Wilbur, Ryan R.

Background: The loss of extensor mechanism continuity that occurs with patellar and quadriceps tendon rupture has devastating consequences on patient function. Purpose: To describe a treatment strategy for extensor mechanism disruption and evaluate the outcomes of 3 techniques: primary repair, repair with semitendinosus tendon autograft augmentation, and reconstruction with Achilles tendon allograft. Study Design: Case series; Level of evidence, 4. Methods: The authors reviewed surgeries for extensor mechanism disruption performed by a single surgeon between 1999 and 2019. Patient characteristics, imaging studies, surgical techniques, and outcomes were recorded. Primary ruptures with robust tissue quality were repaired primarily, and first-time ruptures with significant tendinosis or moderate tissue loss were repaired using quadrupled semitendinosus tendon autograft augmentation. Patients with failed previous extensor mechanism repair or reconstruction and poor tissue quality underwent reconstruction with Achilles tendon allograft. The primary outcome was extensor mechanism integrity at a minimum 1-year follow-up, with extensor mechanism lag defined as >5° loss of terminal, active knee extension. Secondary outcomes included postoperative knee range of motion, International Knee Documentation Committee (IKDC) and Tegner activity scores, and the radiographic Caton-Deschamps Index. Results: Included were 22 patellar tendon and 21 quadriceps tendon surgeries (patients: 82.5% male; mean age, 48.1 years; body mass index, 31). Seventeen (39.5%) cases underwent primary tendon repair, 13 (30.2%) had repair using semitendinosus tendon autograft augmentation, and 13 (30.2%) underwent reconstruction using an Achilles tendon allograft. Seventeen (39.5%) cases had at least 1 prior failed extensor mechanism surgery performed at an outside facility. At the last follow-up, 4 (9.3%) cases had an extensor mechanism lag, no cases required additional extensor mechanism surgery, and all cases were able to achieve >90° of knee flexion. Postoperative IKDC scores were significantly improved with all methods of extensor mechanism surgery, and postoperative Tegner activity scores were significantly improved in patients who underwent primary repair and Achilles tendon allograft reconstruction ( P < .05 for all). Conclusion: Primary repair alone, repair using quadrupled semitendinosus tendon autograft augmentation, and reconstruction using Achilles tendon allograft were all effective methods to restore extensor mechanism and knee function with the proper indications. Persistent knee extensor lag was more common in chronic extensor mechanism injuries after failed surgery, although patients still reported significantly improved postoperative functional outcomes.

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.

Objectives: Meniscus root tears are increasingly being recognized. Meniscus extrusion has previously been associated with medial root tears; however, the relationship between secondary meniscus restraints, such as the meniscotibial (MT) ligament, extrusion, and root tears has yet to be formally evaluated. The purpose of this study was to better understand the association between MT ligament competence, medial meniscus extrusion, and medial meniscus posterior root tears (MMPRT), as well as to determine the progression of meniscus extrusion over time. Methods: Serial MRI’s from our institution were reviewed for patients who showed evidence of medial meniscus extrusion and MMPRT on at least one of 2+ available MRI’s. All patients were symptomatic at the time of diagnosis. All MRI’s were analyzed independently by two board-certified musculoskeletal radiologists. MT ligament disruption, medial meniscus extrusion, and MMPRT presence was recorded for each MRI. The time between MRI’s, presence of insufficiency fractures, and Outerbridge classification for the medial femur and tibia were also evaluated. Results: 27 knees in 26 patients were included in this study, with a total of 63 MRI’s analyzed (21 knees with 2 MRI’s, 3 with 3 MRI’s, and 3 with 4 MRI’s). All patients demonstrated clear medial meniscus extrusion and meniscotibial ligament disruption prior to the subsequent development of MMPRTs (p < 0.001). Mean extrusion at the time of initial MRI was 3.3 ± 1.1 mm, and increased significantly to 5.5 ± 1.8 mm at the time of first imaging with an identified MMPRT (p < 0.001). The average time between initial MRI and the first identification of MMPRT on a later MRI was 1.7 ± 1.6 years. Conclusions: In a sample of 27 symptomatic knees with serial MRI’s both before and after MMPRT diagnosis, all patients demonstrated MT ligament disruption and associated meniscus extrusion prior to the development of subsequent medial meniscus root tears. These findings suggest that MT ligament disruption and medial meniscus extrusion represent early and predisposing events contributing to MMPRT. Therefore, this provides a possible explanation of why meniscus extrusion is not corrected with medial meniscus root repair.

