Levy, Bruce A.

Background: Donor site morbidity after anterior cruciate ligament (ACL) reconstruction with a bone–patellar tendon–bone (BTB) autograft is clinically significant, but evidence with contemporary techniques is lacking. Purpose: To (1) evaluate donor site morbidity at a single institution using modern techniques of BTB autograft harvest at 2-year follow-up, (2) develop a 10-question donor site morbidity instrument, and (3) compare this instrument against traditional outcome tools. Study Design: Case series; Level of evidence, 4. Methods: We analyzed the 2-year follow-up outcomes of 200 consecutive patients who underwent ACL reconstruction with a BTB autograft performed by 2 surgeons at a single institution. The surgical technique utilized modern and consistent BTB autograft harvest, including graft sizing, patellar tendon and peritenon closure, and patellar and tibial donor site bone grafting. There were 187 patients included, with 13 patients undergoing revision ACL reconstruction excluded. An original 10-question scoring instrument evaluating donor site morbidity was administered to each patient (score, 0-100) and compared against each patient’s International Knee Documentation Committee (IKDC) and Lysholm scores. Results: Overall, 13.9% of patients were noted to have anterior knee pain with activity at 2-year follow-up. Moreover, 3.7% of patients reported an inability to kneel on hard surfaces but had no problems on soft surfaces; 5.9% of patients reported mild discomfort but were able to kneel on all surfaces. Additionally, 75.4% of patients had a perfect (100/100) donor site morbidity score. The mean donor site morbidity score at 2-year follow-up was 98.3 ± 3.4. There was a very strong correlation between the IKDC and Lysholm scores but only a strong and moderate correlation when the donor site morbidity score was compared with the IKDC and Lysholm scores, respectively. Conclusion: Donor site morbidity after ACL reconstruction with a BTB autograft was less frequent than reported in the existing literature. Some patients developed anterior knee pain; therefore, an informed discussion is advised. IKDC and Lysholm scores may not capture donor site symptoms after surgery. The 10-question donor site morbidity instrument may provide a more accurate assessment.

Background The iliopsoas is a common source of anterior hip pain. Refractory cases may require surgical intervention, with reported complication rates ranging from 3% to 50%. Development of a minimally invasive, outpatient method of iliopsoas tendon release is desirable and may reduce costs, lower complications, and improve recovery time. Objective To describe and evaluate the safety and reproducibility of an ultrasound‐guided (USG) iliopsoas tendon release using a spinal needle in a cadaveric model. Design Prospective, cadaveric laboratory investigation. Setting Academic Institution Procedural Skills Laboratory. Participants Five unembalmed cadaveric specimens (three female, two male), 69 to 93 years of age (mean 83.2 years), with a mean body mass index (BMI) of 24.5 kg/m 2 (range 19.2 to 30.3 kg/m 2 ). Interventions Two operators each performed five USG iliopsoas tendon releases. Three additional investigators dissected the pelves to assess completeness of tendon release and damage to adjacent structures. Main Outcome Measures Successful transection, completeness (%) of the tendon transection, damage to adjacent structures, and procedural time. Results Nine of 10 releases achieved the target release of ≥75% tendon transection. One procedure achieved 50% tendon release. No injury to adjacent structures was identified. The mean duration of the procedure was 6.19 minutes. Conclusions USG iliopsoas tendon release can be performed in a cadaveric model, consistently achieve the desired percentage of tendon release, does not result in injury to adjacent neurovascular structures, and takes approximately 6 minutes to perform. Although results cannot be generalized to a clinical setting, due to the minimally invasive nature of the procedure, it is likely that this procedure can be performed safely in an outpatient setting under local anesthesia, will cost less, and will facilitate a more rapid recovery when compared to standard surgical procedures. Further research is warranted for clinical application.

