Wilbur, Ryan R.

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.

Background: Arthrofibrosis (AF) after anterior cruciate ligament reconstruction (ACLR) remains a challenge. There is a paucity of data on arthroscopic interventions for AF after ACLR. Purpose: To (1) describe the patient, injury, and surgical characteristics and patient-reported outcomes (PROs) of those requiring an arthroscopic intervention for loss of motion after ACLR and (2) compare outcomes between patients undergoing an early intervention (within 3 months) versus those undergoing a late intervention (after 3 months). Study Design: Case series; Level of evidence, 4. Methods: Patients with a history of ACLR and a subsequent operative procedure for postoperative AF at a single institution between 2000 and 2018 were retrospectively identified. Arthroscopic interventions included lysis of adhesions, capsular release with or without manipulation under anesthesia, and excision of cyclops lesions. Patients were excluded if they had a knee dislocation or multiple-ligament injury, a periarticular fracture, or less than 2-year follow-up from the arthroscopic intervention. PROs including the Tegner activity score, visual analog scale pain score, and International Knee Documentation Committee score as well as knee range of motion (ROM) were recorded. Results: A total of 40 patients were included with a mean age of 27.2 years (range, 11.0-63.8 years) at surgery and a mean follow-up of 10.0 years (range, 2.9-20.7 years). The mean preoperative flexion and extension were 102° (range, 40°-150°) and 8° (range, 0°-25°), respectively. The mean postoperative flexion and extension were 131° (range, 110° to 150°) and 0° (range, –10° to 5°), respectively. After the arthroscopic intervention, the mean ROM improved from 94° (range, 40°-140°) preoperatively to 131° (range, 107°-152°) at final follow-up ( P < .001), and the visual analog scale pain score improved from 3.0 preoperatively to 1.2 postoperatively ( P = .001). Overall, 13 patients (32.5%) underwent an intervention within 3 months and 27 (67.5%) after 3 months. The early intervention group had a higher postoperative International Knee Documentation Committee score compared with the late intervention group (86.8 vs 71.7, respectively; P = .035). Conclusion: An arthroscopic intervention for AF after ACLR successfully improved knee ROM and pain. Patients who underwent either early or late surgery obtained satisfactory motion and function, although improved PROs were observed when the intervention occurred within 3 months of the primary procedure.

Background: There is a paucity of research on the management of partial-thickness tears of the distal bicep tendon, and even less is known about the long-term outcomes of this condition. Purpose: To identify patients with partial-thickness distal bicep tendon tears and determine (1) patient characteristics and treatment strategies, (2) long-term outcomes, and (3) any identifiable risk factors for progression to surgery or complete tear. Study Design: Case-control study; Level of evidence, 3. Methods: A fellowship-trained musculoskeletal radiologist identified patients diagnosed with a partial-thickness distal bicep tendon tear on magnetic resonance imaging between 1996 and 2016. Medical records were reviewed to confirm the diagnosis and record study details. Multivariate logistic regression models were created using baseline characteristics, injury details, and physical examination findings to predict operative intervention. Results: In total, 111 patients met inclusion criteria (54 treated operatively, 57 treated nonoperatively), with 53% of tears in the nondominant arm and a mean follow-up time after surgery of 9.7 ± 6.5 years. Only 5% of patients progressed to full-thickness tears during the study period, at a mean of 35 months after the initial diagnosis. Patients who were nonoperatively treated were less likely to miss time from work (12% vs 61%; P < .001) and missed fewer days (30 vs 97 days; P < .016) than those treated surgically. Multivariate regression analyses demonstrated increased risk of progression to surgery with older age at initial consult (unit odds ratio [OR], 1.1), tenderness to palpation (OR, 7.5), and supination weakness (OR, 24.8). Supination weakness at initial consult was a statistically significant predictor for surgical intervention (OR, 24.8; P = .001). Conclusion: Clinical outcomes were favorable for patients regardless of treatment strategy. Approximately 50% of patients were treated surgically; patients with supination weakness were 24 times more likely to undergo surgery than those without. Progression to full-thickness tear was a relatively uncommon reason for surgical intervention, with only 5% of patients progressing to full-thickness tears during the study period and the majority occurring within 3 months of initial diagnosis.

Purpose To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first‐time anterior shoulder dislocation after the age of 50 years. Methods An established geographic medical record system was used to identify patients who experienced a first‐time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi‐square tests and survivorship curves were generated using Kaplan‐Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment. Results 179 patients were included with a mean follow‐up of 11 years. 14% ( n = 26) underwent early surgery within 3 months and 86% ( n = 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full‐thickness rotator cuff tears (82% vs 55%; P = .01), labral tears (24% vs 8.0%; P = .01), and humeral head fracture (23% vs 8.5%; P = .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate‐severe pain (19% vs 17%; P = .78) and frozen shoulder (8 vs 9%, respectively; P = .87) at final follow‐up. Although nerve palsy (19% vs 8%; P = .08) and progression to osteoarthritis (20% vs 14%; P = .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P = .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent ( n = 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01). Conclusions Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow‐up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery. Level of Evidence Level III, retrospective cohort study.