Purpose To evaluate the effect of the Nonoperative Instability Severity Index Score (NISIS) criteria on an established US‐geographic population‐based cohort of patients with anterior shoulder instability. Methods An established geographically based medical record system was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient demographics and instability characteristics. Patient‐specific risk factors were individually incorporated into the 10‐point NISIS criteria: age (>15 years), bone loss, type of instability (dislocation vs subluxation), type of sport (collision vs noncollision), male sex, and dominant arm involvement. High risk was considered a score of ≥7 points and low risk as <7 points. Failure was defined as either progression to surgery or recurrent instability diagnosed by a consulting physician at any point after initial consultation. Results The study population consisted of 405 patients with a mean follow‐up time of 9.6 ± 5.9 years. Failure was defined as recurrent instability or progression to surgery, and the overall failure rate was 52.8% (214/405). The rate of recurrent instability after initial consultation was 34.6% (140/405), and the rate of conversion to surgery was 37.8% (153/405). A total of 264 (65.2%) patients were considered low risk (NISIS < 7), and 141 (34.8%) patients were considered high risk (NISIS ≥ 7). Patients in the high‐risk group were more likely to fail nonoperative management than those in the low‐risk group (60.3% vs 48.9%; P = .028). Conclusions The NISIS has been proposed as a potentially useful tool in clinical decision‐making regarding the appropriate use of nonoperative treatment in scholastic athletes. When applied to an established US‐geographic population‐based cohort consisting of competitive and recreational athletes under the age of 40 with longer‐term follow‐up, the NISIS high‐risk cutoff was able to predict overall failure with 60.3% accuracy. Level of Evidence III, retrospective observation trial

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.

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force on the elbow. Since the first description of MUCL reconstruction by Jobe et al in 1986, many technical advancements have been implemented to improve outcomes and reduce complications. The docking technique has emerged as one of the most commonly used techniques. Indications: Following repetitive stress on the elbow during the overhead throwing motion, the MUCL may become attenuated, insufficient, or rupture completely. Although nonoperative treatment with rest and therapy is often the initial treatment of choice, individuals who fail conservative measures may require MUCL reconstruction. Technique Description: The major steps of the procedure are (1) harvesting of palmaris longus autograft, (2) incision and exposure, (3) preparation of ulnar tunnel, (4) preparation of docking site on medial epicondyle, (5) graft passage, (6) graft tensioning and length determination, (7) final fixation, and (8) closure. Results: This procedure allows for reconstruction of the MUCL, restoration of valgus stability to the elbow, and return to play rates of 80% to 95%. The docking technique has advantages over previously described MUCL reconstruction techniques in that it minimizes injury to the flexor pronator mass, avoids the ulnar nerve, allows for robust graft tensioning, and reduces the amount of bone removed from the medial epicondyle. Discussion/Conclusion: The docking technique, as described in this video demonstration, is the most common MUCL reconstruction technique used today. When precise surgical steps are followed, complication rates are low and patient outcomes are favorable.

AbstractMany different techniques with multiple graft types have been described for the reconstruction of the injured posterior cruciate ligament (PCL); autograft versus allograft, single- versus double-bundle, open inlay versus arthroscopic inlay versus arthroscopic transtibial, and recently described the arthroscopic “all-inside” socket technique. Reported clinical outcomes have demonstrated no significant difference in any of these PCL reconstruction techniques, likely because of the heterogeneity in injury characteristics and patient population. The ideal surgical technique should be safe, simple, and reproducible while allowing treatment of concomitant knee injuries resulting and return to function.

