Levy, Bruce A.

Objectives: Little is known about the natural history and long-term outcome of a surgically treated symptomatic lateral discoid meniscus. The goals of this study were to describe the rate and factors associated with recurrent lateral meniscus tears and progression to symptomatic lateral compartment osteoarthritis (OA) in patients surgically treated for a symptomatic lateral discoid meniscus. Patients with surgically treated lateral discoid meniscus have a high incidence of meniscus re-tear and progression to lateral compartment OA. Methods: A large, geographic database was reviewed to identify and confirm patients presenting with symptomatic lateral discoid meniscus between 1998 and 2015. Charts were reviewed to document treatment and outcomes at a minimum clinical follow-up of two years. Results: 70 discoid meniscus patients (30 F, 40 M) with a mean age of 27 years (Range: 2.0-66.0) were followed for an average of 5.8 years (Range 2.0-23.7). Sixty patients underwent surgical management: 49 (82%) patients underwent partial lateral meniscectomy and 11 (18%) underwent meniscus repair (including saucerization). Tear-free survival following surgery was 93% at 2 years, 69% at 5 years, and 40% at 8 years. Overall progression to symptomatic lateral compartment OA in the surgical group was 10% at 2 years, 23% at 5 years, and 48% at 8 years. Of those patients who developed lateral compartment OA, 55% (11/20) had a Kellgren-Lawrence score 2 or greater at last radiographic follow-up. Young age and open growth plates were associated with increased incidence of postoperative re-tear (HR: 0.96, CI: 0.93-0.99, p = 0.01). Increased age at diagnosis and BMI ≥ 30 were associated with increased risk of progression to lateral compartment OA on final radiographs. Conclusion: Patients with a surgically treated lateral discoid meniscus tear had a high rate of recurrent meniscus tear at long-term follow-up (60% at 8 years) that was associated with young age. Approximately 48% of surgically treated patients developed symptomatic lateral compartment OA at eight years from initial presentation. The risk of progression to OA increased with older age at diagnosis and BMI ≥ 30.

Objectives: Meniscus repair is desirable over resection to prevent post-meniscectomy arthritis, especially in young and active patients. However, long-term data is currently lacking following isolated meniscus repair, particularly in the pediatric population. The purpose of this study was to report long-term follow-up of isolated meniscus tears treated by meniscus repair in a pediatric population, and to compare those results to previous mid-term follow-up data reported. We hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Methods: Patients less than 18 undergoing repair of an isolated (without concomitant ACL injury) meniscus tear performed between 1990 and 2005 were included. At the time of final followup, recurrent tear, reoperations, and IKDC and Tegner scores were determined. With logistic regression, the overall failure between different tear types was calculated. Wilcoxon signed ranks tests were performed to calculate the differences in clinical outcome for different time-points, and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At an average followup of 17.6 years (13.1 - 26.0 years), 32 patients with 33 isolated meniscus repairs (29 M: 3F) with an average age of 16.1 (9.9 - 18.7) were included in this study. At early follow-up, complex tears (80%) had a higher overall failure rate compared to simple tears (18.2%). However, no further failures occurred since mid-term follow-up with any tear type. At final follow-up, the average IKDC score was 92.3, which was significantly increased when compared to both preoperative 65.3 (p< 0.0001) and mid-term scores, 90.2 (p= 0.01). However, the average Tegner score (6.5) was significantly lower than both pre-operative 8.3 (p< 0.0001) and mid-term 8.4 (p< 0.0001) scores. There was no correlation for Tegner or IKDC values with any risk factors. Conclusion: In conclusion, this study demonstrates overall good to excellent long-term clinical outcomes following isolated meniscus repair in a pediatric population. Early failure and reoperation rates were variable depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears compared to other tear types.