Background: Hip arthroscopy has been previously demonstrated to be an effective treatment for adult mild hip dysplasia. There are many radiographic parameters used to classify hip dysplasia, but to date few studies have demonstrated which parameters are of most importance for predicting surgical outcomes. Purpose: To identify preoperative radiographic parameters that are associated with poor outcomes in the arthroscopic treatment of adult mild hip dysplasia. Study Design: Case-control study; Level of evidence, 3. Methods: Radiographic analysis was performed in patients with mild hip dysplasia who underwent arthroscopic surgery between 2009 and 2015. Preoperative radiographic measurements included lateral center edge angle, Tönnis angle, neck shaft angle, anterior center edge angle, alpha angle, femoral head extrusion index, and acetabular depth-to-width ratio. Failure was defined as failure to achieve the minimal clinically important difference (MCID) utilizing the modified Harris Hip Score or as the need for secondary operation. The equal variance t test was used to analyze radiographic parameters. Statistical significance was determined using a P value of .05. Results: A total of 373 hips underwent analysis with an average follow-up of 41 months (range, 24-102 months). Of these, 46 hips (12%) required secondary operation, and 95 (25%) failed to meet the MCID. The overall failure rate was 32.4%. There was no single measurement or combination thereof associated with failure to reach the MCID. Higher preoperative Tönnis angles were associated with secondary operation, with a mean of 6.7° (95% CI, 5.3°-8.1°) in the secondary operation group versus 4.8° (95% CI, 4.4°-5.3°) in the nonsecondary operation group ( P = .006). The odds ratio was 1.12 (95% CI, 1.0-1.2; P = .05) per degree increase in Tönnis angle for secondary operation. In patients with a Tönnis angle >10°, 84% required secondary operation. Conclusion: Higher Tönnis angles portend a higher risk for revision surgery. The probability of secondary operation was increased by a magnitude of 1.12 with each degree increase in the Tönnis angle. In patients with a Tönnis angle >10°, 84% required a secondary operation.

Purpose To assess whether labral size is predictive of labral repair failure or shows an association with patient outcomes after hip arthroscopy. Methods We performed a retrospective chart review of patients who underwent arthroscopic hip labral repair. Labral size was measured in 4 quadrants with an arthroscopic probe. The average size across torn labral segments was assessed for failure as determined by the change in patient‐reported outcomes, the rate at which subjects achieved the minimal clinically important difference and patient acceptable symptomatic state, and the need for additional surgery. Outcomes were evaluated for any continuous correlation as well as significant differences between the middle 50% of labral sizes and classes of labral sizes derived from upper and lower quartile and decile ranges. Included hips were those from patients aged between 18 and 55 years with 2‐year postoperative follow‐up and lateral center‐edge angles between 25° and 40°. Results The study included 571 hips. Labral width did not show a significant difference between hips requiring revision and those not requiring revision ( P = .4054). No significant correlation was found between labral width and the change in the International Hip Outcome Tool 12 score ( R 2 = 0.05780), modified Harris Hip Score ( R 2 = 0.19826), or Nonarthritic Hip Score ( R 2 = 0.23543) from preoperatively to 2 years postoperatively. Hips with labral sizes in the upper decile of our cohort showed significantly decreased improvement in the International Hip Outcome Tool 12 score ( P = .0287) and Nonarthritic Hip Score ( P = .0490) compared with the middle 50% of labral sizes. No statistically significant difference was found in the rate at which the groups achieved the minimal clinically important difference or patient acceptable symptomatic state. Conclusions Hypertrophic labra in the largest 10th percentile showed lower postoperative outcome scores. However, no detectable clinical benefit was found in terms of patient‐perceived clinical difference or acceptable symptomatic state. For most patients, labral size does not appear to significantly alter patient outcomes or the need for arthroplasty. Level of Evidence Level IV, retrospective case series.

Purpose To determine (1) the demographic characteristics as well as radiographic findings of medial versus lateral meniscal root tears at time of presentation, (2) treatment decisions and clinical outcomes of patients undergoing medial versus lateral root repair, and (3) risk factors for worse clinical and radiographic outcomes. Methods A retrospective review was performed to identify patients with symptomatic, medial, or lateral meniscus posterior root tears with a minimum 2‐year follow‐up. Radiographs were graded using Kellgren‐Lawrence scores. Subanalysis was performed on 62 patients who underwent root repair. Tegner, Lysholm, International Knee Documentation Committee scores, and progression to arthroplasty were analyzed in the repair groups. Patient demographics, radiographic findings, and clinical outcomes were compared between medial meniscus posterior horn root tear (MMRT) and lateral meniscus root repair (LMRT). Results Of the 141 root tears, 109 were MMRTs, 30 were LMRTs, and 2 patients had both. At the time of injury, patients with MMRTs had a significantly higher age (MMRT = 51.4 vs LMRT=24.6, P < .0001), body mass index (MMRT = 32.1 vs LMRT 25.8, P < .0001), Kellgren‐Lawrence score (MMRT = 1.3 vs LMRT=0.6, P < .0001), and higher rate of major meniscal extrusion (MMRT = 72% vs LMRT = 20%, P < .0001). Of the 30 LMRT, 30/30 (100.0%) were treated with meniscal repair. With MMRT, 52/109 (48%) were treated nonoperatively, 27/109 (25%) with partial meniscectomy, and 30/109 (27%) with meniscal repair. Sixty‐two patients underwent meniscus root repair with an average 41‐month follow‐up. LMRT had significantly increased International Knee Documentation Committee (LMRT = 89.5, MMRT = 80.4, P = .02) and Tegner scores (LMRT = 6.5, MMRT = 5.1, P < .05) compared with MMRT. Conclusions Compared with MMRTs, LMRTs occur in younger male patients with lower body mass index, less cartilage degeneration, less extrusion on magnetic resonance imaging, and more commonly with a ligament injury. Although good to excellent clinical outcomes were attained in select patients for both medial and lateral meniscus root repair, LMRTs may have better results after repair, suggesting that differences in injury and patient characteristics may contribute to differences in these outcomes. Level of Evidence Retrospective comparative study, Level III.