Background: Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions. Purpose: To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively. Results: Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort ( P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores. Conclusion: All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.

Background: There is a dearth of knowledge on anterior shoulder instability in older patients. Purpose/Hypothesis: The purposes of this study were to describe the incidence and epidemiology, injury characteristics, and treatment and outcomes in patients ≥50 years old with first-time anterior shoulder instability. We also describe the historical trends in diagnosis and treatment. It was hypothesized that the rates of obtaining a magnetic resonance imaging (MRI) scan and surgical intervention have increased over the past 20 years. Study Design: Descriptive epidemiology study. Methods: An established geographic database was used to identify 179 patients older than 50 years who experienced new onset anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, imaging characteristics, and surgical treatment and outcomes, including recurrent instability. Comparative analysis was performed to identify differences between age groups. Mean follow-up time was 11 years. Results: The incidence of first-time anterior shoulder dislocation in our study population was 28.8 per 100,000 person-years, which is higher than previously reported. Full-thickness rotator cuff tears were found in 62% of the 66 patients who underwent MRI scans. Of all patients, 26% progressed to surgery at a mean time of 1.6 years after injury; 57% of all surgical procedures involved a rotator cuff repair, and 17% included anterior labral repair. All patients who underwent a labral repair also underwent concomitant rotator cuff repair. The rate of recurrent instability for the cohort was 15% at a median of 176 days after the initial instability event. There were no instances of recurrent instability after operative intervention. At an average of 7.5 years after the initial instability event, 14% of patients developed radiographic progression of glenohumeral arthritis. The rate of surgical intervention within 1 year of initial dislocation increased from 5.1% in 1994 to 1999 to 52% in 2015 to 2016. Conclusion: The incidence of first-time anterior shoulder instability in patients aged ≥50 years was 28.8 per 100,000 person-years. Full-thickness rotator cuff tears (62%) were the most common condition associated with anterior shoulder instability, followed by Hill-Sachs lesions (56%). The rate of recurrent instability for the entire cohort was 15%, with no instances of recurrent instability after operative intervention.

Purpose To investigate the incidence of anteroinferior glenoid rim fractures (AGRFs) after anterior shoulder instability (ASI) in patients aged 50 years or older, identify risk factors for surgical intervention for AGRFs, compare initial treatment strategies, and compare clinical outcomes of patients with and without associated AGRFs. Methods An established geographic medical record system was used to identify patients aged 50 years or older with ASI between 1994 and 2016. Patients with radiographic evidence of AGRFs were identified and matched 1:1 to patients without AGRFs. Outcome measures included recurrent instability, recurrent pain events, conversion to arthroplasty, and osteoarthritis graded with the Samilson‐Prieto classification for post‐instability arthritis. Results Overall, 177 patients were identified, with a mean follow‐up period of 10.8 years. Of these patients, 41 (23.2%) had AGRFs and were matched to 41 control patients without AGRFs. The average age was 58.6 and 58.2 years for the AGRF and control groups, respectively. Rates of surgical intervention (27% vs 49%), recurrent instability (12% vs 20%), progression of osteoarthritis (34% vs 39%), and conversion to arthroplasty (2% vs 5%) were similar between AGRF patients and controls. For patients with AGRFs, increased bone fragment size (odds ratio, 1.1) and increased body mass index (odds ratio, 1.2) correlated with an increased risk of surgery. The cutoff value for an increased risk of surgery in patients with AGRFs was a fragment size 33% of the glenoid width or greater. Conclusions Of patients aged 50 years or older at presentation of ASI, 23.2% presented with an associated AGRF. A fragment size 33% of the glenoid width or greater and a higher patient body mass index were significant factors for surgical intervention; however, most patients did not require surgery and still showed acceptable clinical outcomes, and the most common reason for surgical intervention was a rotator cuff tear. Overall, the presence of an AGRF did not portend a worse prognosis as treatment strategies and long‐term outcomes including recurrent instability, progression of osteoarthritis, and conversion to arthroplasty were similar to those in patients without AGRFs. Level of Evidence Level III, retrospective comparative study.

