAT studies, 4 used autologous costal grafts whereas the remainder used autografts from the knee. Outcome measures were heterogeneously reported. A significant improvement in Timmerman‐Andrews scores from preoperatively to postoperatively was reported in 9 of 10 studies. Return‐to‐play rates to the preinjury level of competitive play ranged from 62% to 100% across 16 studies. Significant improvement in motion, most often extension, was noted in most studies. Reported complication, reoperation, and failure rates ranged from 0% to 11%, 0% to 26%, and 0% to 20%, respectively. When used, knee autografts resulted in low donor‐site morbidity (Lysholm scores, 70‐100). Conclusions OAT surgery for large, unstable OCD lesions of the capitellum reliably produced good outcomes, few complications, and a high rate of return to competitive play. Complications are relatively uncommon, and donor‐site morbidity is low. Less is known about the performance of OCA given the paucity of available literature. Level of Evidence Level IV, systematic review of Level II to IV studies.