Krych, Aaron J.

Objectives: Nonoperative management vs. early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehab, platelet rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. Thus, the purpose of this study was to compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for baseball pitchers with partial tears of the MUCL. Methods: A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated pitchers undergoing nonoperative management with and without PRP vs. early UCLR for partial MUCL tears. Utility values, RTP rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, acquired playing-years (PYs), and the incremental cost-effectiveness ratio (ICER). Results: Mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5,395/PY, which falls well below the $50,000 willingness-to-pay threshold (WTP). Overall, early UCLR was determined the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. Conclusions: Based on Monte Carlo microsimulation and probabilistic sensitivity analysis, early UCLR was demonstrated to be more cost-effective than an initial trial of nonoperative management for partial tears of the MUCL for the majority of high-level baseball pitchers. It is important to note that this model does not consider the unique experiences, goals, situations, career trajectory, and pitching horizons of individual patients, and thus a shared decision-making discussion should be conducted regarding optimal initial treatment for partial MUCL tears. This is particularly true as many athletes can successfully be treated non-operatively, which generally results in a quicker return to play when successful compared to surgery.

Objectives: Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability (SI). However, there is a paucity of data evaluating the results of shoulder instability surgery (SIS) in this cohort of athletes. The purpose of this study is to assess reoperation rates, patient-reported outcomes (PRO), and return to wrestling (RTW) following SIS in a cohort of competitive wrestlers. Methods: All competitive wrestlers with a history of SI and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of SI (anterior SI [ASI], posterior SI [PSI], and traumatic multidirectional SI [TMDI]) were analyzed. Exclusion criteria included revision SIS and less than 2 years of clinical follow-up. Patients were contacted for determination of reinjury rates, return to wrestling (RTW), and Western Ontario Shoulder Instability index (WOSI) scores. Results: Ultimately, 104 wrestlers were included at a mean follow-up of 5.2 years (range, 2.0 – 22.0). Fifty-eight (55.8%) wrestlers presented for evaluation after a single SI event while 46 (44.2%) sustained multiple events prior to presentation. ASI was the most common direction (n = 79; 76.0%) followed by PSI (n = 14; 13.4%), and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), followed by an open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) (Table 1). RTW occurred in 57.3% of wrestlers at a mean of 9.8 ± 9.6 months. Recurrent instability was the most common complication in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.6%) wrestlers (Table 2). Across the entire cohort, Kaplan-Meier survivorship free from recurrent instability (Figure 1) and revision surgery (Figure 2) was 91.4% and 98.1% at 1 year, 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Pre-operative recurrent instability was an independent risk factor for post-operative recurrent instability (Hazard ratio [HR], 3.8; 95% confidence interval [CI], 1.33 – 11.03; P = .012). Conclusions: Anterior shoulder instability was the most common direction among competitive wrestlers presenting for SIS. Wrestlers with multiple dislocations prior to initial clinical presentation were 3.8 times more likely to experience post-operative recurrent instability.

