Reardon, Patrick J.

Purpose To (1) assess clinical outcomes of revision multiligament knee injury (MLKI) reconstruction at a minimum of 2 years' follow‐up and (2) present a standardized treatment algorithm used in treating revision MLKI patients. Methods A retrospective review of our institution's MLKI database was performed to identify all patients who underwent revision MLKI reconstructions (≥2 ligaments reconstructed) after implementation of a standardized treatment algorithm in 2000 and had a minimum of 2 years' follow‐up. Patient demographic information, injury description (mechanism of injury, neurovascular status, knee dislocation grade, associated chondral or meniscal injury), surgical technique (repair vs reconstruction, staged vs nonstaged, concomitant procedures), mechanism of failure, knee stability, and range of motion, as well as International Knee Documentation Committee and Lysholm scores, were obtained. Results We assessed 23 patients (8 female and 15 male patients), with an average age of 26.7 ± 11.5 years at primary surgery and 30.8 ± 11.0 years at revision surgery. The mean follow‐up period was 7.5 ± 5.3 years. Of the 23 patients, 10 (43.4%) underwent staged revision procedures: isolated bone grafting in 3, osteotomy in 4, hardware removal with osteochondral allograft in 1, hardware removal with bone grafting in 1, and meniscus repair for a locked knee in 1. The average International Knee Documentation Committee and Lysholm scores were 74.5 ± 22.3 and 79.4 ± 20.2, respectively. High‐energy injury and increasing age at revision surgery were the only risk factors found to be associated with significantly worse outcomes ( P < .05). Conclusions Patients with recurrent instability after MLKI reconstruction present with many concomitant pathologies, including limb malalignment, bone tunnel widening, retained hardware, meniscal incompetence, and cartilage defects. Revision MLKI reconstruction can provide these patients with modest functional outcomes when a standardized treatment algorithm is used focusing on identification and treatment of the concomitant pathology, often in a staged manner. Level of Evidence Level IV, case series.

Background: The cases of patients with medial compartment osteoarthritis who were ≤55 years old and had a proximal tibial osteotomy (PTO) or medial unicompartmental knee arthroplasty (UKA) were compared. Outcomes included postoperative activity level, function, and survivorship free of revision to total knee arthroplasty. Methods: Between 1998 and 2013, data were available for 240 patients between 18 and 55 years old with medial compartment arthritis and varus malalignment who were treated either with PTO (57 patients) or with UKA (183 patients). The mean age was 42.7 years for the 57 patients (41 men and 16 women) in the PTO group versus 49.2 years for the 183 patients (82 men and 101 women) in the UKA group. The Tegner activity level and Lysholm knee scores were evaluated at 3 months and at 1, 2, and 5 years postoperatively as well as at the time of the final follow-up. The end point for survival was defined as revision to total knee arthroplasty. A Wilcoxon rank-sum test was used to evaluate the difference between the groups with respect to the Tegner and Lysholm scores at the respective follow-up intervals. Multivariate regression was used to assess potential confounders. Results: Preoperatively, the PTO and UKA groups had similar Tegner (3.0 ± 1.3 and 2.6 ± 0.09, respectively) and Lysholm scores (69.5 ± 7.3 and 71.6 ± 5.4). Postoperatively, the UKA group had significantly superior mean Tegner scores compared with the PTO group at 3 months (3.82 and 2.02, respectively), at 2 years (4.33 and 3.75), and at the time of the final follow-up (4.48 and 3.08), while the Lysholm scores were higher at 3 months (88.0 and 76.3) and at the final follow-up (90.0 and 80.2) (p < 0.01 for all). Multivariate analysis showed UKA to be an independent predictor of activity level at 3 months, 1 year, and 2 years, as well as at the final follow-up. The survivorship was 77% in the PTO group at an average of 7.2 years and 94% in the UKA group at an average of 5.8 years (p < 0.01). The average time to failure was 98 months (range, 38 to 169 months) in the PTO group and 42 months (range, 2 to 123 months) in the UKA group (p < 0.01). Conclusions: In this comparative cohort study of young patients with isolated unicompartmental arthritis, those treated with UKA reached a higher level of activity early after surgery and it persisted at mid-term follow-up. The UKA group had earlier, but less frequent, revision to total knee arthroplasty. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Purpose To compare microfracture (MFX) and osteochondral autograft transfer (OAT) surgical techniques to determine (1) postoperative activity level, (2) subjective patient outcomes, (3) failure rates, and (4) assess if any lesion characteristics favored one technique over the other. Methods A comprehensive review of literature was performed of all studies comparing MFX and OAT. Studies included were all prospective studies that reported on activity‐based outcome measures such as Tegner activity scores and subjective outcomes such as the International Knee Documentation Committee score. Failure rates, as determined by the publishing authors, were recorded for each study. Meta‐analyses were conducted using a random‐effects model. Paired standardized mean differences (Hedges's g to account for small sample bias) were used for continuous outcome measures, and risk ratios (Mantel‐Haenszel method for small sample bias) for dichotomous outcome measures. Results Six prospective studies satisfied the eligibility criteria and included 249 patients (186 male, 120 female) with an average age of 26.4 years and follow‐up of 67.2 months. Tegner scores were superior in patients treated with OAT compared with MFX (ΔOAT‐MFX for pre‐post scores = 0.94 Tegner points, standardized mean difference [SMD] = 0.469, P = .005). Failure rates of MFX were higher than OAT (OAT = 11%, MFX = 32%, risk ratio = 2.42, P < .036). OAT was superior to MFX at 3 years in relation to subjective outcome scores (SMD = 0.404, P = .008). When assessing OAT lesions larger than 3 cm 2 , OAT was superior to MFX with respect to activity level (SMD = 0.506, P = .001). Conclusions OAT may achieve higher activity levels and lower risk of failure when compared with MFX for cartilage lesions greater than 3 cm 2 in the knee, although there was no significant difference for lesions less than 3 cm 2 at midterm. However, because of variability in patient‐specific factors such as age, preinjury activity level, lesion location and size, the superiority of OAT over MFX cannot be generalized to all patient populations and therefore requires individualized patient care. Level of Evidence Level II, meta‐analysis of Level I and II studies.

