Tagliero, Adam J.

AbstractIntroductionAll‐polyethylene (AP) tibial components have demonstrated equivalent or improved long‐term survivorship and reduced cost compared with metal‐backed (MB) components in primary total knee arthroplasty; however, there is a lack of data comparing these outcomes in the setting of an oncologic endoprosthetic reconstruction.MethodsA total of 115 (88 AP:27 MB) patients undergoing cemented distal femur endoprosthetic reconstruction following oncologic resection were reviewed. Mean age was 40 years and 51% were females. Cumulative incidences of all‐cause revision, tibial component revision, reoperation, and infection were calculated utilizing a competing risk analysis with death as the competitor. Mean follow‐up was 14 years.ResultsThe 10‐year cumulative incidence of all‐cause revision was 19.9% in the AP group and 16.3% in the MB group (hazard ratio [HR] = 0.93, p = 0.88). The cumulative incidence of tibial component revision was significantly lower in AP compared with MB at 10 years (1.1% vs. 12.5%, HR = 0.18, p = 0.03). There was no difference in infection‐free survival when comparing the two groups (p = 0.72).ConclusionsReconstruction utilizing an MB or AP tibia component resulted in equivalent overall outcome; however, the tibial component in the AP group was less likely to be revised. AP tibial component should be considered for all primary oncologic reconstructions in the distal femur.Level of EvidenceLevel III Therapeutic.

AbstractIntroductionThe proximal humerus is a common location for primary and non‐primary tumors. Reconstruction of the proximal humerus is commonly performed with an endoprosthesis with low rates of structural failure. The incidence and risk factors for stress shielding are under reported.MethodsThirty‐nine (19 male, 20 female) patients underwent resection of the proximal humerus and reconstruction with a cemented modular endoprosthesis between 2000 and 2018. The mean resection length was 12 ± 4 cm and was most commonly performed for metastatic disease (n = 26, 67%).ResultsStress shielding was observed in 9 (23%) patients at a mean of 29 (6–132) months postoperatively. Patients with stress shielding were noted to have shorter intramedullary stem length (87 vs. 107 mm, p < .001), longer extramedullary implant length (16 vs. 14 cm, p = .01) and a higher extramedullary implant to stem length ratio (2.1 vs. 1.1, p < .001). The incidence of stress shielding was higher (p = .003) in patients reconstructed with 75 mm stem (n = 6, 67%) lengths.ConclusionStress shielding of the humerus was associated with the use of shorter stems and long extramedullary implants. The long‐term ramifications of stress shielding on implant stability, complications at the time of revision surgery, and overall patient outcomes remain unknown.

AbstractPurposeThere is limited data comparing the outcomes of knee arthroplasty for arthritis secondary to meniscus root tear versus primary osteoarthritis. The aim of this 2:1 matched case control series was to compare outcomes in patients who underwent arthroplasty for arthritis following a meniscus root tear (root tear cohort—“RTC”) with a control group of patients with primary osteoarthritis (primary osteoarthritis—“controls”). The authors hypothesized that the meniscus root tear patients would have similar clinical outcomes, return to activity, complication and reoperation rates as their matched controls.MethodsA consecutive series of patients who had a clinically and radiographically confirmed meniscus root tear between 2002 and 2017 at a mean 4.8 year follow‐up that developed secondary arthritis were matched 2:1 by laterality, surgery, age at surgery, date of surgery, sex, and surgeon to a control group of patients with primary osteoarthritis, without a root tear, who underwent arthroplasty. No patients were lost to follow‐up. Patient demographics, Kellgren–Lawrence grades at the time of surgery, pre‐ and post‐operative Knee Society Score pain and function scores, Tegner score, complications, and survival free of reoperation were analyzed between groups.ResultsA total of 225 subjects were identified, including 75 root tear cohort patients (13 UKA, 62 TKA) and 150 control patients. The root tear cohort had significantly lower Kellgren–Lawrence grades than the control group at the time of arthroplasty (p ≤ 0.001), but similar baseline pre‐operative Knee Society Score pain, Knee Society Score function, and Tegner activity scale score. Post‐operatively, Knee Society Score pain scores were comparable, and root tear cohort Knee Society Score function scores statistically significantly improved (p ≤ 0.007). Complication rates and survival free of reoperation at final follow‐up were not statistically significantly different between groups.ConclusionPatients treated with arthroplasty for secondary arthritis after a meniscus root tear demonstrated less severe radiographic arthritis, but similar pre‐operative pain levels compared to matched controls with primary osteoarthritis. The root tear cohort patients demonstrated improved outcomes with respect to function, and similar outcomes with respect to pain, activity level, complication rates, and reoperation rates. The authors conclude that arthroplasty can be a reliable option for selected patients with an irreparable root tear and ongoing pain and dysfunction refractory to non‐operative management, even in the setting of less advanced osteoarthritis on X‐ray.Level of evidenceIII.

