Economopoulos, Kostas J

Purpose The purpose of this study was to compare graft failure and clinical outcomes following primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon autograft (QA), with or without a modified Lemaire lateral extra‐articular tenodesis (LET). Methods Patients with ACL deficiency who underwent primary QA ACLR with or without LET and completed at least 2‐year follow‐up were included. Patients with a Beighton score ≥4, a preoperative pivot shift grade ≥2, or an intention to return to cutting and pivoting sports were offered LET. The primary outcome variable assessed was graft failure as defined by graft rupture or grade ≥2 pivot shift at any point postoperatively. Secondary outcomes included return to sport clearance rates, the International Knee Documentation Committee and Lysholm scores and postoperative complications. Results There were 122 undergoing QA ACLR with LET (QA + LET group) and 152 undergoing isolated QA ACLR (QA group). The QA + LET group had a significantly lower failure rate of 14.8% versus 29.6% in the QA group ( P = .02). In addition, the QA + LET group had a lower residual pivot shift rate compared with the QA group (11.3% vs. 26.3% respectively; P = .01). There was no difference in graft retear rates between the 2 groups ( P = .37). The QA + LET returned to sport significantly faster at 8.8 months compared with 9.7 months in the QA group ( P = .038). Conclusions The addition of LET to QA ACLR was associated with a significantly lower overall graft failure rate and lower percentage of patients with residual pivot shifts after ACLR compared with QA alone at 2‐year follow up. However, there was no difference between the 2 groups with regard to graft retear rates. The addition of an LET to QA ACLR also allowed athletes to return to sports faster compared with QA alone. Level of Evidence Level III, retrospective comparative study.

Purpose To determine if preoperative femoral or tibial bone marrow edema (BME) is indicative of higher rates of re‐tear and conversion to total knee arthroplasty (TKA) after posterior medial meniscal root tear repair, and, secondarily, whether preoperative BME impacted patient‐reported outcome measures and rates of infection and arthrofibrosis. Methods Patients that underwent posterior medial meniscal root tear repair between 2013 and 2021 with a 2‐year minimum follow‐up were retrospectively analyzed. Primary outcome measures included re‐tears and TKA conversion. Secondary outcomes included International Knee Documentation Committee (IKDC) score and Lysholm score, infection, and arthrofibrosis. Cohort‐specific minimally clinically important difference and Patient Acceptable Symptomatic Scale rates were calculated. Two‐tailed t‐tests, Wilcoxon rank‐sum tests, and Fisher's exact tests were used where appropriate. Results The study population consisted of 97 knees (74 without BME [NBME], 23 with BME) with average follow‐up of 38.9 months (24‐68). Preoperatively, the NBME group had higher IKDC scores ( P = .008). Postoperatively, the NBME group had higher IKDC scores at 6 months, 1 year, and 2 years (84.5 [6.0] vs 68.5 [11.0]) ( P = .041, <.001, <.001). IKDC minimally clinically important difference rates were not significantly different between groups at all follow‐ups. Patient Acceptable Symptomatic Scale rates were higher for the NBME group at 1‐year and final follow‐up (100.0% vs 60.9%) ( P < .001 for both). Lysholm scores were higher for the NBME group at 1‐year and final follow‐up (84.0 [5.6] vs 74.6 [12.8]) ( P = .019 and .008, respectively). Re‐tear occurred in 17.4% of the BME group and 0% of the NBME group ( P = .003). TKA conversion rates were 21.7% in the BME group and 2.7% in the NBME group ( P = .008). There was no difference in arthrofibrosis or infection rates. Conclusions Preoperative BME in patients undergoing posterior medial meniscal root tear repair is associated with higher rates of recurrent meniscal root tearing and conversion to TKA in addition to lower subjective IKDC and Lysholm scores compared to patients without preoperative BME. Level of Evidence Level III, retrospective prognostic case control series.