Background: Radiography is the initial imaging modality used to evaluate femoroacetabular impingement (FAI), and diagnostic radiographic findings are well-established. However, the prevalence of these radiographic findings in patients with hip pain is unknown. Purpose: The purpose was 3-fold: (1) to determine the overall prevalence of radiographic FAI deformities in young patients presenting with hip pain, (2) to identify the most common radiographic findings in patients with cam-type FAI, and (3) to identify the most common radiographic findings in patients with pincer-type FAI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A geographic database was used to identify patients aged 14 to 50 years with hip pain between the years 2000 to 2016. The following were evaluated on radiographs: cam type: typical pistol grip deformity, alpha angle >55°; pincer type: crossover sign (COS), coxa profunda or protrusio acetabuli, lateral center edge angle (LCEA) ≥40°, Tönnis angle <0°; and mixed type: both cam- and pincer-type features. Posterior wall sign (PWS) and ischial spine sign (ISS) were also evaluated. The prevalence of each was determined. Descriptive statistics were performed on all radiographic variables. Results: There were 1893 patients evaluated, and 1145 patients (60.5%; 1371 hips; 374 male and 771 female; mean age, 28.8 ± 8.4 years) had radiographic findings consistent with FAI. Of these hips, 139 (10.1%) had cam type, 245 (17.9%) had pincer type, and 987 (72.0%) had mixed type. The prevalence of a pistol grip deformity and an alpha angle >55° was 577 (42.1%) and 1069 (78.0%), respectively. The mean alpha angle was 66.9°± 10.5°. The prevalence of pincer-type radiographic findings was the following: COS, 1062 (77.5%); coxa profunda, 844 (61.6%); ISS, 765 (55.8%); PWS, 764 (55.7%); Tönnis angle <0°, 312 (22.8%); LCEA ≥40°, 170 (12.4%); and protrusio acetabuli, 7 (0.5%). Conclusion: The overall prevalence of radiographic findings consistent with FAI in young patients with hip pain was 60.5%. Radiographic findings for mixed-type FAI were the most prevalent. The most common radiographic finding for cam-type FAI was an alpha angle >55°. The most common radiographic finding for pincer-type FAI was the COS.

AbstractFailed multiligament knee reconstruction is a challenging problem due to recurrent pathologic laxity that is often associated with limb malalignment, meniscus deficiency, articular cartilage insufficiency, decreased motion, compromised bone stock, and a paucity of graft sources. Revision surgical indications and techniques require a comprehensive evaluation of the patient, injury and treatment factors along with a focused physical examination and advanced imaging. A stepwise treatment approach can be effective in the evaluation of revision surgery and also in setting realistic patient goals.

Background: There are limited data comparing the outcomes of similarly matched patients with a medial meniscus posterior root tear (MMPRT) treated with nonoperative management, partial meniscectomy, or repair. Purpose/Hypothesis: The purpose was to compare treatment failure, clinical outcome scores, and radiographic findings for a matched cohort of patients who underwent either nonoperative management, partial meniscectomy, or transtibial pull-through repair for an MMPRT. We hypothesized that patients who underwent meniscus root repair will have lower rates of progression to arthroplasty than patients who were treated with nonoperative management or partial meniscectomy. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent transtibial medial meniscus posterior horn root repair were matched by meniscal laterality, age, sex, and Kellgren-Lawrence (K-L) grades to patients treated nonoperatively or with a partial meniscectomy. Progression to arthroplasty rates, International Knee Documentation Committee and Tegner scores, and radiographic outcomes were analyzed between groups. Results: Forty-five patients were included in this study (15 nonoperative, 15 partial meniscectomy, 15 root repair). Progression to arthroplasty demonstrated significant differences among treatment groups at a mean of 74 months (nonoperative, 4/15; partial meniscectomy, 9/15; meniscal repair, 0/15; P = .0003). The meniscus root repair group had significantly less arthritic progression, as measured by change in K-L grade from pre- to postoperatively (nonoperative, 1.0; partial meniscectomy, 1.1; meniscal repair, 0.1; P = .001). Conclusion: Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared with nonoperative management and partial meniscectomy in a matched cohort based on patient characteristics.