Objectives: Meniscal root disruption results in a loss of hoop strain resistance, increased articular cartilage contact pressure, and acceleration of degenerative changes. There is limited data comparing the outcomes of similarly matched patients with a medial meniscus posterior root tear treated with non-operative management, partial meniscectomy, or repair. The purpose of this study is to compare treatment failure, clinical outcome scores, and radiographic findings for a matched cohort of patients who underwent either non-operative management, partial meniscectomy, or transtibial pull-through repair for a medial meniscus posterior root tear (MMPRT). Our hypothesis is that patients who underwent meniscus root repair will have lower rates of progression to arthroplasty than patients who were treated with non-operative management or partial meniscectomy. Methods: Patients who underwent transtibial medial meniscus posterior horn root repair were matched by meniscus laterality, age, sex and K-L grades to patients treated non-operatively or with a partial meniscectomy. Progression to arthroplasty rates, IKDC and Tegner scores, and radiographic outcomes were analyzed between groups. Results: Forty-five patients were included in this study (15 non-operative, 15 partial meniscectomy, 15 root repair). Progression to arthroplasty demonstrated significant differences among treatment groups at a mean 74 months (non-operative 4/15, partial meniscectomy 9/15, meniscus repair 0/15, p=.0003). The meniscus root repair group had significantly less arthritic progression, as measured by change in K-L grade from pre-op to post-op (non-operative 1.0, partial mensicectomy 1.1, and meniscus repair 0.1, p=.001). Conclusion: Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared to non-operative management and partial meniscectomy in a demographically matched cohort.

Purpose To determine (1) the demographic characteristics as well as radiographic findings of medial versus lateral meniscal root tears at time of presentation, (2) treatment decisions and clinical outcomes of patients undergoing medial versus lateral root repair, and (3) risk factors for worse clinical and radiographic outcomes. Methods A retrospective review was performed to identify patients with symptomatic, medial, or lateral meniscus posterior root tears with a minimum 2‐year follow‐up. Radiographs were graded using Kellgren‐Lawrence scores. Subanalysis was performed on 62 patients who underwent root repair. Tegner, Lysholm, International Knee Documentation Committee scores, and progression to arthroplasty were analyzed in the repair groups. Patient demographics, radiographic findings, and clinical outcomes were compared between medial meniscus posterior horn root tear (MMRT) and lateral meniscus root repair (LMRT). Results Of the 141 root tears, 109 were MMRTs, 30 were LMRTs, and 2 patients had both. At the time of injury, patients with MMRTs had a significantly higher age (MMRT = 51.4 vs LMRT=24.6, P < .0001), body mass index (MMRT = 32.1 vs LMRT 25.8, P < .0001), Kellgren‐Lawrence score (MMRT = 1.3 vs LMRT=0.6, P < .0001), and higher rate of major meniscal extrusion (MMRT = 72% vs LMRT = 20%, P < .0001). Of the 30 LMRT, 30/30 (100.0%) were treated with meniscal repair. With MMRT, 52/109 (48%) were treated nonoperatively, 27/109 (25%) with partial meniscectomy, and 30/109 (27%) with meniscal repair. Sixty‐two patients underwent meniscus root repair with an average 41‐month follow‐up. LMRT had significantly increased International Knee Documentation Committee (LMRT = 89.5, MMRT = 80.4, P = .02) and Tegner scores (LMRT = 6.5, MMRT = 5.1, P < .05) compared with MMRT. Conclusions Compared with MMRTs, LMRTs occur in younger male patients with lower body mass index, less cartilage degeneration, less extrusion on magnetic resonance imaging, and more commonly with a ligament injury. Although good to excellent clinical outcomes were attained in select patients for both medial and lateral meniscus root repair, LMRTs may have better results after repair, suggesting that differences in injury and patient characteristics may contribute to differences in these outcomes. Level of Evidence Retrospective comparative study, Level III.

