Krych, Aaron J

Background: Historically, symptomatic hip labral lesions were treated with arthroscopic debridement. Hip labral repair has become the standard treatment for labral pathology; however, to date, there are limited long-term studies regarding the outcomes of isolated labral debridement. Purpose: To (1) evaluate the long-term patient-reported outcomes of isolated labral debridement, (2) report reoperation and arthroplasty rates, and (3) identify risk factors contributing to reoperation or poor clinical outcomes. Study Design: Case series; Level of evidence, 4 Methods: A retrospective review of a prospectively generated cohort of 59 hips in 57 patients from 1996 to 2010 who underwent hip arthroscopy with labral debridement was performed. Only patients with Tönnis grade <3 were included. Additionally, given the time period analyzed, resection of cam morphology was not performed, and the interportal capsulotomy was not repaired. The pre- and postoperative modified Harris Hip Score; Hip Outcome Score (HOS)-Activities of Daily Living and -Sports scores; and reoperation, conversion to total hip arthroplasty, and risk factors were analyzed. Results: In total, 48 hips in 47 patients (14 men, 33 women; mean age, 48.0 ± 12.9 years) met inclusion criteria and were followed for a mean of 17 ± 3 years (range, 13-27 years). The mean preoperative Tönnis grade was 1.3 ± 0.6 (range, 0-2), the mean chondral acetabular International Cartilage Regeneration & Joint Preservation Society (ICRS) grade was 1.7 ± 1.6 (range, 0-4), the mean chondral femoral ICRS grade was 0.9 ± 1.4, and the mean acetabular labral articular cartilage grade was 2.5 ± 1.2 (range, 0-4). At the final follow-up, mean the modified Harris Hip Score, HOS-Activities of Daily Living score, and HOS-Sports score were 82.2 ± 16.6, 81.9 ± 20.5, and 82.2 ± 20.5, respectively. Nineteen hips underwent subsequent reoperation at a mean of 5.5 ± 6.2 years (range, 0.5-21.2 years) postoperatively, including 16 hips (33% overall) being converted to total hip arthroplasty. Higher acetabular ICRS chondral grades at the time of surgery were observed in patients who went on to subsequent surgery compared with those who did not (2.3 ± 1.6 vs 1.1 ± 1.5; P = .02). In reoperation-free hips, Tönnis grade demonstrated a trend of increasing over time (1.4 preoperatively vs 1.7 at radiographic follow-up; P = .08). At the final follow-up, 19 hips (40%) had undergone reoperation, and 5 additional hips (10%) were rated as “abnormal” or “severely abnormal” in function, resulting in an overall clinical failure rate of 50%. Conclusion: Isolated labral debridement was found to result in high rates of failure and reoperation, with a third of patients being converted to arthroplasty and half of patients meeting criteria for reoperation or clinical failure. Of note, for patients remaining reoperation-free, satisfactory outcome scores were observed.

Purpose To describe the patient‐reported clinical outcomes following medial meniscus root repair with meniscus centralization and to identify common complications and detail provisional results. Methods Patients undergoing medial meniscus root repair with meniscus centralization from 2020 to 2022 were identified using an institutional database. Patients were followed prospectively using postoperative Tegner Activity Scale, visual analog scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, International Knee Documentation Committee score, and a Likert score for improvement, surgery satisfaction, and subsequent surgeries at minimum 1‐year follow‐up with mean 2‐year follow‐up. Demographics, injury characteristics, and surgical details were also collected. Results Twenty‐five patients (age: 50 ± 11 years; sex: 76% female; body mass index: 33 ± 8) were included in this study. Postoperative Tegner score was maintained at preoperative levels ( P = .233), and VAS at rest, VAS with use, Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and International Knee Documentation Committee improved significantly postoperatively ( P = .003; P < .001, P < .001, P = .023, respectively). Eighty‐eight percent of patients reported subjective improvement in their knee at final follow‐up. Postoperative radiographs did not show any significant osteoarthritis progression, and no patients had undergone a revision meniscus surgery or total knee arthroplasty at the time of follow‐up. Conclusions At minimum 1‐year follow‐up and mean 2‐year follow‐up, patients undergoing medial meniscus root repair with meniscus centralization demonstrated significant postoperative improvements in pain, function, and quality of life and reported high rates of surgery satisfaction. There was no evidence of significant arthritic progression on postoperative imaging, and no patients underwent revision meniscus surgery or total knee arthroplasty. Level of Evidence Level IV, case series.