Objectives: A DFO can be performed via two techniques: a lateral opening wedge (LOW) osteotomy and a medial closing wedge (MCW) osteotomy. Small case series have looked at how leg length is affected by a lateral opening wedge DFO, however, there is a lack of research comparing these leg length changes to medial closing DFO. Additionally, no studies have presented a model for predicting the leg length changes that will occur following DFO of either technique. Given that limb length differences can lead to accelerated osteoarthritis, back pain, hip pain, and other issues, being able to predict which technique can help prevent this pathology without a secondary procedure would be an important finding. Finally, the medial closing wedge osteotomy can allow for immediate weight-bearing while the lateral opening wedge does not and typically has associated cost with bone grafting. Therefore, we designed this study to validate a tool designed to predict leg length changes after distal femoral osteotomy (DFO) and compare changes following medial closing wedge (MCW) and lateral opening wedge (LOW) techniques. Methods: A collaborative retrospective review was performed of patients from Rush and Mayo Clinic databases who received a DFO and had full-length standing radiographs both pre-and postoperatively. For each preoperative radiograph, the region on the medial (for LOW) or lateral (for MCW) distal femur cortex that would be the “hinge point” during DFO was identified. The distances from the center of the femoral head to the hinge point (“A”), from the hinge point to the center of the tibial plafond (“B”), and the resultant angle at the hinge point (“α”) were measured (Figure 1). Figure 2 demonstrates the equation used to plot a graph of the predicted leg length changes corresponding to the change in α angle produced by DFO. Final leg length was calculated on postoperative radiographs, and the difference between predicted and true leg length changes was compared using paired Wilcoxon signed rank exact tests. Results: 10 MCW and 10 LOW patients were included. For both LOW (n=10) and MCW (n=10) osteotomies, the predicted leg length change was equivalent to the true change measured on postoperative radiographs (LOW P=0.16; MCW P=0.85). LOW DFO’s had 5.10 ± 2.77 mm (range: 1.45-10.87 mm) of leg lengthening, compared to 2.61 ± 1.25 mm (range: 0.50-4.56 mm) of leg shortening (p<0.001) for MCW (Figure 3). On average, there was 0.85 mm of lengthening (range 0.5-1.3 mm) for every 1° of mechanical axis correction with LOW DFO, compared to 0.45 mm of shortening (range: 0.1-1.4 mm) per 1° of MCW correction. Conclusions: This study presents a tool to accurately and reliably predict the leg length changes seen after both medial closing and lateral opening wedge DFO’s. Knowing what leg length changes to expect with each DFO technique is a useful tool that surgeons can utilize during surgical planning. Preoperative radiographic imaging can be used to predict leg length change following DFO with high reliability and accuracy. Surgeons can expect approximately 0.85mm of lengthening per 1° of DFO correction when performing LOW, compared to 0.45mm of shortening per 1° correction for MCW osteotomies.

Objectives: Hip arthroscopy is rapidly advancing, with literature increasingly reporting positive outcomes at short- and mid-term follow-up; however, available long-term data remains limited. The purpose of this study is to evaluate long-term outcomes of primary hip arthroscopy at minimum 10-year follow-up at two academic centers by describing patient-reported outcomes (PROs) and determining reoperation, revision, and total hip arthroplasty (THA) rates. Methods: Primary hip arthroscopies performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative PROs including Visual Analogue Scale (VAS), Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Scale (HOS-ADL/HOS-SS), modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), 12-item International Hip Outcome Tool (iHOT-12), surgery satisfaction, function, and reoperations. Results: Two-hundred ninety-four primary hip arthroscopies with a mean age of 40±14 years; 66% female; and a mean body mass index (BMI) of 27±6 kg/m 2 were followed for mean 12±3 years (range: 10-24). Labral debridement and repair were performed in 41% and 59% of patients, respectively. All patients underwent interportal capsulotomy and 2% underwent T-capsulotomy. Eleven percent of patients underwent capsular repair. At final follow-up, patients reported mean VAS at rest of 2±2, with use of 3±3, iHOT-12 of 68±27, NAHS of 81±18, mHHS of 79±17, HOS-ADL of 82±19, and HOS-SS of 74±25. Mean surgical satisfaction was 8.4±2.4 (Table 1). Sixty-five hips (23%) underwent THA and 33 (11%) underwent revision arthroscopy (Table 2). Risk factors for THA included older age (p<0.001), higher BMI (p<0.001), lower lateral center-edge angle (p=0.039), larger alpha angle (p=0.001), higher Tönnis grade (p=0.011), labral debridement (p=0.004), and capsular nonrepair (p=0.030). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared to 31% for patients undergoing combined labral debridement and capsular nonrepair (p=0.006) (Table 3). Labral repair trended towards increased 10-year THA-free survival (84% vs. 77%, p=0.085) while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%, p=0.032) (Figure 1). Conclusions: At minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high rates of satisfaction and acceptable outcome scores. In total, 11% of patients underwent revision hip arthroscopic surgery with a THA conversion rate of 23%. Conversion to THA was associated with patient factors including older age and higher Tönnis grade as well as potentially modifiable surgical factors including labral debridement and capsular nonrepair.