Objectives: Following ACL reconstruction, objective measurements of functional testing are often incorporated into the decision-making process with regard to clearance for return to sport (RTS), in order to reduce the risk of second ACL injury. However, there is limited data to assess the predictive value of functional testing to risk of second ACL injury. Therefore, the purpose of this study was to determine whether performance on functional testing following primary ACL reconstruction can predict second ACL injuries. Methods: Patient records were retrospectively analyzed for individuals who presented with an ACL injury at a single institution from 1990-2010. A total of 335 patients who underwent primary ACL reconstruction, had functional testing at the six month ± one month time point postoperatively, and had a minimum of two year post-operative follow-up were included in this study. Functional testing included vertical jump, single leg hop, and triple leg hop. Functional testing is represented as a measure of limb symmetry and was calculated as the involved limb divided by the uninvolved limb providing a percentage relative to the uninvolved limb. Statistical analysis was performed to determine the significance of functional test limb symmetries between those with and without a secondary tear by sex, then by age. Unpaired T-tests with an alpha level less than 0.05 was performed with JMP 13 (SAS Institute Inc., Cary, NC). Group distributions as well as effect sizes were calculated. Results: 335 patients with a mean age of 25 (SD 9.76) at an average time of 9.05 years (SD 3.54) of follow-up after ACL reconstruction met inclusion criteria and underwent statistical analysis (females= 150, male= 185). Of the cohort, 53 patients (18%) experienced second tears (female= 26, male= 27) at an average time of 44.19 months (6.03- 168.4) following ACL reconstruction with 34 occurring on the contralateral side and 19 on the ipsilateral side. Results at six month post ACL reconstruction indicate a significant difference between those who experienced a second ACL injury and those who didn’t with respect to single hop limb symmetry (95% ±7% vs.90% ± 12%, P<0.01). Triple hop limb symmetry was also significantly different between those who suffered a second ACL tear and those who did not (94% ± 6% vs. 90% ±11%, P<0.01). No significant differences were found in limb symmetry of vertical jump. When data was analyzed by sex, significant differences were found in females in the single hop limb symmetry (96% ± 8%, vs. 89% ± 14%, P<0.05) as well as triple hop limb symmetry (95% ± 5% vs. 90% ± 12%, P< 0.05). No significant differences were found in vertical jump for neither females nor males. No significant differences were found when data was categorized by age or sex and age. Conclusion: Overall, at an average of 9.05 years follow-up, 18% of a young and active population of primary ACL reconstructions had a second ACL injury. Contralateral ACL injuries were observed at an increased frequency relative to subsequent ipsilateral ACL tears. Patients with greater limb symmetry on single hop or triple hop functional testing at 6 months are at an increased risk for second ACL tears. When functional testing is used for return-to-sport decisions, physicians should caution patients about the risk of subsequent ACL injury for high performing patients.

Background: Little is known about the natural history of a surgically treated symptomatic lateral discoid meniscus. The goals of this study were to describe the rate and factors associated with recurrent lateral meniscal tears and progression to symptomatic lateral compartment osteoarthritis (OA) in patients surgically treated for a symptomatic lateral discoid meniscus. Hypothesis: Patients with surgically treated lateral discoid meniscus have a high incidence of meniscal retear and progression to lateral compartment OA. Study Design: Case series; Level of evidence, 4. Methods: A large geographic database was reviewed to identify and confirm patients presenting with symptomatic lateral discoid meniscus between 1998 and 2015. Charts were reviewed to document treatment and outcomes at a minimum clinical follow-up of 2 years. Results: A total of 59 patients (27 females, 32 males) with a mean age of 25.7 years (range, 4.0-66.0 years) underwent surgical management of a discoid lateral meniscus and were evaluated for a mean of 5.6 years (range, 2.0-23.7 years). Of these, 48 (82%) patients underwent partial lateral meniscectomy, with 24 patients undergoing concurrent saucerization. Eleven (18%) underwent meniscal repair. Tear-free survival following surgery was 41% at 8 years. Progression to symptomatic lateral compartment OA was 50% at 8 years. Young age (hazard ratio, 0.96; 95% CI, 0.93-0.99; P = .01) and open growth plates (hazard ratio, 3.19; 95% CI, 1.15-8.88; P = .03) were associated with increased incidence of postoperative retear. Older age at diagnosis and body mass index ≥30 kg/m 2 were associated with increased risk of progression to lateral compartment OA on final radiographs. Conclusion: Patients with a surgically treated lateral discoid meniscal tear had a high rate of recurrent meniscal tear (59% at 8 years). Approximately 50% of surgically treated patients developed symptomatic lateral compartment OA at 8 years from diagnosis.

