Kruckeberg, Bradley M.

Case: A 21-year-old woman with a surgical history of 2 prior right hip surgeries presented with ongoing right hip pain. Radiographic findings demonstrated a labral tear, osteoarthritic changes, and cam over-resection. Arthroscopic iliotibial band autograft labral reconstruction and bony remplissage of the femoral defect using a greater trochanter autograft were performed. Conclusion: Arthroscopic bony hip remplissage is a viable treatment option for young patients who present after failed hip arthroscopy with cam over-resection.

Abstract Introduction Labral reconstruction has seen an increase in utilization over the last decade. As a result of the increasing number of labral reconstructions being performed, there has been a subsequent increase in the number of failed labral reconstructions requiring revision. The purpose of the present study was to report the short-term survivorship and outcomes of patients who underwent segmental acetabular labral reconstruction in the setting of a failed prior labral reconstruction. Methods A retrospective review of all labral reconstructions performed by the senior author between 01/01/2010-04/01/2022 was conducted. Patients who underwent a labral reconstruction and were over 18 at the time of surgery were included. Patients with a history of avascular necrosis, Legg-Calvé-Perthes, or with a lateral center edge angle < 18° were excluded. Demographics, radiographic parameters, and patient reported outcomes (PROs) were collected. Patients who underwent a labral reconstruction in the setting of a prior failed labral reconstruction (Group B) were matched in a 1:1 fashion to patients in a control group who underwent only one labral reconstruction (Group A) by age, sex, LCEA, minimum joint space, and the presence of an Outerbridge Grade 3 or 4 defect. Results A total of 24 hips (23 patients) were included in Group B. Mean age at the time of surgery was 36 ± 13 years, and most hips were female (n=14, 58%). Twenty-two (92%) of the hips met a study endpoint, with 3 (14%) converting to total hip arthroplasty (THA) and 3 (14%) undergoing a subsequent hip-preserving surgery. The remaining 16 hips reported 2-year minimum PROs and had a median patient satisfaction of 9.5 (Range: 6-10). Additionally, they demonstrated significant improvement from baseline in SF-12 PCS (p=0.004), WOMAC Total (p<0.001), mHHS (p=0.004), HOS-ADL (p=0.002), and HOS-Sport (p=0.002). Notably, patients in Group B demonstrated similar improvement in PROs from baseline compared to the matched-control group (Group A). Conclusion Patients who undergo revision labral reconstruction in the setting of a failed prior labral reconstruction demonstrate significant improvement in PROs post-operatively compared to baseline at a rate similar to patients who underwent only one labral reconstruction.

Abstract Anterior shoulder instability is a common cause of shoulder pain and dysfunction in young patients and may be associated with concomitant bony and soft tissue pathology. Humeral avulsion of the glenohumeral ligament (HAGL) and rotator cuff tears are often seen in the setting of traumatic anterior shoulder instability events, especially in patients over 40 years of age, and portend poor postoperative outcomes if not addressed appropriately. While arthroscopic repair of rotator cuff tears is standard of care, both arthroscopic and open approaches for HAGL repair have been described and are associated with good clinical outcomes. Open HAGL repair affords the ability to address additional pathologies, including subscapularis tears and biceps tendon tears/SLAP tears with open subpectoral tenodesis, with direct visualization of the tear, while affording protection of the neurovascular structures. In this Technical Note, the authors describe their preferred technique for combined arthroscopic rotator cuff tear and open HAGL repair. Technique Video video See video under supplementary data.