Objectives: Meniscal allograft transplantation (MAT) is an accepted and effective treatment option in the context of unsalvageable menisci, particularly in young and active patients. It has been shown to reduce pain and improve knee function in previously symptomatic patients. However, there is still limited knowledge about the long-term survival rates of allografts, the durability of clinical results, and the influence of patient-specific parameters, such as leg alignment, tibial slope, and preoperative International Cartilage Regeneration & Joint Preservation Society (ICRS) grade. The purpose of this study was to determine (1) the long-term clinical success rate after MAT with bony fixation in a large, single-center cohort of consecutive patients, and (2) if patient-specific and procedural variables influence the clinical, anatomic, and subjective outcomes and risk of failure. Methods: Data on 185 consecutive knees undergoing MAT in a single institution were prospectively collected and screened for inclusion in this study. The minimum follow-up time was 2 years. Radiographic variables (International Cartilage Regeneration & Joint Preservation Society [ICRS] grade and Kellgren and Lawrence grade) were assessed preoperatively and at follow-up. Subjective patient-reported outcome measures (PROMs), Lysholm score, Knee Disability and Osteoarthritis Outcome Score (KOOS) including subscores, International Knee Documentation Committee (IKDC) score, and visual analog score (VAS) were collected preoperatively and at follow-up. Clinical failure was defined as revision surgery due to graft failure or conversion to total knee arthroplasty (TKA). Anatomic failure was considered a tear covering >20% of the allograft, any peripheral tear, and unstable peripheral fixation leading to dislocation of the graft. Subjective failure was defined as Lysholm score ≤65. Preoperative tibial slope and leg alignment were assessed. Survival analyses were performed utilizing the Kaplan-Meier estimate. Univariate and multivariate analyses were performed to determine risk factors for clinical and anatomic failure. Results: A total of 157 knees met inclusion criteria (Table 1). After a mean follow-up time of 7 ± 3.5 years, 127 (80.9%) knees were free of clinical, anatomic, and subjective failure. Fourteen (8.9%) knees experienced clinical failure, 26 (16.6%) knees were identified as anatomic failure, and 13 patients (8.3%) suffered from subjective failure with a reported Lysholm score of ≤65 at a mean follow-up of 7 years. Concurrent osteochondral allograft transplantation was identified as a predictor of both clinical (HR 4.55; 95% CI 1.46-14.17; p=0.009) and anatomic failure (HR 3.05; 95% CI 1.34-6.92; p=0.008). Cartilage damage of ICRS grade 3 or 4 of the index compartment conveyed an increased risk for clinical (HR 3.41; 95% CI 1.05-11.01; p=0.04) and anatomic failure (HR 3.04; 95% CI 1.31-7.11; p=0.01) (Table 2). There were no differences in outcomes between medial and lateral MAT. High-grade cartilage damage (defined as ICRS grades 3 and 4) preoperatively (HR 10.67; 95% CI 1.037-109.768; p=0.046), patients age over 25 (HR 5.44; 95% CI 0.120-246.070; p=0.384), and a body mass index >30 (HR 2.24; 95% CI 0.748-6.705; p=0.149) were associated with subjective failure. Considering the entire study population, PROMs including KOOS and IKDC were significantly improved at final follow-up compared to preoperative scores across all measurements (p<0.005). Conclusions: MAT showed good-to-excellent clinical results at a mean follow-up of 7 years. Low ICRS lesion grade was associated with a higher clinical and anatomic survival rate. Patients with concurrent osteochondral allograft transplantation are at higher risk of clinical and anatomic failure, but still report significantly improved PROMs. These results suggest MAT has a lasting beneficial effect both as in isolation and in complex cases with one or more concurrent procedures.

Abstract Unstable osteochondritis dissecans lesions of the medial femoral condyle have classically been treated with open reduction and fixation under direct visualization through an open arthrotomy. Given the value of avoiding open arthrotomies, we present an arthroscopic approach for lesion elevation, debridement, and fixation. The lesion is first elevated using an arthroscopic elevator, leaving a laterally based osseous hinge. Once elevated, fibrous debris is debrided from the base of the lesion. Subsequently, the fragment is reduced, and percutaneous transpatellar instrumentation is used for fixation. The use of this technique allows for excellent mobilization, debridement, and fixation of the osteochondritis dissecans lesion while minimizing violation of periarticular soft tissues. Technique Video video See video under supplementary data.