Objectives: Medial meniscus posterior root tears (MMPRTs) present a unique challenge for both patients and surgeons as these tears have shown to be biomechanically equivalent to complete meniscectomy. However, little is known about the natural history of these lesions. Therefore, the purpose of this study is to describe the clinical course of MMPRTs with respect to subsequent operative and non-operative treatments, and associated comorbidities. Methods: Over 2600 MRIs were identified by searching radiologist reads for the terms “root” or “root tear” from 2005-2013. Presence or absence of MMPRTs and other associated boney, meniscal, or ligamentous injuries were identified and recorded. Of these MRIs, 102 MRIs from 102 patients who had unrepaired MMPRTs with minimum 2-year follow-up and no prior ligamentous surgery were followed. These MRIs were evaluated to confirm the presence of a meniscal root tear and the presence or absence of associated meniscal or ligamentous injuries, as well as meniscal extrusion, subchondral edema, or insufficiency fractures. Chart review was performed to obtain the treatment summary after diagnosis. Radiographs from before and after the diagnosis of MMPRT were reviewed and Kellgren-Lawrence scores were determined. Finally, the association between concomitant boney, ligamentous, or meniscal injuries, patient factors, and rate of arthroplasty, as well as final Kellgren-Lawrence scores were evaluated. Chi-square analysis was used for categorical variables, and Wilcoxon Rank-Sums was used for continuous variables. Kaplan-Meier analysis was used to evaluate the effect of meniscal extrusion on the time-dependant rate of arthroplasty. Results: 104 patients (43 M:61F) were diagnosed with MMPRTs at a mean age of 54±13. These patients were followed for a mean of 66±26 months. 75 (74%) patients had associated meniscal extrusion, 64 (62%) had associated subchondral edema, and 14 (13%) had associated insufficiency fractures at the time of diagnosis. After initial diagnosis, 59 (58%) underwent subsequent surgical treatment. This included 52 (51%) patients undergoing arthroscopic partial meniscectomy, and 29 (28%) patients undergoing total knee arthroplasty at a mean 38±32 (range 3-107) months after MRI. Kellgren-Lawrence grades worsened from 1.3±0.7 before diagnosis to 2.2±1.0 after (p<0.001), with a mean 44±32 months between radiographs. There was a higher rate of radiographic arthritis (K-L grade 2+) after diagnosis (73%) than before diagnosis (36%) (p<0.001). The presence of meniscal extrusion on MRI was associated with the presence of arthritis on post-diagnosis radiographs (p=0.03). Meniscal extrusion, subchondral edema, and insufficiency fractures were not associated with increased rates of surgical treatment, or time to arthroplasty. Conclusion: Little information is available to guide patients and physicians on the clinical outcomes for MMPRTs. These injuries are associated with a relatively high rate of arthroplasty and worsening arthritis, especially with concomitant meniscal extrusion. More information is needed to determine the efficacy of meniscal root repair in preventing these unfavorable outcomes.