Purpose To compare clinical outcomes between augmented subchondral drilling (aSCD) and nonsubchondral drilling (NoSCD) techniques, both using a cartilage scaffold, in the treatment of isolated patellar cartilage lesions. Methods A retrospective cohort study was conducted on patients who underwent surgical treatment for isolated patellar cartilage using either an aSCD technique (a subchondral drilling augmented with a particulated cartilage allograft scaffold or a flexible osteochondral allograft scaffold) or a NoSCD technique (a particulated juvenile articular cartilage scaffold or a flexible osteochondral allograft scaffold implanted without performing a subchondral drilling). Patients were included if they had a minimum 2‐year follow‐up and excluded if they underwent concomitant meniscal or ligamentous procedures. While tibial tubercle osteotomy (TTO) was commonly performed, it was not a strict inclusion criterion. All procedures were performed through arthrotomy with a standardized postoperative rehabilitation protocol. Clinical outcomes included International Knee Documentation Committee (IKDC) and Lysholm scores, reoperation rates, conversion to total knee arthroplasty, and complications. Results A total of 65 knees were included: 31 in the aSCD group and 34 in the NoSCD group, with a mean follow‐up of 50.4 months (range, 24‐88 months). In the aSCD group, particulated allograft cartilage hydrated with platelet‐rich plasma was used in 80.7% of cases and flexible osteochondral allograft in 19.3%, while the NoSCD group was treated with Cartiform (Arthrex) in 70.6% and particulated juvenile articular cartilage in 29.4% of cases. TTO was performed in 87.0% of aSCD and 91.2% of NoSCD cases. Average defect sizes were 3.7 cm 2 (aSCD) and 4.0 cm 2 (NoSCD). At final follow‐up, the NoSCD group had significantly better outcomes, with higher median IKDC scores (81.0 vs 74.0; P < .001) and median Lysholm scores (83.0 vs 77.0; P < .001). A significantly greater proportion of NoSCD patients exceeded the minimal clinically important difference for IKDC (100% vs 80.6%; P = .024) but not for Lysholm (97.1% vs 93.5%; P = .935) at final follow‐up. In multivariable regression adjusting for scaffold type, TTO, and defect size, aSCD remained a significant independent predictor of lower final IKDC (β = –8.97; P = .001) and Lysholm (β = –12.71; P < .001) scores. The aSCD group had a significantly higher rate of repeat surgery (45.2% vs 14.7%; P = .015). There was no significant difference in conversion to total knee arthroplasty between groups ( P = .432). Conclusions For the treatment of isolated patellar cartilage lesions, a nonsubchondral drilling technique with scaffolding was associated with improved patient‐reported outcomes and fewer complications compared to a subchondral drilling technique with scaffolding, although there was no difference in the rate of conversion to total knee arthroplasty. Level of Evidence Level III, retrospective comparative study.

Abstract Like all diagnoses and comorbidities, patients with hip pain should be managed with individualized treatment plans. Patients with fibromyalgia undergoing hip arthroscopy are no different. Even if their absolute scores remain lower than those without fibromyalgia, these patients can achieve clinically meaningful improvements in patient‐reported outcomes after treatment of femoroacetabular impingement. As orthopaedic providers, we should be aware of potential bias against patients with chronic musculoskeletal pain and critically evaluate the literature that supports clinically relevant improvement after surgical intervention. Fibromyalgia should not be viewed as a condition that excludes or increases the threshold for hip arthroscopy but rather as a factor requiring nuanced, multidisciplinary perioperative care and realistic goal‐setting.

Purpose To evaluate the effectiveness of adding lateral extra‐articular tenodesis (LET) to primary anterior cruciate ligament reconstruction (ACLR) in competitive female soccer athletes with greater preoperative generalized ligamentous laxity. Methods A retrospective review of female high school and collegiate soccer players who underwent primary ACLR from 2013 to 2021, with a minimum of 2 years of follow‐up, was conducted. Participants were divided into 2 groups: those who received ACLR alone and those who received ACLR with LET. Generalized ligamentous laxity was defined as a Beighton score ≥4 and was not considered an indication for LET. Anterior cruciate ligament (ACL) autografts included the quadriceps, bone−patellar tendon−bone, and hamstrings in both groups. Patient demographics and physical examination findings, including pivot shift results, were collected. Positive pivot‐shift refers to a grade ≥2. Patient outcomes included graft failure (defined as ACL retear), International Knee Documentation Committee score, Lysholm score, return to sport, and complications. Independent t tests, χ 2 tests, and Mann‐Whitney U tests were conducted to compare outcomes between the 2 groups. Minimally clinical important difference was calculated from preoperative to final follow‐up. Results A total of 133 female soccer players who underwent ACLR met inclusion criteria, including 43 patients that received an ACLR + LET and 90 patients who underwent isolated ACLR. Average follow‐up was 39.0 and 36.1 months in the LET group and the control group, respectively. Patients who underwent LET had a greater generalized ligamentous laxity rate (48.8% vs 18.9%; P < .001) and greater median Beighton score (3.0 vs 1.0; P < .001) than those without LET. There was a similar rate of graft failure in patients who underwent LET compared with the control group (4.7% vs 3.0%; P = .658). On the basis of minimally clinical important difference thresholds, there were no clinically relevant differences in International Knee Documentation Committee or Lysholm scores noted between the 2 groups. Return‐to‐sport rates also were comparable between the LET and control cohorts (90.7% vs 85.6%; P = .807). Conclusions The addition of LET during ACLR in female soccer players with preoperative generalized ligamentous laxity yields graft retear and return‐to‐sport rates comparable with those of athletes without ligamentous laxity. Level of Evidence Level III, retrospective comparative study.