AbstractPurposeRecovery following elective knee arthroscopy can be compromised by prolonged postoperative opioid utilization, yet an effective and validated risk calculator for this outcome remains elusive. The purpose of this study is to develop and validate a machine‐learning algorithm that can reliably and effectively predict prolonged opioid consumption in patients following elective knee arthroscopy.MethodsA retrospective review of an institutional outcome database was performed at a tertiary academic medical centre to identify adult patients who underwent knee arthroscopy between 2016 and 2018. Extended postoperative opioid consumption was defined as opioid consumption at least 150 days following surgery. Five machine‐learning algorithms were assessed for the ability to predict this outcome. Performances of the algorithms were assessed through discrimination, calibration, and decision curve analysis.ResultsOverall, of the 381 patients included, 60 (20.3%) demonstrated sustained postoperative opioid consumption. The factors determined for prediction of prolonged postoperative opioid prescriptions were reduced preoperative scores on the following patient‐reported outcomes: the IKDC, KOOS ADL, VR12 MCS, KOOS pain, and KOOS Sport and Activities. The ensemble model achieved the best performance based on discrimination (AUC = 0.74), calibration, and decision curve analysis. This model was integrated into a web‐based open‐access application able to provide both predictions and explanations.ConclusionFollowing appropriate external validation, the algorithm developed presently could augment timely identification of patients who are at risk of extended opioid use. Reduced scores on preoperative patient‐reported outcomes, symptom duration and perioperative oral morphine equivalents were identified as novel predictors of prolonged postoperative opioid use. The predictive model can be easily deployed in the clinical setting to identify at risk patients thus allowing providers to optimize modifiable risk factors and appropriately counsel patients preoperatively.Level of evidenceIII.

AbstractPurposeOvernight admission following anterior cruciate ligament reconstruction has implications on clinical outcomes as well as cost benefit, yet there are few validated risk calculators for reliable identification of appropriate candidates. The purpose of this study is to develop and validate a machine learning algorithm that can effectively identify patients requiring admission following elective anterior cruciate ligament (ACL) reconstruction. MethodsA retrospective review of a national surgical outcomes database was performed to identify patients who underwent elective ACL reconstruction from 2006 to 2018. Patients admitted overnight postoperatively were identified as those with length of stay of 1 or more days. Models were generated using random forest (RF), extreme gradient boosting (XGBoost), linear discriminant classifier (LDA), and adaptive boosting algorithms (AdaBoost), and an additional model was produced as a weighted ensemble of the four final algorithms.ResultsOverall, of the 4,709 patients included, 531 patients (11.3%) required at least one overnight stay following ACL reconstruction. The factors determined most important for identification of candidates for inpatient admission were operative time, anesthesia type, age, gender, and BMI. Smoking history, history of COPD, and history of coagulopathy were identified as less important variables. The following factors supported overnight admission: operative time > 200 min, age < 35.8 or > 53.5 years, male gender, BMI < 25 or > 31.2 kg/m2, positive smoking history, history of COPD and the presence of preoperative coagulopathy. The ensemble model achieved the best performance based on discrimination assessed via internal validation (AUC = 0.76), calibration, and decision curve analysis. The model was integrated into a web‐based open‐access application able to provide both predictions and explanations.ConclusionModifiable risk factors identified by the model such as increased BMI, operative time, anesthesia type, and comorbidities can help clinicians optimize preoperative status to prevent costs associated with unnecessary admissions. If externally validated in independent populations, this algorithm could use these inputs to guide preoperative screening and risk stratification to identify patients requiring overnight admission for observation following ACL reconstruction.Level of evidenceIV.