Abstract Varus knee malalignment caused by medial compartment arthritis results in progressive asymmetric wear of the tibiofemoral joint. This wear can cause progressively painful gonarthrosis. Surgical methods to address varus knee malalignment include lateral closing‐wedge proximal tibial osteotomy, medial opening‐wedge osteotomy, and arthroplasty. Medial opening‐wedge proximal tibial osteotomy is an effective procedure for restoring proper coronal alignment and reducing knee pain. In this technical note, we present a reproducible technique for proximal tibial osteotomy. Technique Video video See video under supplementary data.

Background: Hip arthroscopy for young patients with femoroacetabular impingement (FAI) has been successful, but the efficacy of hip arthroscopy in older patients is not clearly defined. Purpose: To evaluate the clinical outcomes of patients 55 years and older who are undergoing hip arthroscopy and to compare outcomes with those of patients younger than 55 years. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 201 (63 male, 138 female) patients undergoing primary hip arthroscopy for FAI without radiographic arthritis (Tönnis grade <3) were isolated from a prospective database and stratified by age to <55-year and ≥55-year groups. Patients were evaluated preoperatively and 1 and 2 years postoperatively using the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS: functional scores, as well as Activities of Daily Living [ADL] and Sport subscales). A Wilcoxon signed rank sum test was used to evaluate the differences in outcome scores between the cohorts at each interval. Results: The <55-year group included 174 patients (mean age, 37 ± 12 years), and the ≥55-year group included 27 patients (mean age, 61 ± 5 years). The minimum follow-up time was 2 years in each group. Preoperative Tönnis grades and mHHS scores (59 vs 59; P = .75) were similar between groups. The ≥55-year cohort underwent labral debridement more frequently (78% vs 36%; P =.02) and were more likely to have full-thickness cartilage defects (22% vs 4%; P = .04). Despite this, the mHHS in both groups improved significantly from baseline, without significant differences at 1 year (86 [≥55 years] vs 81 [<55 years]; P = .53) or 2 years (73.88 [≥55 years] vs 79.54 [<55 years]; P = .06). However, at a minimum 2-year follow-up, patients <55 years had significant improvements over patients ≥55 years in the HOS subscales for ADL score (85.6 vs 75.2; P = .03), ADL rating (80.1 vs 70.0; P = .004), Sport score (70.2 vs 55.6; P = .04), and Sport rating (70.2 vs 58.0; P = .04). Conclusion: Although younger patients had superior HOS outcomes reported at 2 years compared with older patients after hip arthroscopy for FAI, both groups had significant improvement compared with their baseline. These data suggest that carefully selected patients 55 years and older without radiographic arthritis may benefit from hip arthroscopy.

Abstract Coronal limb malalignment is a significant contributor to asymmetric joint wear, gait abnormalities, and the development and progression of degenerative joint disease. Osteotomies about the knee were developed to realign the mechanical axis of the limb to unload the affected compartment. Valgus malalignment is less common than varus malalignment, but can contribute to a variety of clinical conditions, including lateral compartment cartilage defects and arthritis, lateral patellofemoral instability, and medial collateral ligament laxity. In this article, we describe our preferred operative technique for a lateral opening wedge varus‐producing distal femoral osteotomy to correct mild to moderate valgus malalignment. Technique Video video See video under supplementary data.

