Duethman, Nicholas C.

Objectives: Meniscus injuries remain a common source of morbidity in patients over the age of 40. Historically, meniscus injuries in this age group have been treated non-operatively or with surgical management limited to debridement procedures. There is strong evidence for repair over meniscectomy in younger patients, however literature remains sparce regarding repair outcomes and re-operation rates for patients over the age of 40. The objectives of this study were to document patient reported outcomes, complications, and re-operation rates for meniscus repairs in patients above the age of 40 and determine what patient demographics or injury characteristics correlated with reoperation. Methods: A retrospective chart review was conducted at a single academic institution after obtaining IRB approval. An initial query of patients over the age of 40, was performed via the CPT code 29882. Inclusion criteria consisted of patient age greater than 40 at time of initial meniscal repair. Exclusion criteria consisted of prior surgery in the ipsilateral knee, meniscal root repair, septic arthritis postoperatively, and any form of knee trauma postoperatively. Patients that met inclusion criteria were chart reviewed for relevant data including demographic information, comorbidities, surgical procedure information such as type of implant used, laterality of meniscus tear, type of tear and pattern, and revision/re-operation data. Patients were then contacted to answer full 100-point KOOS (Knee Injury and Osteoarthritis Outcome Score) questionnaires. Results: 413 total patients met inclusion criteria. The average age at time of surgery was 46 years (IQR, 43-51), and 214 patients were female (51.8%). KOOS scores were reported at a median follow-up of 24-months (IQR, 3-62). Median symptom, pain, activity of daily living (ADL), sport, and quality of life (QoL) subscales were reported as 78.6 (IQR, 60.7-92.9), 87.5 (IQR, 69.4-97.2), 94.1 (IQR, 82-100), 80.0 (IQR, 55-95), and 68.8 (IQR, 40.6-81.3), respectively. A total of 74 patients underwent reoperation (17.8%). There was no significant difference in reoperation rates when stratified by age group (40-49, 50-59, 60-69) (p=0.515). Reoperation rates were not affected by type of implant used for initial meniscus repair (Fast-fix anchor, Omnispan meniscal anchor, Meniscal cinch implant, Fiberwire, MaxBraid suture, Ethibond suture, PDS suture or Bionics meniscal arrow) (p>0.7). Average number of all-inside anchors used for repair was 2 (IQR, 2-3) and did not correlate with reoperation (p=0.49). Location of initial meniscus tear (body or posterior horn) and tear pattern did not correlate with reoperation rates (p>0.36, p>0.28 respectively). A total of 47 patients complained of postoperative stiffness, of which 28 (6.7%) underwent lysis of adhesions and/or arthroscopic debridement (p=.042). Twenty-five patients sustained a meniscal re-tear or injury, of which 17 underwent reoperation with partial or total meniscectomy. Of the total patient cohort, only seven patients ultimately went on to require ipsilateral total knee arthroplasty (1.6%). Conclusions: Patients over the age of 40 who underwent meniscus repair showed favorable reported outcomes at a mean 2-year follow-up. Reoperation rates were associated with postoperative stiffness and repeat injury. Re-operation rates in patients over 40 are comparable to reported rates of younger patients who undergo meniscus repair.

Objectives: The current literature lacks evidence to guide treatment of isolated lateral meniscus tears in young patients. Accordingly, the purpose of this study was to describe our institutional experience in young patients with lateral meniscus tear with regard to i) treatment trends in meniscectomy and repair ii) long-term patient reported and radiographic outcomes, and iii) failure rates and associated patient and treatment factors. Methods: Patients <26 years of age who underwent surgery for lateral meniscus tears between 2001 and 2017. Patients with ligamentous injury or prior surgeries in the same knee were excluded. Records were reviewed to obtain patient demographics, injury characteristics, surgical details, reoperation rates, repeat imaging, and patient outcome scores. Statistical analysis compared treatment trends over time. Patient reported outcomes (PROs), imaging outcomes, and failure rates were compared by treatment modality. Failure was defined as reoperation, symptomatic osteoarthritis, or IKDC <75. Simple logistic regressions were calculated to predict failure and IKDC based on treatment, type of tear, location of tear, or amount of meniscus removed. Results: 226 knees in 217 patients were identified with average clinical follow-up of 3.2 years. Our cohort consisted of 158 male patients, and average age was 17.4 years (7-25). 138 patients (144 knees) were treated with meniscectomy (partial to complete) (64%) and 79 patients (82 knees) were treated with repair (36%). Repair rates compared to meniscectomy (any degree) increased over time with 63% of lateral meniscus tears from 2013-2017 treated with repair compared to 23% from 2001 -2004 ( P = <.0001). IKDC scores in the meniscectomy group increased from 76.3 ± 9.1 pre-operatively to 97.2 ± 3.9 post-operatively ( P = <.0001) and increased in the repair group from 71.0 ± 11.5 pre-operatively to 97.4 ± 4.1 post-operatively ( P = <.0001).The change in IKDC score was greater in repair (26.0 ± 12.3) than meniscectomy (21.1 ± 9.8) ( P = .002). Reoperation rates in meniscectomy (20%) and repair (20%) were similar ( P = .910). Pre-operative IKDC scores were lower in the repair group ( P = .001), but final IKDC scores were similar ( P = 0.695). Symptomatic OA was noted in 17 patients in the meniscectomy group (22%) and 5 patients in the repair group (11%) ( P = .121). The failure rate was similar between meniscectomy (35%) and repair (28%) ( P = .307). Regression equations evaluating treatment modality, type and location of tear, and amount of meniscus removed did not reach significance in predicting IKDC or failure. Conclusions: In this cohort of young patients with isolated lateral meniscus tears, rate of repair increased over time. IKDC scores improved more in the repair group compared to the meniscectomy patients, however IKDC scores obtained at final follow-up were similar. Rates of symptomatic OA, reoperation, and failure were similar between groups. Treatment modality, type and location of tear, and amount of meniscus removed were not predictive of final IKDC or failure.