Background: There are limited data comparing the outcomes of similarly matched patients with a medial meniscus posterior root tear (MMPRT) treated with nonoperative management, partial meniscectomy, or repair. Purpose/Hypothesis: The purpose was to compare treatment failure, clinical outcome scores, and radiographic findings for a matched cohort of patients who underwent either nonoperative management, partial meniscectomy, or transtibial pull-through repair for an MMPRT. We hypothesized that patients who underwent meniscus root repair will have lower rates of progression to arthroplasty than patients who were treated with nonoperative management or partial meniscectomy. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent transtibial medial meniscus posterior horn root repair were matched by meniscal laterality, age, sex, and Kellgren-Lawrence (K-L) grades to patients treated nonoperatively or with a partial meniscectomy. Progression to arthroplasty rates, International Knee Documentation Committee and Tegner scores, and radiographic outcomes were analyzed between groups. Results: Forty-five patients were included in this study (15 nonoperative, 15 partial meniscectomy, 15 root repair). Progression to arthroplasty demonstrated significant differences among treatment groups at a mean of 74 months (nonoperative, 4/15; partial meniscectomy, 9/15; meniscal repair, 0/15; P = .0003). The meniscus root repair group had significantly less arthritic progression, as measured by change in K-L grade from pre- to postoperatively (nonoperative, 1.0; partial meniscectomy, 1.1; meniscal repair, 0.1; P = .001). Conclusion: Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared with nonoperative management and partial meniscectomy in a matched cohort based on patient characteristics.

Aims A number of methods have been described to remove a well-fixed humeral implant as part of revision shoulder arthroplasty. These include the use of cortical windows and humeral osteotomies. The router bit extraction technique uses a high-speed router bit to disrupt the bone-implant interface. The implant is then struck in a retrograde fashion with a square-tip impactor and mallet. The purpose of this study was to determine the characteristics and frequency of the different techniques needed for the removal of a well-fixed humeral stem in revision shoulder arthroplasty. Patients and Methods Between 2010 and 2018, 288 revision shoulder arthroplasty procedures requiring removal of a well-fixed humeral component were carried out at a tertiary referral centre by a single surgeon. The patient demographics, indications for surgery, and method of extraction were collected. Results Of the 288 revisions, 284 humeral stems (98.6%) were removed using the router bit extraction technique alone. Four humeral stems (1.39%) required an additional cortical window. Humeral osteotomy was not necessary in any procedure. Most of the humeral stems removed (78.8%) were cementless. Of the four humeral stems that required a cortical window, three involved removal of a hemiarthroplasty. Two were cemented and two were cementless. Conclusion The router bit extraction technique removed a well-fixed humeral component in a very high proportion of patients (98.6%). This method allows surgeons to avoid more invasive approaches involving a cortical window or humeral osteotomy, and their associated complications. Cite this article: Bone Joint J 2019;101-B:1280–1284

Objectives: Meniscus repair is desirable over resection to prevent post-meniscectomy arthritis, especially in young and active patients. However, long-term data is currently lacking following isolated meniscus repair, particularly in the pediatric population. The purpose of this study was to report long-term follow-up of isolated meniscus tears treated by meniscus repair in a pediatric population, and to compare those results to previous mid-term follow-up data reported. We hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Methods: Patients less than 18 undergoing repair of an isolated (without concomitant ACL injury) meniscus tear performed between 1990 and 2005 were included. At the time of final followup, recurrent tear, reoperations, and IKDC and Tegner scores were determined. With logistic regression, the overall failure between different tear types was calculated. Wilcoxon signed ranks tests were performed to calculate the differences in clinical outcome for different time-points, and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At an average followup of 17.6 years (13.1 - 26.0 years), 32 patients with 33 isolated meniscus repairs (29 M: 3F) with an average age of 16.1 (9.9 - 18.7) were included in this study. At early follow-up, complex tears (80%) had a higher overall failure rate compared to simple tears (18.2%). However, no further failures occurred since mid-term follow-up with any tear type. At final follow-up, the average IKDC score was 92.3, which was significantly increased when compared to both preoperative 65.3 (p< 0.0001) and mid-term scores, 90.2 (p= 0.01). However, the average Tegner score (6.5) was significantly lower than both pre-operative 8.3 (p< 0.0001) and mid-term 8.4 (p< 0.0001) scores. There was no correlation for Tegner or IKDC values with any risk factors. Conclusion: In conclusion, this study demonstrates overall good to excellent long-term clinical outcomes following isolated meniscus repair in a pediatric population. Early failure and reoperation rates were variable depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears compared to other tear types.