Background: Young female patients undergoing hip arthroscopy have an increased prevalence of baseline capsular laxity of the hip joint. This laxity, along with superimposed postoperative iatrogenic capsular deficiency secondary to an unrepaired capsule, could potentially lead to worse outcomes after arthroscopic treatment of femoroacetabular impingement (FAI) in this population. Purpose: To compare outcomes and revision rates for young female patients undergoing hip arthroscopy for FAI and labral tear with capsular closure (CC group) versus capsular nonclosure (CNC group). Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of prospectively collected data of patients who underwent index hip arthroscopy using interportal capsulotomies by a single surgeon between January 2014 and February 2020 was performed. Female patients aged 12 to 21 years who underwent hip arthroscopy with cam or pincer osteoplasty and labral repair with a 2-year minimum follow-up were included. The Beighton score was assessed. The Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Hip Outcome Score–Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at 3 months, 1 year, and 2 years postoperatively. Data were analyzed using the Mann-Whitney U test and Fisher exact test. Results: A total of 23 hips (20 patients) were included in the CC group and 17 hips (16 patients) were included in the CNC group. The groups were not different regarding characteristics and preoperative patient-reported outcome scores. At all follow-up intervals postoperatively, the CC group scored significantly higher HOS-ADL and HOS-SSS. Fifteen of 17 (88.2%) patients in the CC group returned to sports versus 8 of 14 (57.1%) in the CNC group ( P = .03). Four (17.4%) hips in the CC group had revision surgery compared with 9 (52.9%) hips in the CNC group (odds ratio, 5.1; 95% CI, 1.2-22.5; P = .02). Conclusion: Young female patients treated with CC while undergoing arthroscopic FAI had improved outcomes, fewer revisions, and a higher return-to-sports rate than those treated without CC.

Purpose To compare the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using hamstring autograft (HA) plus lateral extra‐articular tenodesis (LET), isolated all‐soft tissue quadriceps autograft (QA), and isolated HA. Methods A retrospective review was performed comparing high‐risk patients undergoing ACL reconstruction with isolated HA, isolated QA, or HA + LET from August 2013 to January 2023. High‐risk patients, as determined by high‐grade pivot shift or generalized ligament laxity, with at least a 2‐year follow‐up, were included. Lysholm and International Knee Documentation Committee scores were compared at 3, 6, 12, and 24 months postoperatively. Retear rate, postoperative pivot‐shift grade, return to sport, and complications were recorded. Results In total, 159 patients (56 HA, 47 HA + LET, and 56 QA) were included. At 6 months postoperatively, the HA International Knee Documentation Committee score was significantly lower than that of the HA + LET and QA groups ( P < .0001). Similarly, the Lysholm score was significantly lower in the HA cohort at 6 months, 1 year, and 2 years postoperatively ( P < .0001‐.02). There was no difference in the rate of achieving the minimally important clinical difference between the cohorts for either of these outcome scores. The retear rate was significantly higher in the HA group (17.9%) compared to the HA + LET (4.3%) and QA (1.8%) cohorts ( P = .01). The rate of postoperative pivot shift of grade 2 or more was also higher in the isolated HA group ( P = .04). Conclusions The use of an all‐soft tissue QA or HA + LET for ACL reconstruction resulted in a lower retear rate and postoperative pivot‐shift grade compared to an isolated HA graft in high‐risk patients at 2 years postoperatively. There was no difference in the rate of achieving the minimal clinically important difference between the cohorts. The QA and HA + LET reconstruction options may improve stability and decrease the failure rate compared with HA reconstruction alone. Level of Evidence Level III, retrospective cohort study.

Purpose To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow‐up (6 weeks) and 1‐year (or most recent) follow‐up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow‐up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow‐up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow‐up ( P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow‐up. Conclusions In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow‐up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence Level III, case–control study.

Purpose To compare the 5‐year clinical and functional outcomes of the soft‐tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft. Methods A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft‐tissue QT or double‐tendon HT autograft with at least 5 years of follow‐up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications. Results A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2‐years’ postoperatively. At 5 years’ postoperatively, the QT group demonstrated significantly greater IKDC ( P = .018) and Lysholm ( P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years’ postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications. Conclusions Although the QT autograft demonstrated increased patient‐reported outcome scores when compared with the HT at 5 years’ postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years’ postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid‐term follow‐up. Level of Evidence III, retrospective comparison study.