Background: Meniscal tears are common in active patients, but treatment trends and surgical outcomes in young patients with lateral meniscal tears are lacking. Purpose: To evaluate treatment trends, outcomes, and failure rates in young patients with lateral meniscal tears. Study Design: Cohort study; Level of evidence, 3. Methods: Patients aged ≤25 years treated surgically for isolated lateral meniscal tears from 2001 to 2017 were identified. Treatment trends were compared over time. International Knee Documentation Committee (IKDC) scores and failure rates were compared by treatment modality (meniscectomy vs meniscal repair). Failure was defined as reoperation, symptomatic osteoarthritis, or a severely abnormal IKDC score. Univariate regression analyses were performed to predict failure and IKDC scores based on treatment, type and location of tear, or extent of meniscectomy. Results: Included were 217 patients (226 knees) with a mean age of 17.4 years (range, 7-25 years); of these patients, 144 knees (64%) were treated with meniscectomy and 82 knees (36%) with meniscal repair. Treatment with repair increased over time compared with meniscectomy ( P < .001). At a minimum 2-year follow-up (mean, 6.1 ± 3.9 years), 107 patients (110 knees) had IKDC scores, and analysis indicated that although scores in both groups improved from pre- to postoperatively (repair: from 69.5 ± 13.3 to 97.4 ± 4.3; meniscectomy: from 75.7 ± 9.0 to 97.3 ± 3.9; P < .001 for both), improvement in IKDC score was greater after repair (27.9 ± 13.9) versus meniscectomy (21.6 ± 9.4) ( P = .005). Included in the failure analysis were 184 patients (192 knees) at a mean follow-up of 8.4 ± 4.4 years. The rates of reoperation, symptomatic osteoarthritis, and failure were not significantly different between the meniscectomy and repair groups. Conclusion: An increase was seen in the rate of isolated lateral meniscal tear repair in young patients. IKDC score improvement was greater after repair than meniscectomy, although postoperative IKDC scores were similar. Symptomatic arthritis, reoperation, and failure rates were similar between groups; however, there was a trend for increased arthritis symptoms in patients treated with meniscectomy, especially total meniscectomy. Treatment modality, type and location of tear, and amount of meniscus removed were not predictive of final IKDC scores or failure.

Purpose To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long‐term outcomes of nonoperative treatment after the index traumatic anterior instability event. Methods The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long‐term outcomes (recurrence rate, pain at last follow‐up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan‐Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. Results A total of 379 patients met the study criteria, with an average follow‐up period of 10.2 years (range, 0.53‐25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow‐up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow‐up (HR, 4.21; P < .001). Conclusions Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. Level of Evidence Level III, retrospective database review.

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.

Background: There is limited literature regarding the treatment of concomitant scapholunate ligament (SL) injuries in acute distal radius fractures (DRFs). We hypothesized that surgical treatment of SL injuries in adult patients with DRFs leads to improved functional outcomes. Methods: A retrospective review was made of 42 adult patients who underwent surgical treatment of a DRF with a SL injury between 2005 and 2013. In all, 39 of the 42 patients sustained an intra-articular DRF (AO B or C). SL injury was diagnosed by SL diastasis > 3 mm on posteroanterior (PA) radiographs, magnetic resonance imaging, or with wrist arthroscopy. Patients were divided into 3 groups: 23 had a SL repair and were treated within 21 days of injury (acute), 8 underwent SL repair greater than 21 days from injury (subacute/chronic), and 11 did not undergo repair (non-operative). Median overall time to clinical follow-up was 5.1 years. Mayo Wrist Scores (MWS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were used to evaluate functional outcome. Results: Clinical outcomes measured by the MWS at final follow-up (6 months-12 years) showed no significant differences between the 3 groups. Of patients treated acutely, 17.3% had good to excellent MWS. MWS at 1-year follow-up was 68.4, 70, and 64 in the acute, subacute/chronic, and non-operative groups, respectively. DASH scores were 16.7, 14.3, and 11.8 in the acute, subacute/chronic, and nonoperative groups, respectively, at a mean of 7.8 years. Conclusions: At mid-term follow-up, all 3 treatment groups had similar DASH scores to the general population. There were no statistical functional differences between any of the groups based upon MWS or DASH scores.