Jones, Morgan H

ObjectiveTo estimate the risk of magnetic resonance imaging (MRI)–based structural changes in knee osteoarthritis (OA) among individuals with meniscal tear and knee OA, using MRIs obtained at baseline and 18 and 60 months after randomization in a randomized controlled trial of arthroscopic partial meniscectomy (APM) versus physical therapy (PT).MethodsWe used data from the Meniscal Tear in Osteoarthritis Research (METEOR) trial. MRIs were read using the MRI OA Knee Score (MOAKS). We used linear mixed‐effects models to examine the association between treatment group and continuous MOAKS summary scores, and Poisson regression to assess categorical changes in knee joint structure. Analyses assessed changes in OA between baseline and month 18 and between months 18 and 60. We performed both intention‐to‐treat and as‐treated analyses.ResultsThe analytic sample included 302 participants. For both treatment groups, more OA changes were seen during the early interval than during the later interval. ITT analysis revealed that, between baseline and month 18, APM was significantly associated with an increased risk of having a worsening cartilage surface area score, involving both any worsening across all knee joint subregions (risk ratio [RR] 1.35 [95% confidence interval (95% CI) 1.14, 1.61]) and the number of subregions damaged (RR 1.44 [95% CI 1.13, 1.85]) having a worsening effusion‐synovitis score (RR 2.62 [95% CI 1.32, 5.21]), and having ≥1 additional subregion with osteophytes (RR 1.24 [95% CI 1.02, 1.50]). Significant associations were detected between months 18 and 60 only for having any subregion with a worsening osteophyte score (RR 1.28 [95% CI 1.04, 1.58]).ConclusionThese findings suggest that the association between APM and MRI‐based structural changes in knee OA is most apparent during the initial 18 months after surgery. The reason for attenuation of this association over longer follow‐up merits further investigation.

Purpose To analyze failure rate in 2‐year increments to determine if graft choice changed over time and graft failure rate. Methods A prospective 2002‐2008 database was used to identify risk factors for anterior cruciate ligament (ACL) retear. Subjects who had primary ACL retear with no history of contralateral surgery and 2‐year follow‐up were included. Subjects who underwent a multiligament reconstruction were excluded. Graft type, age, sex, smoking status, body mass index, Marx activity level at index surgery, medial and lateral meniscus status at time of ACL retear, sport played after ACL reconstruction, and clinical site were evaluated. Analysis was repeated using 2002‐2003 (early) and 2007‐2008 (late) 2‐year databases. Analysis of variance with post hoc analysis was performed to detect significant differences in age and Marx score by graft type over time. Results Two‐year follow‐up for graft failure was obtained on 2,497 of 2,692 (93%) subjects. There were 112 of 2,497 (4.5%) ACL retears identified at 2‐year follow‐up. The only predictor that changed between early/late periods was allograft use. Allograft odds ratio decreased from 13.1 to 9.5 ( P < .01). Allografts were used in older patients (31‐40 years) and with lower Marx scores (10‐8) from early to late periods. The mean age of subjects who received bone–patellar tendon–bone autografts did not significantly change over time (22.8‐23.5). The mean age of subjects who received hamstring autografts fell (27.9‐25.5). The mean age of subjects who received allografts rose significantly (31.3‐39.8, P < .01). The mean Marx score of subjects who received bone–patellar tendon–bone and hamstring autografts did not significantly change over time. The mean Marx score of subjects who received allografts decreased significantly ( P < .01). Conclusions After early recognition, allograft use in young active patients was a risk factor for retear; graft choice by surgeons changed in the late period to use of allografts in older and less‐active patients, which correlated with a significant decrease in retear risk. Level of Evidence Level III, case control study.