Purpose To determine the relationship between cam morphology of the hip and ipsilateral sacroiliac motion compared to the native hip in a cadaveric model. Methods A simulated cam state was created using a 3‐dimensional printed cam secured to the head‐neck junction of 5 cadaveric hips. Hips were studied using a computed tomography–based optic metrology system and a 6 degree‐of‐freedom robot to exert an internal rotation torque at 3 different torque levels (6 N‐m, 12 N‐m, 18 N‐m). Outcomes included translational and rotational movement about 3 axes and composite (total) translational motion at the ipsilateral sacroiliac (SI) joint. Statistical analysis included a linear mixed model regression with repeated measures. Results The presence of a simulated cam was associated with medial motion in the coronal plane ( P = .03) and posterior motion in the sagittal plane ( P < .01) but not composite motion ( P = .37). Motion in the axial plane was in an inferior direction ( P = .08). Cam morphology significantly changed rotation in the sagittal plane ( P < .01) but not in the coronal ( P = .63) or axial plane ( P = .18). Composite motion was related to the amount of torque applied to the hip ( P < .01). The amount of torque applied to the hip was related to rotation in the coronal plane ( P < .01), axial plane ( P < .01), and sagittal plane ( P < .01) with increased effects as torque increased. Torque was not associated with translation movement in any of the anatomic planes. Conclusions The presence of simulated cam morphology is associated with motion in a more medial, inferior, and posterior direction at the ipsilateral SI joint relative to a native state. Increasing torque affects the magnitude of translation, but not its direction, which in this study is primarily influenced by cam morphology. Clinical Relevance This biomechanical connection between cam‐type femoroacetabular impingement syndrome and the ipsilateral SI joint provides insight into SI joint dysfunction in patients with femoroacetabular impingement syndrome.

Purpose To report the rate of anterior cruciate ligament (ACL) graft failure by physis status (open, closing, closed) and to analyze which factors were associated with higher risk of ACL graft failure. Methods Patients younger than 18 years who underwent transphyseal ACL reconstruction (ACLR) between 2000 and 2018 at a single institution were reviewed at minimum 2 years after ACLR. Patient records were reviewed for anthropometrics, surgical techniques, and ACL graft failure. Patients were subsequently stratified based on physis status (open, closing, closed) and analyzed. Results A total of 272 patients (mean age of 15.4 ± 1.3 years) were assessed. The transtibial technique was used in 63.6% of cases. A hamstring autograft was used exclusively in the open physis group. A patellar tendon autograft was used in 65.9% of patients with a closing physis and 80.9% of patients with a closed physis. The overall graft failure rate was 13.2%, with a contralateral ACL injury rate of 11.0%. Kaplan‐Maier analysis by physis status showed different injury free from ACL reinjury ( P < .001). An open physis was associated with increased risk of ACL reinjury (hazard ratio, 5.2; P < .001) when compared to a closed physis. A closing physis presented a higher hazard ratio but was not statistically significant (hazard ratio, 2.6; P = .08). Hamstring graft type ( P = .03) and lower graft diameter ( P = .04) were significantly related to higher ACL reinjury after adjusting for physis status. Conclusions Transphyseal ACLR is a safe procedure in pediatric patients. The rate of reinjury was 13.2%. This rate decreases with skeletal maturity, use of patellar tendon autograft, and a larger graft diameter. Level of Evidence Level III, retrospective cohort study.

Cartilage injuries can present in a diverse setting of anatomic locations, with varying severity, and can impact athletes of all ages and competition levels. Moreover, the timing of when an injury presents introduces an additional dimension to treatment decision-making. Frequently, the level of competition, in conjunction with career trajectory and short-term and long-term athlete goals, will dictate whether a temporary or definitive treatment strategy is ideal. Although indicating the correct therapeutic regimen may prove challenging, understanding the athlete-specific considerations can be essential to meeting the goals of the athlete and other stakeholders involved in the athlete’s career. The purpose of this review is to comprehensively present the deliberations a treating physician must consider in managing cartilage injuries within a spectrum of athletic levels ranging from youth to professional levels, with a secondary focus on the presentation of temporizing treatment strategies and associated outcomes.

Background: Nonoperative management versus early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehabilitation, platelet-rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. Purpose: To compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for young, high-level baseball pitchers with partial tears of the MUCL and with aspirations to continue play at the next level (ie, collegiate and/or professional). Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 young, high-level, simulated pitchers undergoing nonoperative management with and without PRP versus early UCLR for partial MUCL tears. Utility values, return to play rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors’ institution. Outcome measures included costs, acquired playing years (PYs), and the incremental cost-effectiveness ratio (ICER). Results: The mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5395/PY, which falls well below the $50,000 willingness-to-pay threshold. Overall, early UCLR was determined to be the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined to be the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. Conclusion: Despite increased upfront costs, UCLR is a more cost-effective treatment option for partial tears of the MUCL than an initial trial of nonoperative management for most high-level baseball pitchers.