Johnson, Nicholas R.

Background: There are limited data comparing the outcomes of all-inside versus inside-out meniscal repair techniques. Purpose: To assess failure rates and clinical outcomes after the surgical repair of bucket-handle meniscal tears utilizing either an all-inside or inside-out technique. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with bucket-handle meniscal tears undergoing all-inside or inside-out repair at a single institution between 2003 and 2013 were analyzed. A total of 28 mensici repaired utilizing second-generation all-inside suturing devices and 42 menisci repaired using an inside-out technique were eligible for inclusion. Rigorous propensity matching was performed on the basis of age, sex, tear laterality, rim width, and concomitant anterior cruciate ligament reconstruction (ACLR), resulting in a total of 40 patients equally distributed between the 2 repair techniques for comparison. Retear-free survival as well as preoperative and postoperative International Knee Documentation Committee (IKDC) and Tegner scores and physical examination findings were subsequently analyzed. Results: Twenty patients who underwent all-inside repair (14 male; mean age, 23.7 ± 6.7 years) were successfully propensity matched to 20 patients who underwent inside-out meniscal repair (15 male; mean age, 22.5 ± 7.6 years), with a mean retear-free follow-up of 4.4 years (range, 2.5-7.4 years). Four (20%) all-inside repairs and 4 (20%) inside-out repairs failed over the course of follow-up ( P > .999), with a mean time to failure of 2.7 years (range, 1.3-4.4 years) and 5.0 years (range, 0.8-7.5 years), respectively ( P = .25). Increasing patient age trended toward a decreased clinical retear rate, independent of the repair technique (hazard ratio, 0.86; P = .056). There were no significant differences in the Tegner scores, IKDC scores, or range of motion between the groups as a whole or when subcategorizing by age, sex, body mass index, tear complexity, rim width, isolated versus concomitant ACLR, or medial- versus lateral-sided repair. There were no complications in the all-inside group, while there was a 10% rate of minor complications in the inside-out group ( P = .49). Conclusion: Overall, satisfactory clinical outcomes are achievable at short-term to midterm follow-up with both inside-out and all-inside repair techniques of bucket-handle meniscal tears in rigorously matched patients with similar meniscal tear patterns.

Background: Multi-ligament knee injury (MLKI) associated with knee dislocation can result in vascular injury. The purpose of this study was to compare knee function after MLKI between patients with a vascular injury requiring popliteal artery bypass grafting and patients without vascular involvement. Additionally, factors associated with poor knee function in patients who had MLKI with vascular injury were evaluated. Methods: This retrospective study identified patients with an MLKI between 1992 and 2014. Each patient who had a concomitant vascular injury requiring bypass grafting (vascular cohort, n = 16; mean age, 30.3 years) was matched to 2 patients without a vascular injury (control cohort, n = 32; mean age, 31.4 years) on the basis of age, knee dislocation (KD) grade, and peroneal nerve status. Fifteen patients in the vascular cohort and 26 patients in the control cohort had an isolated knee injury. Functional outcomes were assessed with physical examination of range of motion and ligamentous stability as well as patient-reported outcome scores. Results: The vascular cohort had a mean Lysholm score of 62.5 points (range, 16 to 100 points) and a mean International Knee Documentation Committee (IKDC) score of 59.7 points (range, 14.9 to 100 points) at a mean (and standard deviation) of 8.3 ± 5.0 years after surgery. The control cohort had a mean Lysholm score of 86.4 points (range, 51.0 to 100.0 points) and a mean IKDC score of 83.8 points (range, 35.6 to 100.0 points) at a mean of 6.0 ± 4.0 years. The vascular cohort had significantly lower Lysholm (p = 0.001) and IKDC (p = 0.002) scores than the control cohort. A body mass index (BMI) of >30 kg/m 2 was predictive of lower IKDC (p = 0.0009) and Lysholm (p = 0.0008) scores. Conclusions: Patients who sustain an MLKI with an associated popliteal artery injury requiring bypass grafting have significantly lower knee function scores than patients without vascular involvement. This information can be used to help counsel patients with combined multiple ligament and popliteal artery injuries. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Osteochondritis dissecans (OCD) is a disorder of subchondral bone that causes adverse effects on the overlying cartilage and commonly affects the knee. The incidence of OCD and its long-term effect on the knee joint are controversial. Hypothesis/Purpose: The purpose of this study was to (1) evaluate the rate of osteoarthritis and knee arthroplasty in a population-based cohort of patients with OCD lesions treated operatively and (2) evaluate factors that may predispose patients to knee osteoarthritis and arthroplasty. The investigators hypothesized that OCD lesions diagnosed after skeletal maturity and treatment with fragment excision would be predictive of a diagnosis of osteoarthritis. Study Design: Cohort study; Level of evidence, 3. Methods: The investigators identified 221 patients (mean ± SD age, 26.1 ± 13.6 years) with OCD lesions treated operatively between 1976 and 2010 and followed for 16.3 ± 11.4 years (mean ± SD) from diagnosis. Information related to the diagnosis, laterality of lesion, details of treatment, and progression to osteoarthritis was obtained from the medical record. Surgical treatment was classified as fragment excision, fragment preservation (lesion drilling and/or fragment fixation), or chondral defect grafting (osteochondral allograft or autograft). Factors predictive of osteoarthritis and arthroplasty were examined. Results: There were 134 patients in the fragment excision group, 78 patients in the fragment preservation group, and 9 patients in the chondral defect grafting group. In the fragment excision group, the cumulative incidence of osteoarthritis was 12.0% at 5 years, 17.0% at 10 years, 26.0% at 15 years, 39.0% at 20 years, and 70% at 30 years. The cumulative incidence of arthroplasty was 2.0% at 5 years, 4.0% at 10 years, 4.0% at 15 years, 10.0% at 20 years, and 32.0% at 30 years. In the fragment preservation group, the cumulative incidence of osteoarthritis was 3.0% at 5 years, 7.0% at 10 years, 16.0% at 15 years, 25.0% at 20 years, and 51% at 30 years. The cumulative incidence of arthroplasty was 0.0% at 5 years, 0.0% at 10 years, 3.0% at 15 years, 6.0% at 20 years, and 11.0% at 30 years. No patients in the chondral defect grafting group developed osteoarthritis or underwent arthroplasty. Body mass index (BMI) greater than 25 kg/m 2 (hazard ratio [HR] 3.3; 95% CI, 1.6-7.0), older age at diagnosis (HR 4.9; 95% CI, 1.8-17.3), and fragment excision (HR 2.3; 95% CI, 1.2-4.6) were predictive of osteoarthritis. Conclusion: OCD patients treated with fragment excision have a high rate of osteoarthritis and knee arthroplasty at long-term follow-up. In contrast, patients treated with fragment preservation or chondral defect grafting have lower rates of osteoarthritis and arthroplasty. BMI greater than 25 kg/m 2 , older age at diagnosis, and fragment excision were predictive of osteoarthritis.