Background: The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted by lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring the MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair; however, long-term comparative studies are limited. Purpose: To compare long-term clinical outcomes, complications, and recurrence rates of isolated MPFL reconstruction and MPFL repair for recurrent lateral patellar instability. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 55 patients (n = 58 knees) with recurrent lateral patellar instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. The exclusion criteria were previous or concomitant tibial tubercle osteotomy or trochleoplasty and follow-up of <8 years. Pre- and postoperative descriptive, surgical, imaging, and clinical data were recorded for each patient. Results: MPFL repair was performed on 26 patients (n = 29 knees; 14 women, 15 men), with a mean age of 18.4 years. MPFL reconstruction was performed on 29 patients (n = 29 knees; 18 women, 11 men), with a mean age of 18.2 years. At a mean follow-up of 12 years (range, 8.3-18.9 years), the reconstruction group had a significantly lower rate of recurrent dislocation compared with the repair group (14% vs 41%; P = .019). There were no differences in the number of preoperative dislocations or tibial tubercle–trochlear groove distance. The reconstruction group had significantly more time from initial injury to surgery compared with the repair group (median, 1460 days vs 627 days; P = .007). There were no differences in postoperative Tegner, Lysholm, or Kujala scores at the final follow-up. In addition, no statistically significant differences were detected in return to sport (RTS) rates (repair [81%] vs reconstruction [75%]; P = .610) or reoperation rates for recurrent instability (repair [21%] vs reconstruction [7%]; P = .13). Conclusion: MPFL repair resulted in a nearly 3-fold higher rate of recurrent patellar dislocation (41% vs 14%) at the long-term follow-up compared with MPFL reconstruction. Given this disparate rate, the authors recommend MPFL reconstruction over repair because of the lower failure rate and similar, if not superior, clinical outcomes and RTS.

Purpose The purposes of this study were to determine the incidence and key characteristics of meniscus injuries in professional baseball players, assess current treatment strategies, determine the return to play rates at any level (RTP) and at the same level (RSL), and identify prognostic factors that predict injury severity. Methods After approval from the Major League Baseball (MLB) Research Committee and our institutional review board, the MLB Health and Injury Tracking System was used to identify meniscus injuries occurring across MLB and Minor League Baseball (MiLB) from 2011 to 2017. Analyzed injuries occurred during normal baseball activity in a player who was active on an MLB or MiLB roster and resulted in at least 1 day missed. Results A total of 293 professional baseball players sustained 314 meniscus injuries from 2011 to 2017 (7 years) for a mean of 44.9 injuries/y. Pitchers were the most injured position (31.8%), followed by infielders (26.4%). Catchers and infielders missed the most median number of days (50 days). When comparing injuries to landing leg vs push‐off leg in pitchers, injury to the push‐off leg resulted in significantly more days missed per injury compared to the lead leg (59.6 vs 39.9 days, P = .048). Overall, RTP was 93.0%, while RSL was 84.4%. Conclusions Over 7 professional baseball seasons, 314 meniscus injuries occurred in 293 players. Pitchers and catchers were most injured, and overall, the number of meniscal injuries per year declined while the percentage of injuries that required surgery increased over time. High rates of RTP were observed. Level of Evidence Level IV, therapeutic case series.

Aims We have previously reported the mid-term outcomes of revision total knee arthroplasty (TKA) for flexion instability. At a mean of four years, there were no re-revisions for instability. The aim of this study was to report the implant survivorship and clinical and radiological outcomes of the same cohort of of patients at a mean follow-up of ten years. Methods The original publication included 60 revision TKAs in 60 patients which were undertaken between 2000 and 2010. The mean age of the patients at the time of revision TKA was 65 years, and 33 (55%) were female. Since that time, 21 patients died, leaving 39 patients (65%) available for analysis. The cumulative incidence of any re-revision with death as a competing risk was calculated. Knee Society Scores (KSSs) were also recorded, and updated radiographs were reviewed. Results The cumulative incidence of any re-revision was 13% at a mean of ten years. At the most recent-follow-up, eight TKAs had been re-revised: three for recurrent flexion instability (two fully revised to varus-valgus constrained implants (VVCs), and one posterior-stabilized (PS) implant converted to VVC, one for global instability (PS to VVC), two for aseptic loosening of the femoral component, and two for periprosthetic joint infection). The ten-year cumulative incidence of any re-revision for instability was 7%. The median KSS improved significantly from 45 (interquartile range (IQR) 40 to 50) preoperatively to 70 (IQR 45 to 80) at a mean follow-up of ten years (p = 0.031). Radiologically, two patients, who had not undergone revision, had evidence of loosening (one tibial and one patellar). The remaining components were well fixed. Conclusion We found fair functional outcomes and implant survivorship at a mean of ten years after revision TKA for flexion instability with a PS implant. Recurrent instability and aseptic loosening were the most common indications for re-revision. Components with increased constraint, such as a VVC or hinged, should be used in these patients in order to reduce the risk of recurrent instability. Cite this article: Bone Joint J 2022;104-B(10):1126–1131.