Purpose To (1) evaluate long‐term outcomes of osteochondral allograft (OCA) with regard to clinical outcome scores, reoperation and failure rates, and (2) examine if certain factors predispose patients to worse outcomes. Methods A comprehensive review was performed with specific inclusion criteria for studies with long‐term outcomes after OCA. Studies reported on patient clinical scores such as Hospital for Special Surgery score, Knee Society Score (knee and function score), and Lysholm score. Reoperation and failure rates were recorded for each study. Modified Coleman Methodology Scores assessed study methodological quality. Results Five studies with a total of 291 patients (55% male, 45% female) and average age of 34.8 years (range, 15 to 69 years) were included. Of all lesions, 67% were on the femoral condyles, 29% on the tibial plateau, and 4% were patellofemoral. All scores (Knee Society Function Score, Knee Society Knee Score, and Lysholm score) have significant mean improvement from preoperative to final follow‐up. The mean postoperative Hospital for Special Surgery score was 84.1. The mean failure rate was 25% at 12.3 years with a reoperation rate of 36%. A total of 72% of the failures were conversion to total (68%) or unicompartmental (4%) knee arthroplasty and 28% involved graft removal, graft fixation, and graft revision. Patellofemoral lesions (83%) had a significantly higher reoperation rate than lesions involving the tibial plateau or the femoral condyles (34%, P = .01). Conclusions Overall, OCA demonstrated significant improvements in clinical outcome scores and good durability with successful outcomes in 75% of the patients at 12.3 years after surgery. Patellofemoral lesions are associated with decreased clinical improvement and more frequent reoperations. The orthopaedic literature is limited by heterogeneity in surgical technique, lesion and patient characteristics, and reporting of nonstandardized outcome measures. Level of Evidence Level IV, systematic review of Level II and IV studies.

Objective Autologous chondrocyte implantation (ACI) has not been proven to be durable over the long-term. The purpose of this systematic review was (1) to evaluate activity level and knee function, (2) to evaluate reoperation and failure rates, and (3) to analyze risk factors for reoperation and failure of ACI at minimum long-term follow-up. Design A comprehensive review was performed for studies with long-term outcomes after ACI for cartilage defect repair. Studies reported outcome scores such as Tegner score, Lysholm score, and International Knee Documentation Society (IKDC) score along with rates of failure and reoperation. Modified Coleman Methodology Scores were calculated to assess study methodological quality. Results Nine studies with a total of 771 patients with a mean age of 33.4 ± 2.5 years, mean defect size of 5.9 ± 1.6 cm 2 , and mean follow-up of 11.4 years were included. Tegner score, Lysholm score, and IKDC score change from preoperative to final follow-up was 1.1 (95% CI 0.8-1.4, P < 0.001), 24.9 points (95% CI 18.8-31, P < 0.001), and 16.5 points (95% CI 5.4-27.5, P < 0.01), respectively. The mean failure and reoperation rates were 18% and 37%, respectively. Increased age and lesion size (>4.5 cm 2 ) were significantly correlated with increased risk of reoperation and failure. Conclusions Overall, ACI demonstrated successful outcomes in 82% of patients over the long-term. Increased patient age and lesion size greater than 4.5 cm 2 were risk factors for a higher reoperation and failure rate. Nonetheless, this review is limited by heterogeneity in surgical technique, and lesion and patient characteristics.

Purpose To evaluate (1) activity level and knee function, (2) reoperation and failure rates, and (3) risk factors for reoperation and failure of osteochondral autograft transfer (OAT) at minimum long‐term follow‐up. Methods A comprehensive review was performed for long‐term outcomes after OAT. Studies reported on activity‐based outcomes (Tegner Activity Scale) and clinical outcomes (Lysholm score and International Knee Documentation Committee score). Reoperation and failure rates, as defined by the publishing authors, were recorded for each study. Modified Coleman Methodology Scores were calculated to assess study methodological quality. Results Ten studies with a total of 610 patients with an average age of 27.0 years at the time of surgery and a mean follow‐up of 10.2 years were included. The mean defect size was 2.6 cm 2 (range, 0.9 to 20.0 cm 2 ). The mean duration of symptoms before surgery was 4.8 years. From preoperative to final follow‐up, International Knee Documentation Committee scores and Lysholm scores improved significantly by 42.4 (95% confidence interval [CI], 31.8 to 53.1, P < .001) and 21.1 (95% CI, 12.2 to 30.0, P < .01), respectively. Tegner score did not improve significantly (0.76, 95% CI, −0.83 to 2.36, P = .35). Overall failure rate was 28% and reoperation rate was 19%. Increased age, previous surgery, and defect size positively correlated with increased risk of failure. Concomitant surgical procedures negatively correlated with failure rate. Conclusions Overall, OAT showed successful outcomes in 72% of patients at long‐term follow‐up. Increased age, previous surgery, and defect size correlated positively with failure rate, whereas success improved with concomitant surgical procedures. Nonetheless, this systematic review is limited by heterogeneity in a surgical technique, lesion and patient characteristics, and reporting of nonstandardized outcome measures. Level of Evidence Level IV, systematic review of Level I‐IV studies.