Objectives: Distal biceps tendon tears, although rare, significantly impair patient’s elbow mobility and function. There is a paucity of contemporary literature reporting long term outcomes of distal biceps (DB) injuries. Therefore, the authors sought to identify magnetic resonance imaging (MRI) confirmed distal bicep tears and report on (1) patient demographics and injury characteristics of all patients with distal bicep pathology, (2) outcomes of all patients with non-operatively managed DB pathology, and (3) outcomes of all patients with operatively managed DB pathology. Methods: Patients with an MRI-confirmed distal biceps rupture from 1996 to 2016 were identified through an institutional image database. Patients from the initial search were then cross-referenced with the [REDACTED] 1 to ensure record availability. Patients were included if they had complete medical records and ≥5 years of clinical follow-up. Patients with inflammatory arthritis and enthesitis, polytrauma, or incidental findings without clinical assessment were excluded. Medical records were reviewed to confirm the diagnosis of distal biceps tears and obtain further subject details. Results: A total of 158 patients (22 female, 136 male) with a mean age 51.5 years (44.8-61.2) were identified and included. Baseline patient demographics including BMI, smoking status, dominant-handedness, laborer occupation, and gender were gathered (Table 1). Patients had a mean clinical follow-up of almost 14 years (Table 1, range 8.4 -17.8). Outcomes of the 52 non-operative and 106 operatively managed patients, included severe complications, functional outcomes, and health-related productivity loss are reported in Table 2. There were 7 re-operations (4%), 5 re-ruptures (3%), and overall 35% of the operatively treated cohort experienced a complication. Conclusions: Patients with distal bicep pathology tended to be a male laborer in their 50s without clinically significantly associated risk factors. The majority of patients regained full ROM, and 83% were able to return to work without modifications, irregardless of operative or non-operative management. At long term follow up, patients treated operatively were more likely to report missing time from work and averaged more days missed than their non-operatively treated counterparts. Additionally, operative patients had no statistically significant gains functional outcomes, and were subject to potential post-operative complications. Surgeon bias may play a role in deciding treatment for distal biceps tears. As such, careful patient selection for surgical intervention for distal biceps pathology should be employed; surgeons should consider restricting surgical intervention to patients who have significant clinical symptoms or fail non-operative management. [Table: see text][Table: see text]

Objectives: Background: Although they are common, there remains a paucity of data regarding traumatic anterior shoulder dislocations (ASI) associated with anteroinferior glenoid rim fractures (AGRF) in older patients. Purpose: To describe the incidence of AGRF in this population following ASI, identify risk factors for AGRF, compare treatment strategies, and compare clinical outcomes of patients with and without an associated AGRF. Methods: An established geographic medical record system was used to identify patients >50 years of age with ASI between 1994 and 2016. Patients with radiographic evidence of AGRF were identified and matched 1:1 to patients without AGRF. Comparative analysis was conducted to determine differences between groups. Results: Overall, 186 patients were identified with a mean follow-up of 10.4 years (range, 2.0 – 25.4). Of these, 42 (22.6%) had AGRF and were matched to 42 control patients without AGRF. Average age was 58.9 and 58.2 years for the AGRF and control groups, respectively. Rates of surgical intervention (29% vs. 43%), recurrent instability (14% vs. 17%), progression of osteoarthritis (34% vs. 39%), and conversion to arthroplasty (2% vs. 5%) were similar between AGRF and control cohorts. Control patients were more likely to report recurrent pain (p=.046). For patients with AGRF, increased bone fragment size (OR 1.1) and increased BMI (OR 1.2) correlated with an increased risk for surgery. The cut-off value for surgery in patients with AGRF was a fragment size ≥33% of the glenoid width. Conclusions: In patients ≥ 50 years at presentation of ASI, 22.6% presented with an associated AGRF. Increased fragment size and greater patient BMI were significant factors associated with undergoing surgical intervention; however, most patients did not require surgery. Patients without AGRF were more likely to report recurrent pain, possibly due to a higher prevalence of rotator cuff derangement. Overall, the presence of an AGRF did not portend a worse prognosis as treatment strategies and long-term outcomes in terms of recurrent instability, progression of osteoarthritis, and conversion to arthroplasty were similar between patients with and without AGRF at the time of ASI diagnosis.

Objectives: Anterior shoulder instability (ASI) is a well-studied topic in young patients, however there is a dearth of knowledge about older patients with this pathology. The goals of this study were to describe patient demographics, injury characteristics and outcomes in patients >50 years old with anterior shoulder instability along with historical trends in diagnosis and treatment. Methods: An established geographic database was used to identify 179 patients who experienced new onset anterior shoulder instability after the age 50 between 1994-2016. Mean age was 59.7 years, mean BMI was 31.3 and 54.2% were female. The dominant arm was involved in 62.2% of instability events. 26.8% of our study population were laborers and 50% reported current or former smoking habits. The primary etiology for ASI involved trauma in 96.6% of cases. Comparative analysis was performed to identify differences between age groups. Mean follow up time was 11 years. Results: The overall incidence of ASI in our study population was 28.8/100,000 person years with the highest incidence in the age cohort 60-64 at 38.9/100,000 person years. At initial presentation, 73% of all patients were found to have a lesion apparent on either XR or MRI. Rotator cuff tears were found in 92.4% of all patients undergoing MRIs. 26.2% ultimately progressed to surgery at a mean time of 1.57 years after injury. 53% of all surgical procedures involved a rotator cuff repair whereas only 25% were performed for instability. In terms of historical trends, the one-year rate of obtaining an MRI after an ASI event has increased from 10% in the late 1990s to 46% in 2015-16. Similarly, the one-year rate of performing surgery has increased from 5.1% to 47% from 1994-1999 to 2015-2016. Conclusions: In our cohort, patients over the age of 50 with ASI were found to often have concomitant pathology on imaging, however only ¼ of all patients required surgery. Although the rate of ASI has stayed relatively stable over the last 20 years, the rate of obtaining an MRI and of surgical management has increased. [Figure: see text]