ObjectiveTo determine the 5‐year outcome of treatment for meniscal tear in osteoarthritis.MethodsWe examined 5‐year follow‐up data from the Meniscal Tear in Osteoarthritis Research trial (METEOR) of physical therapy versus arthroscopic partial meniscectomy. We performed primary intent‐to‐treat (ITT) and secondary as‐treated analyses. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale; total knee replacement (TKR) was a secondary outcome measure. We used piecewise linear mixed models to describe change in KOOS pain. We calculated 5‐year cumulative TKR incidence and used a Cox model to estimate hazard ratios (HRs) for TKR, with 95% confidence intervals (95% CIs).ResultsThree hundred fifty‐one participants were randomized. In the ITT analysis, the KOOS pain scores were ~46 (scale of 0 [no pain] to 100 [most pain]) at baseline in both groups. Pain scores improved substantially in both groups over the first 3 months, continued to improve through the next 24 months (to ~18 in each group), and were stable at 24–60 months. Results of the as‐treated analyses of the KOOS pain score were similar. Twenty‐five participants (7.1% [95% CI 4.4–9.8%]) underwent TKR over 5 years. In the ITT model, the HR for TKR was 2.0 (95% CI 0.8–4.9) for subjects randomized to the arthroscopic partial meniscectomy group, compared to those randomized to the physical therapy group. In the as‐treated analysis, the HR for TKR was 4.9 (95% CI 1.1–20.9) for subjects ultimately treated with arthroscopic partial meniscectomy, compared to those treated nonoperatively.ConclusionPain improved considerably in both groups over 60 months. While ITT analysis revealed no statistically significant differences following TKR, greater frequency of TKR in those undergoing arthroscopic partial meniscectomy merits further study.

Objectives: Hip arthroscopy is becoming more advanced and commonly performed. However, significant controversy exists regarding whether high grade acetabular cartilage lesions should be treated with debridement or microfracture. In addition, patients treated with microfracture are subject to extended partial weight-bearing rehabilitation in order to mitigate risk of subchondral plate fracture and protect fibrocartilage tissue formation. The purpose of this study was to determine the mid-term patient-reported outcomes and failure rate and patient-reported outcomes of Grade 3 and 4 acetabulum labrum articular disruption (ALAD) lesions managed with microfracture or debridement. Methods: Primary arthroscopic labral repair cases at two centers from November 2008 to April 2016 were reviewed in patients aged < 55 years with unipolar ALAD Grade 3 and 4 pathology. Patients undergoing microfracture and debridement were compared using visual analog pain scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score - Sports Specific Subscale (HOS-SSS) to determine predictors of outcomes and failure. Results: 127 hips in 123 patients (47 M, 76 F, mean age 34.7 ± 11.1) undergoing debridement (n = 95) or microfracture (n = 32) were followed for a mean of 4.9 years (range 2.0 - 8.5). Patients undergoing debridement achieved 3.5 point mean improvements in VAS (p < 0.01), 20.9 point improvements in mHHS (p < 0.01), and 25.5 point improvements in HOS-SSS (p < 0.01), which was statistically similar to that observed in microfracture patients (p ≥ 0.19). Five-year survival free of revision surgery was 83.0% in the debridement group and 85.6% in the microfracture group (p = 0.85). Cartilage treatment technique was found not to be predictive of revision risk during both univariate (p = 0.84) and multivariate (p = 0.84) analysis. Conclusion: Patients undergoing debridement of high grade unipolar acetabular cartilage lesions demonstrate similar patient reported outcome scores and revision rates compared to patients undergoing microfracture. These outcomes support debridement of acetabular lesions in order to optimize recovery while maintaining established positive outcomes following hip arthroscopy. [Table: see text]