Objectives The purpose of this study was to describe an arthroscopic surgical approach to identify and expose the popliteus tendon (PT), posterior fibular head, Fibular collateral ligament (FCL), popliteal fibular ligament (PFL), biceps femoris tendon, and the peroneal nerve. Methods 10 fresh human cadaveric knees were examined arthroscopically using standard anterior and posterior portals. The use of a transeptal approach with both posteromedial and posterolateral portals was required using a standard 30 degrees arthroscope. Optimal portal placement and specific technique and sequence for appropriate visualization of the PLC structures were tested and documented. Results In all specimens, all the PLC structures that we attempted to identify were successfully visualized. These included the PT, posterior fibular head, the FCL, the PFL, biceps femoris tendon, peroneal nerve, PT and FCL femoral attachments. Conclusion This study demonstrated that the identification and exposure of the PLC structures using an all arthroscopic approach can be successfully performed with precise portal placement. This technique may serve as a basis for arthroscopic treatment of PLC injuries.

Background: 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/abrasion or microfracture. In addition, patients treated with microfracture are subject to extended protected weightbearing rehabilitation to mitigate risk of subchondral plate fracture and to protect fibrocartilage tissue formation. Purpose: To determine the midterm patient-reported outcomes and failure rate of patients with grade 3 and 4 acetabular labrum articular disruption (ALAD) lesions managed with debridement/abrasion or microfracture. Study Design: Cohort study; Level of evidence, 3. Methods: Primary arthroscopic labral repair cases at 2 centers from November 2008 to April 2016 were reviewed for patients aged <55 years with unipolar ALAD grade 3 and 4 chondrolabral acetabular delamination. Patients undergoing microfracture and debridement/abrasion were compared using the 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: A total of 113 hips in 110 patients (66 males, 44 females; mean age, 34.5 ± 1.1 years) undergoing debridement/abrasion (n = 82) or microfracture (n = 31) were followed for a mean of 4.9 years (range, 2.0-8.5 years). Lesion size was not statistically different between the debridement/abrasion (1.3 ± 1.0 cm 2 ) and microfracture cohorts (1.4 ± 1.0 cm 2 ) ( P = .47). Patients undergoing debridement/abrasion achieved 3.6-point mean improvements in VAS ( P < .01), 21.2-point improvements in mHHS ( P < .01), and 25.4-point improvements in HOS-SSS ( P < .01), which were not significantly different from those observed in microfracture patients ( P≥ .20). The 5-year rate of survival free of revision surgery was 84.0% in the debridement/abrasion group and 85.6% in the microfracture group ( P = .78). The cartilage treatment technique was found not to be predictive of revision risk during both univariate (hazard ratio [HR], 1.01; P = .98) and multivariate (HR, 0.93; P = .90) analysis accounting for patient age, lesion grade, and acetabular coverage. Conclusion: Patients undergoing debridement/abrasion of high-grade unipolar acetabular cartilage lesions demonstrate similar outcome scores and revision rates compared with those of patients undergoing microfracture. These outcomes support the consideration of preferential debridement/abrasion at the discretion of the treating surgeon to optimize recovery while maintaining established positive outcomes after hip arthroscopy.