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level. » The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics. » Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments. » In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

Purpose To describe the clinical and radiographic features associated with isolated hypermobile lateral meniscus (HLM), and report patient outcomes following surgically repaired isolated HLM. Methods All patients diagnosed with HLM from 2000 to 2020 at a single academic institution were identified and reviewed. Patients were excluded if they had concomitant ligament injury or lacked 2‐year follow‐up. Preoperative and postoperative visual analog scale (VAS) pain scores were determined from clinical notes. Statistical analysis was performed in JMP, and statistical significance was determined with use of a paired t ‐test. Results Eighteen knees in 17 patients met inclusion criteria. Mean patient age was 24.1 (range: 6‐61) years. Mean follow‐up was 73 months (25‐151 months). All 18 knees reported pain at presentation; 94% (17/18) had mechanical symptoms. All 18 knees had preoperative MRIs, but only 1 (5.6%) knee was correctly diagnosed by a musculoskeletal trained radiologist. Most repairs were performed with an all‐inside technique (61%, 11/18). VAS score improved significantly from 7.2 ± 2.9 preoperatively to 0.7 ± 1.9 postoperatively, with average improvement of VAS score of 6.5 ( P < .001). Only one (5.6%) knee required revision meniscal surgery. Conclusions Hypermobile lateral meniscus patients commonly see multiple providers, fail to have their HLM diagnosed on MRI, and undergo various treatments prior to a successful diagnosis. Localized lateral joint line pain, mechanical symptoms, and absence of distinct meniscus tear on MRI are the most frequent clinical presentations. Surgery with meniscus repair is a reliable solution to improve pain and mechanical symptoms. Level of Evidence Level IV, therapeutic case series.

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.

Purpose To evaluate long‐term patient‐reported outcomes and achievement rates of patient acceptable symptomatic state (PASS) in young athletes undergoing hip arthroscopy, and to report long‐term sports continuance and reoperation. Methods Inclusion criteria consisted of age <24 years at surgery, femoroacetabular impingement undergoing primary hip arthroscopy with labral repair, and participation in sport with intent to return to sport after surgery. The enrollment period was from April 2009 to June 2014. Modified Harris Hip Scores (mHHS), Hip Outcome Score (HOS), HOS Activities of Daily Living (HOS‐ADL), and HOS Sport (HOS‐Sport) were collected preoperatively, 2 years’ postoperatively, and final follow‐up. Patients were evaluated for PASS achievement, reoperation, and sports participation. Results Forty‐two hips in 37 patients (11 male, 26 female, age: 17.7 ± 2.1 years, range 13.6‐23.0, body mass index 22.8 ± 2.9, range 17.6‐33.7) met inclusion criteria and were followed for 10.0 ± 1.3 years (range 8.5‐13.0) postoperatively. Mean mHHS, HOS‐ADL and HOS‐Sports outcome scores at minimum 8.5 years were 82.2 ± 12.9, 89.6 ± 10.9, and 81.8 ± 16.4, respectively, with significant ( P < .001) postoperative improvements. Thirty survey respondents (83%) met PASS for mHHS, 27 (75%) for HOS‐ADL, and 24 (67%) for HOS‐Sports. At minimum 8.5‐year follow‐up, only 9 of 37 (24%) cited their hip as the reason for stopping sport. Of the remaining patients, 17 of 28 (61%), continued playing their initial sport. There was no difference in patient‐reported outcomes between patients who endorsed sports continuance and patients who did not report sports continuance and did not cite their hip as a reason ( P ≥ .229). At final follow‐up, 4 hips (10%) had undergone subsequent surgical intervention at a mean of 4.8 ± 3.3 years (range 1.0‐8.4) postoperatively. Conclusions Durable mid‐term outcomes and satisfactory PASS achievement rates are observed in young amateur athletes undergoing primary hip arthroscopy. At minimum 8.5‐year follow up, approximately 1 in 4 patients discontinue their sports due to hip related reasons. Level of Evidence Level IV, case‐series.

Purpose To (1) evaluate the efficacy of surgery for arthrofibrosis (AF), as measured by preoperative and postoperative range of motion (ROM), and (2) evaluate patient‐reported outcomes at mid‐ to long‐term follow‐up. Methods We performed a retrospective review of a prospectively collected database including patients who sustained multiligamentous knee injuries (MLKIs) managed surgically, sustained loss of ROM after surgical intervention, and underwent subsequent lysis of adhesions (LOA) and/or manipulation under anesthesia (MUA). Loss of ROM was defined as clinically symptomatic loss of terminal extension (flexion deformity) and/or flexion compared with the contralateral side. Results In total, 12 patients (6 male and 6 female patients; age, 36.0 ± 8.7 years; body mass index, 36.3 ± 8.7) met the inclusion criteria and underwent LOA and/or MUA at a mean of 14 ± 27 months (median, 4.0 months; interquartile range, 3.5‐9.3 months) after MLKI surgery. Prior to AF intervention, patients showed mean flexion of 75.9° ± 36.0° (range, 30°‐129°), mean extension of 3.2° ± 5.2° (range, 0°‐12°), and a mean arc of motion of 72.7° ± 34.1° (range, 30°‐117°). At a mean follow‐up of 7.0 ± 3.9 years (range, 2.4‐16.6 years) after AF intervention, patients showed a significant increase in knee flexion of 49° ( P = .003), a significant increase in arc of motion of 51° ( P = .002), and an increase in extension of 3° ( P = .086). The mean final International Knee Documentation Committee score was 59.5 ± 23.9; Lysholm score, 72.1 ± 20.6; Tegner activity scale score, 5.6 ± 2.8; visual analog scale score at rest, 1.0 ± 1.6; and visual analog scale score with use, 3.3 ± 2.5. At final follow‐up, 2 patients (17%) had undergone conversion to total knee arthroplasty (TKA) at 10.3 and 24.8 years after MLKI surgery. Of the 10 patients who did not go on to TKA, 9 (90%) reported that they were satisfied or very satisfied with their AF knee surgery. Conclusions At mid‐term follow‐up, LOA and/or MUA for symptomatic AF after multiligamentous knee surgery results in high rates of patient satisfaction and improved knee ROM and pain scores, as well as durable and satisfactory functional outcomes in patients not undergoing TKA. Level of Evidence Level IV, therapeutic case series.