Objectives: The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted with a lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair, but no long-term, comparative studies are available in the literature. Methods: A total of 55 patients (58 knees) with recurrent lateral instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. Exclusion criteria included prior or concomitant tibial tubercle osteotomy or trochleoplasty, and follow-up less than 8 years. Pre- and post-operative demographic, surgical, imaging and clinical data were recorded for each patient. Results: MPFL repair was performed on 26 patients (29 knees; 14 females, 15 males) at a mean age of 19.1 years. MPFL reconstruction was performed on 29 patients (29 knees; 18 females, 11 males) at a mean age of 18.2 years. Mean follow-up was 12.0 years (range 8.3-18.9). The reconstruction group had a significantly lower rate of recurrent dislocation compared to the repair group (14% vs 41%, p=0.019) at final follow up. There were no differences in the number of pre-operative dislocations (greater than or less than 3), degree of patellar facet chondromalacia, TT-TG distance, or Tegner scores. The reconstruction group had significantly more time from injury to surgery compared to the repair group (median, 1,460 days vs 627 days, p =0.007). There were no differences in post-operative Tegner, Lysholm or Kujala scores at final follow-up. Additionally, there were no differences in return to play rates (repair 80.8% vs reconstruction 75.0%, p=0.610) or reoperation rates (repair 20.7% vs reconstruction 13.8%, p=0.487). Conclusions: Repair of the MPFL leads to nearly 3-fold higher rate of recurrent patellar dislocation (41% vs. 14%) at long term follow-up compared to MPFL reconstruction. However, MPFL repair and reconstruction provide similar clinical results, return to play rates and reoperation rates. [Table: see text][Table: see text]

AbstractIntroductionThe elbow is a rare location for primary and metastatic tumors in the upper extremity. The goal of reconstruction is to provide painless motion and stability for hand function. Total elbow arthroplasty (TEA) is commonly utilized, with either off‐the‐self components, modular segmental endoprosthesis, or allograft‐prosthesis composites (APC). The purpose of this study was to analyze and compare commonly utilized elbow reconstructions and report outcomes of (1) patient function and (2) implant survival and complications.MethodsWe reviewed 33 patients (18 females and 15 males) undergoing elbow arthroplasty for reconstruction of an underlying oncologic process including linked TEA (n = 22, 67%), APC (n = 9, 27%), and endoprosthesis (n = 2, 6%). The most common indication was metastatic disease (n = 17, 52%), with 24 patients (73%) presenting with a pathologic fracture.ResultsFive‐year implant survival was following elbow reconstruction was 88%. The mean most recent Mayo Elbow Performance Score and Musculoskeletal Tumor Society Score were 84 ± 18 and 78 ± 15%. Postoperative complications occurred in 15 elbows (45%), most commonly periprosthetic fracture (n = 5, 15%), leading to reoperation in six elbows (18%).ConclusionAlthough elbow arthroplasty is associated with a high incidence of complications, it provides a stable platform for upper extremity function in patients with oncologic processes of the elbow.

Background: Controversy exists surrounding antibiotic use in the setting of pediatric supracondylar humerus fractures treated with closed reduction and percutaneous Kirschner wire (K-wire) fixation. While the reported incidence of infection in the literature is low, surgeons frequently administer preoperative antibiotics. The purpose of this study was to retrospectively review preoperative antibiotic use and incidence of infection in children with supracondylar humerus fractures treated with closed reduction and K-wire fixation. It was hypothesized that antibiotic administration will not affect the incidence of infection following this procedure. Methods: We performed a retrospective review of 1053 patients with supracondylar humerus fractures treated with closed reduction and K-wire fixation at 3 institutions between 2006 and 2016. Patient demographics, antibiotic administration and follow-up data were reviewed in 905 patients. Results: Of 905 patients, 755 patients received preoperative antibiotics and 150 patients did not. The incidence of infection was 2.5% (n=22) in the group that received preoperative antibiotics and 2.0% in the group that did not receive antibiotics with an overall incidence of infection of 2.4%. The difference between groups did not reach significance (P>0.5). The majority of infections were treated with oral antibiotics with or without early pin removal. Four patients, all in the preoperative antibiotic group, required surgical debridement and intravenous antibiotics. Conclusions: Retrospective review of the incidence of infection in closed reduction and percutaneous pinning of supracondylar humerus fractures found no difference between patients who received preoperative antibiotics and those who did not receive preoperative antibiotics. Level of Evidence: Level III—therapeutic.

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.