AbstractThere is limited evidence guiding management of medial collateral ligament (MCL) avulsions or functional disruptions distal to the medial joint line. This study aims to determine outcomes of a series of patients with grade III distal MCL injuries managed with acute surgical repair. Patients with grade III, distal MCL injuries, with or without multiligament involvement were identified. Demographic, clinical examination, and midterm patient-reported outcomes (PRO) data were collected. Clinical follow-up included physical examination and ligamentous stress testing at a minimum of 6 months. PROs included Lysholm's knee scoring scale, Tegner's activity score, and subjective International Knee Documentation Committee (IKDC) scores at minimum of 2 years follow-up. Of the 24 eligible patients, outcomes data were available for 20 (83%). Of the 20 included patients, 16 had a concomitant anterior cruciate ligament (ACL) injury, 3 had ACL and posterior cruciate ligament (PCL) injuries, and 1 had an isolated MCL injury. Mean time from injury to surgery was 5 weeks. At mean clinical follow-up of 20.3 months, all patients showed valgus stability and satisfactory range of motion (ROM). Anteroposterior stability was normal in all but one patient who demonstrated a 2+ posterior drawer but with firm end points. At a mean follow-up of 5.7 years for PROs, mean Lysholm's score was 91.5 (standard deviation [SD] = 12.2), median Tegner's activity score was 7 (range, 4–9), and mean subjective IKDC score was 88.8 (SD: 9.9). The surgical repair of grade III distal MCL injuries delivered satisfactory clinical and functional outcomes. Future comparative studies with larger patient samples are needed.

Purpose To determine the degree of correlation of radiographic measurements, degree of correlation of intraoperative pathology, and difference in outcomes between sides of patients requiring staged bilateral hip arthroscopy. Methods Two high‐volume hip preservation centers retrospectively reviewed hip preservation databases for staged bilateral hip arthroscopies conducted between 2008 and 2015. Patients were separated into those who presented with bilateral hip pain and those that presented with unilateral pain and developed contralateral pain >2 years later. Patients were analyzed for radiographic correlation (alpha angle, lateral center edge angle, anterior center edge angle, magnetic resonance imaging alpha angle, Tönnis grade) and correlation of intraoperative pathology (acetabular labrum articular disruption grade, Outerbridge grade/location, Villar class ligamentum teres tears, labral tear location, symmetry of Seldes tear types, and the differences between operative procedures). Patient‐reported outcomes were analyzed (modified Harris Hip Score, Non‐Arthritic Hip Score, International Hip Outcome Tool‐12, hip outcome score‐sport specific subscale, visual analog scale, patient satisfaction). Correlative tests included Pearson and Spearman; univariate and multivariate analysis for differences included χ‐square test and Student t tests for ordinal and continuous variables respectively. Results A total of 133 of 2,705 patients (4.6%) underwent bilateral hip arthroscopy. Radiographic alpha angle, magnetic resonance imaging alpha angle, lateral center edge angle, and anterior center edge angle demonstrated strong correlation (Pearson's coefficients 0.651, 0.648, 0.644, 0.667, respectively, P < .0001). Tönnis grade was weakly correlated (Pearson's coefficient 0.286, P = .001). Intraoperative pathology was moderately correlated (Pearson's coefficients for acetabular Outerbridge location, 0.300, P = .0170; acetabular labrum articular disruption, 0.490, P < .0001; acetabular Outerbridge; 0.530; P < .0001; femoral head Outerbridge, 0.459, P < .0001; Villar class, 0.393, P < .0001; and labral tear location, 0.468, P < .0001). Labral tear Seldes type was compared with Bowker's symmetry test and there was no significant difference between sides. There were no significant differences in surgical interventions performed between sides. Patients with bilateral hip arthroscopies significantly improved in all measured patient‐reported outcomes and had a high patient satisfaction after both procedures. Final patient‐reported outcomes and change in patient‐reported outcomes were not different between procedures; follow up ranged from 3 months to 8 years. Conclusions This study demonstrated an incidence of 4.6% of patients who require bilateral hip arthroscopy. These patients can expect significant improvement after surgical intervention. Patients that had 1 side done gained similar improvement when the contralateral side was performed. Preoperative radiographic, intraoperative pathology, and procedures performed were similar between hips. Level of Evidence Level III, retrospective cohort study.