Background: Knee laxity in the setting of suspected anterior cruciate ligament (ACL) injury is frequently assessed through physical examination using the Lachman, pivot-shift, and anterior drawer tests. The degree of laxity noted on these examinations may influence treatment decisions and prognosis. Hypothesis: Increased preoperative knee laxity would be associated with increased risk of subsequent revision ACL reconstruction and worse patient-reported outcomes 2 years postoperatively. Study Design: Cohort study; Level of evidence, 2. Methods: From an ongoing prospective cohort study, 2333 patients who underwent primary isolated ACL reconstruction without collateral or posterior cruciate ligament injury were identified. Patients reported by the operating surgeons as having an International Knee Documentation Committee (IKDC) grade D for Lachman, anterior drawer, or pivot-shift examination were classified as having high-grade laxity. Multiple logistic regression modeling was used to evaluate whether having high-grade preoperative laxity was associated with increased odds of undergoing revision ACL reconstruction within 2 years of the index procedure, controlling for patient age, sex, Marx activity level, level of competition, and graft type. Multiple linear regression modeling was used to evaluate whether having high-grade preoperative laxity was associated with worse IKDC score or Knee injury and Osteoarthritis Outcome Score Knee-Related Quality of Life subscale (KOOS-QOL) scores at a minimum 2 years postoperatively, controlling for baseline score, patient age, ethnicity, sex, body mass index, marital status, smoking status, sport participation, competition level, Marx activity rating score, graft type, and articular cartilage and meniscus status. Results: Pre-reconstruction laxity data were available for 2325 patients (99.7%). Two-year revision data were available for 2259 patients (96.8%), and patient-reported outcomes were available for 1979 patients (84.8%). High-grade preoperative laxity was noted in 743 patients (31.9%). The mean postoperative IKDC score was 81.8 ± 15.9, and the mean KOOS-QOL score was 72.0 ± 22.0. The presence of high-grade pre-reconstruction laxity was associated with significantly increased odds of ACL graft revision (odds ratio [OR] = 1.87 [95% CI, 1.19-2.95]; P = .007). The presence of high-grade pre-reconstruction laxity was not associated with any difference in postoperative IKDC (β = −0.56, P = .44) or KOOS-QOL (β = 0.04, P = .97). Conclusion: The presence of high-grade pre-reconstruction knee laxity as assessed by manual physical examination under anesthesia is associated with significantly increased odds of revision ACL surgery but has no association with patient-reported outcome scores at 2 years after ACL reconstruction.

Background: One complication of anteroinferior glenohumeral shoulder dislocation is a critical bone defect that requires surgical repair to prevent recurrent instability. However, controversy exists regarding the surgical management because both open and arthroscopic surgeries have respective advantages and disadvantages. Moreover, it is difficult to determine the patient’s preferred treatment, as factors that influence treatment choice include recurrence rates, morbidity of the procedures, and patient preferences. Hypothesis: Patients who have a higher probability of recurrent instability after arthroscopic surgery will select open surgery whereas patients with a lower probability of recurrent instability after arthroscopic surgery will favor arthroscopy. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A decision tree was constructed to model each hypothetical outcome after open or arthroscopic surgery for glenohumeral instability in patients with bone defects. A literature review was performed to determine the probability of occurrence for each node while utility values for each outcome were obtained via patient-administered surveys given to 50 patients without prior history of shoulder injury or dislocation. Fold-back analysis was then performed to show the optimal treatment strategy. Finally, sensitivity analysis established the thresholds at which open treatment becomes the optimal treatment. Results: The ultimate expected value—the objective evaluation of all potential outcomes after choosing either open or arthroscopic surgery—was found to be greater for arthroscopic surgery than for open surgery (87.17 vs 81.64), indicating it to be the preferred treatment. Results of sensitivity analysis indicated that open surgery becomes the preferred treatment when probability of recurrence after arthroscopic treatment is ≥23.8%, although varying the utility, defined as an aggregate patient preference for a particular outcome, has no effect on the model. When the rate of no complication after open surgery is 97.6%, open surgery becomes the patient’s preferred treatment. Conclusion: Arthroscopic surgery is an acceptable treatment if recurrent instability occurs consistently at ≤23.8%. This has important implications given the technical difficulty of successfully performing arthroscopic fixation to resolve recurrent anteroinferior glenohumeral dislocations associated with critical osseous defects. However, due to a lack of clinical outcomes studies, more research is needed to better predict the optimal operative treatment.