Background: The rate of patellofemoral arthritis after lateral patellar dislocation is unknown. Purpose/Hypothesis: The purpose of this study was to compare the risk of patellofemoral arthritis and knee arthroplasty between patients who experienced a lateral patellar dislocation and matched individuals without a patellar dislocation. Additionally, factors predictive of arthritis after patellar dislocation were examined. The hypothesis was that the rate of arthritis is likely higher among patients who experience a patellar dislocation compared with those who do not. Study Design: Cohort study; Level of evidence, 3. Methods: In this study, 609 patients who had a first-time lateral patellar dislocation between 1990 and 2010 were compared with an age- and sex-matched cohort of patients who did not have a patellar dislocation. Medical records were reviewed to collect information related to the initial injury, recurrent dislocation, treatment, and progression to clinically significant patellofemoral arthritis (defined as symptoms with degenerative changes on patellar sunrise radiographs). Factors associated with arthritis (age, sex, recurrence, osteochondral injury, trochlear dysplasia) were examined. Results: At a mean follow-up of 12.3 ± 6.5 years from initial dislocation, 58 patients (9.5%) in the dislocation cohort were diagnosed with patellofemoral arthritis, corresponding to a cumulative incidence of arthritis of 1.2% at 5 years, 2.7% at 10 years, 8.1% at 15 years, 14.8% at 20 years, and 48.9% at 25 years. In the control cohort, 8 patients (1.3%) were diagnosed with arthritis, corresponding to a cumulative incidence of arthritis of 0% at 5 years, 0% at 10 years, 1.3% at 15 years, 2.9% at 20 years, and 8.3% at 25 years. Therefore, patients who experienced a lateral patellar dislocation had a significantly higher risk of developing arthritis (hazard ratio [HR], 7.8; 95% CI, 3.9-17.6; P < .001) than individuals without a patellar dislocation. However, the risk of knee arthroplasty was similar between groups (HR, 2.8; 95% CI, 0.6-19.7; P = .2). Recurrent patellar dislocations (HR, 4.5; 95% CI, 1.6-12.6), osteochondral injury (HR, 11.3; 95% CI, 5.0-26.6), and trochlear dysplasia (HR, 3.6; 95% CI, 1.3-10.0) were associated with arthritis after patellar dislocation. Conclusion: Patellar dislocation is a significant risk factor for patellofemoral arthritis, as nearly half of patients have symptoms and radiographic changes consistent with arthritis at 25 years after lateral patellar dislocation. Osteochondral injury, recurrent patellar instability, and trochlear dysplasia are associated with the development of arthritis.