ObjectiveThe present study was undertaken to evaluate changes in knee magnetic resonance imaging (MRI) findings over the course of 18 months in subjects with osteoarthritic change and meniscal tear treated with arthroscopic partial meniscectomy (APM) or nonoperatively with physical therapy (PT).MethodsWe used 18‐month follow‐up data from the Meniscal Tear in Osteoarthritis Research Trial. MRI results were read with reference to the MRI Osteoarthritis Knee Score. We focused on 18‐month change in bone marrow lesions (BMLs), cartilage thickness, cartilage surface area, osteophyte size, effusion‐synovitis, and Hoffa‐synovitis. We used multinomial logistic regression to assess associations between MRI‐based changes in each feature and treatment type.ResultsA total of 351 subjects were randomized, and 225 had both baseline and 18‐month MRI results. In both treatment groups, patients experienced substantial changes in several MRI‐based markers. In 60% of the APM group, versus 33% of the PT group, cartilage surface area damage advanced in ≥2 subregions (adjusted odds ratio 4.2 [95% confidence interval 2.0–9.0). Patients who underwent APM also had greater advancement in scores for osteophytes and effusion‐synovitis. We did not find significant associations between treatment type and change in cartilage thickness, BMLs, or Hoffa‐synovitis.ConclusionThis cohort of patients with meniscal tear and osteoarthritis showed marked advancement in MRI‐based features over 18 months. Patients treated with APM showed more advancement in some features compared to those treated nonoperatively. The clinical relevance of these early findings is unknown and requires further study.

Background: Avulsion fractures involving the tibial eminence are considered equivalent in etiology to anterior cruciate ligament tears, however there is limited data comparing outcomes of adolescent patients undergoing surgical fixation of tibial eminence fractures to those undergoing anterior cruciate ligament (ACL) reconstruction. Purpose: The purpose of this study was to compare clinical outcomes, subsequent ACL injury rates, and activity levels between adolescent patients who underwent tibial eminence fracture fixation to patients with mid-substance ACL tears who required acute ligament reconstruction. Methods: This study included a group of patients with tibial eminence fractures treated with surgical fixation matched to a group of similar patients with ACL tears treated with reconstruction between the years of 2001 and 2015. Data regarding initial injury, surgical intervention, ACL/ACL graft injury rates, and physical examination findings were recorded. Clinical and functional outcomes were obtained using physical examination, IKDC subjective scores, Lysholm scores, and Tegner Activity levels. Results: Sixty patients with a mean follow-up of 57.7 (24-206) months were included. 20 patients (11 M:9 F) who underwent surgical fixation for tibial eminence fractures (TEF) with a mean age of 11.9 (7-15) years were matched to a group of 40 patients (23 M:17 F) who underwent ACL reconstruction for ACL tears with a mean age of 12.5 (8-15) years. The TEF group demonstrated significantly lower postoperative IKDC (TEF group: 94.0, ACL group: 97.2 (p=0.04)) and Lysholm scores (TEF group: 92.4, ACL group: 96.9 (p=0.02)). The TEF group returned to sport 121 days sooner (p<0.01), but there was no difference in postoperative Tegner scores (TEF group: 7.3, ACL group: 7.6 (p=0.16)). The TEF group demonstrated increased postoperative anterior laxity (p=0.02) and a higher rate of postoperative arthrofibrosis (p=0.04). There was no difference in subsequent ACL injury (p=0.41). Conclusion: Patients with tibial eminence fractures demonstrated lower mean clinical outcome scores compared to patients with ACL tears at minimum 2-year follow up. Additionally, they experienced more postoperative anterior laxity and had a higher rate of postoperative arthrofibrosis. There was no difference in subsequent ACL injury rate. The TEF group returned to sport sooner than the ACL group, but the postoperative activity level was similar.