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain, especially in young patients. When left untreated, it has been demonstrated to be a risk factor for the onset or progression of osteoarthritis (OA) and has been identified as one of the main contributors leading to the need for total hip arthroplasty (THA) at a young age. While the short-term therapeutic potential of hip arthroscopy is widely recognized, little is known regarding its potential mid- to long-term preventive effect on the progression of hip OA. Purpose: To (1) report clinical outcomes of arthroscopically treated FAI syndrome with a minimum 5-year follow-up and compare the results to a cohort with FAI treated nonsurgically and (2) determine the influence of hip arthroscopy on the onset and progression of hip OA in patients diagnosed with FAI. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who had hip pain and were diagnosed with FAI were included. Exclusion criteria were (1) previous or concomitant hip surgery, (2) <5 years of follow-up, and (3) insufficient radiographs. Patients treated with hip arthroscopy were compared with a cohort of patients with FAI who were treated nonsurgically. Kaplan-Meier estimates of failure (defined as conversion to THA) were performed. Bivariate analysis and Cox regression were used to identify factors associated with inferior clinical and radiographic outcomes. Results: A total of 957 patients (650 female, 307 male; 1114 hips) (mean age, 28.03 ± 8.9 years [range, 6.5-41.0 years]) with FAI were included. A total of 132 hips underwent hip arthroscopy and 982 hips were nonoperatively treated. The mean follow-up was 12.5 ± 4.7 years (range, 5.0-23.4 years). At the final follow-up, the rate of OA progression was 26.5% in the operative group and 35.2% in the nonoperative cohort ( P < .01). Conversion to THA was performed in 6.8% of the surgical patients and 10.5% of the initially nonsurgical patients ( P = .19). Additionally, there was no significant difference in the risk of failure between the operatively and nonoperatively treated patients. Male sex, increased age at initial diagnosis, presence of cam morphology, and increased initial Tönnis grade were risk factors for failure (male sex: hazard ratio [HR], 2.3; P < .01; per year of increased age: HR, 1.1; P < .01; presence of cam: HR, 3.5; P < .01; per Tönnis grade: HR, 4.0; P < .01). Conclusion: At a mean follow-up of nearly 13 years, 7% of patients of the surgical group experienced progression to THA, compared with 11% of the nonoperative control group. While most of the operative group showed little to no OA at final follow-up, moderate OA (Tönnis grade 2) was present in 12% of the cohort compared with 22% of nonsurgical patients. Increased age at diagnosis, male sex, presence of a cam morphology, and presence of initial arthritic joint changes were found to be risk factors for failure. The results of this study demonstrated evidence for a preventive effect of hip arthroscopy on the development and progression of OA in young patients with FAI at mid- to long-term follow-up.

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.

Purpose To use unsupervised machine learning clustering to define the “optimal observed outcome” after surgery for anterior shoulder instability (ASI) and to identify predictors for achieving it. Methods Medical records, images, and operative reports were reviewed for patients <40 years old undergoing surgery for ASI. Four unsupervised machine learning clustering algorithms partitioned subjects into “optimal observed outcome” or “suboptimal outcome” based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan‐Meier survival curves. Variables were assessed for prognostic value through multivariate stepwise logistic regression. Results Two hundred patients with a mean follow‐up of 11 years were included. Of these, 146 (64%) obtained the “optimal observed outcome,” characterized by decreased: postoperative pain (23% vs 52%; P < 0.001), recurrent instability (12% vs 41%; P < 0.001), revision surgery (10% vs 24%; P = 0.015), osteoarthritis (OA) (5% vs 19%; P = 0.005), and restricted motion (161° vs 168°; P = 0.001). Forty‐one percent of patients had a “perfect outcome,” defined as ideal performance across all outcomes. Time from initial instability to presentation (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.92‐0.98; P = 0.006) and habitual/voluntary instability (OR = 0.17; 95% CI, 0.04‐0.77; P = 0.020) were negative predictors of achieving the “optimal observed outcome.” A predilection toward subluxations rather than dislocations before surgery (OR = 1.30; 95% CI, 1.02‐1.65; P = 0.030) was a positive predictor. Type of surgery performed was not a significant predictor. Conclusions After surgery for ASI, 64% of patients achieved the “optimal observed outcome” defined as minimal postoperative pain, no recurrent instability or OA, low revision surgery rates, and increased range of motion, of whom only 41% achieved a “perfect outcome.” Positive predictors were shorter time to presentation and predilection toward preoperative subluxations over dislocations. Level of Evidence Level IV, retrospective cohort.