Purpose To compare patellar bone socket and cortical surface fixation techniques for isolated medial patellofemoral ligament (MPFL) reconstruction and determine whether there was a difference in (1) complication rates, including fracture of the patella; (2) redislocation rates; or (3) patient‐reported outcomes. Methods A literature search was conducted following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, or less than 3 months of follow‐up were excluded. Risk‐of‐bias assessment was performed using the Methodological Index for Non‐randomized Studies (MINORS) system. Studies were classified by surgical technique (patellar bone socket group [group S] vs cortical fixation group [group F]), and complications, redislocations, and patient‐reported outcomes were collected. Results A total of 29 studies yielded 981 patients with MPFL reconstruction for inclusion. Of the patients, 620 underwent a patellar bone socket technique and 361 underwent a cortical fixation technique. Patients ranged in age from 11 to 68 years. Patellar fracture rates ranged from 0% to 17% in group S and were 0% in all group F studies. Mean Kujala scores ranged from 83.5 to 93.6 in group S and from 84.4 to 94.5 in group F. Mean Lysholm scores ranged from 84.6 to 91.7 in group S and from 83.5 to 95 in group F. Redislocation rates ranged from 0% to 21% in group S and from 0% to 13% in group F. Although heterogeneous in nature, complication rates ranged from 0% to 28% in group S and from 0% to 4% in group F. Conclusions MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall, complications remained uncommon. Clinically, the bone socket group had comparable postoperative redislocation rates and patient outcomes to the group treated with cortical fixation techniques. Level of Evidence Level IV, systematic review of Level I through IV studies.

Background: Meniscal repair is desirable over resection to prevent postmeniscectomy arthritis, especially among young and active patients. However, long-term data are currently lacking following isolated meniscal repair, particularly in the pediatric population. Purpose/Hypothesis: To report long-term follow-up of isolated meniscal tears treated by meniscal repair in a pediatric and adolescent population and to compare those results with previous midterm follow-up data reported. The authors hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Forty-four patients aged ≤18 years undergoing repair of an isolated meniscal tear (without concomitant anterior cruciate ligament injury) between 1990 and 2005 were included. At the time of final follow-up, recurrent tear, reoperations, and International Knee Documentation Committee (IKDC) and Tegner scores were determined. With logistic regression, the overall failure among tear types was calculated. Wilcoxon rank sum analysis were performed to calculate the differences in clinical outcome for different time points, and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At a mean follow-up of 17.6 years (range, 13.1-25.9 years), 32 patients with 33 isolated meniscal repairs (29 male, 3 female) with a mean age of 16.1 years (range, 9.9-18.7 years) at surgery were included in this study. At early follow-up, the overall failure rate was 14 of 33 (42%); complex tears (80%) and bucket-handle tears (47%) had higher overall failure rates when compared with simple tears (18.2%), although only complex tears had a significantly higher failure rate. However, no further failures occurred since midterm follow-up with any tear type. At final follow-up, the mean IKDC score was 92.3, which was significantly increased when compared with preoperative (65.3, P < .0001) and midterm (90.2, P = .01) scores. The mean Tegner score (6.5) was significantly lower than both preoperative (8.3, P < .0001) and midterm (8.4, P < .0001) scores. There was no difference in Tegner or IKDC score for patients with successful versus failed repair. Conclusion: In conclusion, while there was a high early failure rate, this study demonstrated overall good to excellent long-term clinical outcomes after isolated meniscal repair in an adolescent population, even for those requiring reoperation. Early failure and reoperation rates were variable, depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears as compared with other tear types.