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AbstractPurposeThe purpose of this study was to evaluate the effect of preoperative patella alta on clinical outcomes, survivorship, and complication and reoperation rates on patellofemoral arthroplasty (PFA).MethodsAll patients who underwent PFA for isolated patellofemoral arthritis by a single surgeon at our institution were identified. Preoperative radiographs were measured by two independent observers for patellar height using the Caton Deschamps (CD), Insall‐Salvati (IS), and Blackburne‐Peele (BP) methods. Patients were classified as either “patella alta” or “non‐patella alta” for all three measurement methods. Clinical scores including KSS Pain, KSS Function, and Tegner Activity Scores were collected pre‐ and post‐operatively. Failure was defined as conversion to total knee arthroplasty (TKA). Clinical outcomes and survivorship were compared between patients with “patella alta” and “non‐patella alta” height measurements.ResultsThere were 119 patients with 153 knees (86% female) included in the study with a mean age of 55.8 years. Outcome scores improved from pre‐operative to post‐operative for both patella alta and non‐patella alta patients for Tegner, KSS pain and KSS function scores. The mean change in Tegner scores for patella alta and non‐patella alta patients were not significantly different for CD (p = 0.24), IS (p = 0.25) or BP measurements (p = 0.39). The mean change in KSS pain scores between groups were not significantly different for CD (p = 0.33) or IS measurements (p = 0.22), but was improved more significantly in patella alta patients vs non‐patella alta patients (21.2 and 14.4; p = 0.02) for BP measurement. The mean change in KSS function scores between groups was not significantly different for CD (p = 0.61) IS (p = 0.90) or BP measurements (p = 0.79). The overall survivorship from conversion to total knee arthroplasty (TKA) was 94.1% at a mean follow‐up time of 5.0 (SD 2.6) years. There were no significant differences in survivorship from TKA between patella alta and non‐patella alta groups (CD: p = 0.72, IS: p = 0.63, BP: p = 0.66).ConclusionsThis study suggests that there are no significant differences in clinical outcome scores or survivorship from TKA between patella alta and non‐patella alta patients who underwent onlay design PFA. Both patella alta and non‐patella alta patients demonstrated excellent improvement in outcome scores from pre‐operative to post‐operative.Level of evidenceIV.

Abstract Background The majority of patients with of Mitral-valve-prolapse (MVP) have a excellent prognosis. Until recently most cases of mortality were thought to be related to mitral regurgitation and left ventricular dysfunction. The concept of the arrhythmic MVP emerged to describe cases of sudden cardiac death (SCD) in the presence of isolated MVP yet it’s phonotype remains incompletely and inconsistently defined. Purpose To analyze the prevalence, severity and characteristics of ventricular-arrhythmia (VA), to determine it’s phenotypical context and independent impact on outcome in patients with MVP. Methods A cohort of 595 (65 ± 16 years, 278 female) consecutive patients with MVP and comprehensive clinical, arrhythmia (24hour-Holter) and Doppler-echocardiographic characterization, was identified and long-term outcome analyzed. Results VA was frequent, present in 43% of patients with at least ventricular ectopy≥5%, but was most often moderate (ventricular-tachycardia—VT 120-179bpm) in 27% and rarely severe (VT≥180/min) in 8.6%. Presence of VA was associated with older age, male sex, bileaflet-prolapse, marked leaflet redundancy, mitral-annulus-disjunction (MAD), larger left-atrium and left ventricular end-systolic diameter, and T-wave-inversion/ST-depression (all P ≤ 0.001). Severe VA was independently associated with presence of MAD, leaflet-redundancy and T-wave-inversion/ST-depression (all P < 0.0001) but not with mitral regurgitation severity or ejection-fraction. Outcome primary endpoint of overall survival after arrhythmia diagnosis (8-year 87 ± 2%) was strongly associated with arrhythmia-severity (8-year 90 ± 2% for no/trivial arrhythmia, 85 ± 3% for mild/moderate and 76 ± 7% for severe arrhythmia. P = 0.02, Figure). Excess-mortality was substantial for severe-arrhythmia (univariate-hazard-ratio 2.70[1.27-5.77], P = 0.01 vs. no/trivial arrhythmia), even adjusted comprehensively including for MVP-characteristics (adjusted-hazard-ratio 2.94[1.36-6.36], P = 0.006) ). Conclusions This large cohort of isolated consecutive MVP characterized with 24-hour-Holter monitoring, clinical and Echocardiographic assessment, demonstrates that VA are frequent with MVP but rarely severe. The arrhythmic MVP was independently and strongly associated with specific ECG and morphologic patterns, particularly ST-T changes, MAD presence and marked leaflet redundancy, suggestive of a specific arrhythmic MVP phenotype, independently of MR-severity. Arrhythmia, particularly severe, is associated with long-term excess-mortality, independently of any other characteristics, including MR severity and LVEF. These findings lay the foundation for novel risk-stratification of MVP for the conduct of prospective controlled studies evaluating the management of MVP high-risk patients. Figure – Impact on survival of ventricular arrhythmia Overall survival of MVP stratified by ventricular arrhythmia (Panel A) or ventricular arrhythmia severity (Panel B) throughout follow-up. Abstract Figure.

Objectives: Little is known about the natural history and long-term outcome of a surgically treated symptomatic lateral discoid meniscus. The goals of this study were to describe the rate and factors associated with recurrent lateral meniscus tears and progression to symptomatic lateral compartment osteoarthritis (OA) in patients surgically treated for a symptomatic lateral discoid meniscus. Patients with surgically treated lateral discoid meniscus have a high incidence of meniscus re-tear and progression to lateral compartment OA. Methods: A large, geographic database was reviewed to identify and confirm patients presenting with symptomatic lateral discoid meniscus between 1998 and 2015. Charts were reviewed to document treatment and outcomes at a minimum clinical follow-up of two years. Results: 70 discoid meniscus patients (30 F, 40 M) with a mean age of 27 years (Range: 2.0-66.0) were followed for an average of 5.8 years (Range 2.0-23.7). Sixty patients underwent surgical management: 49 (82%) patients underwent partial lateral meniscectomy and 11 (18%) underwent meniscus repair (including saucerization). Tear-free survival following surgery was 93% at 2 years, 69% at 5 years, and 40% at 8 years. Overall progression to symptomatic lateral compartment OA in the surgical group was 10% at 2 years, 23% at 5 years, and 48% at 8 years. Of those patients who developed lateral compartment OA, 55% (11/20) had a Kellgren-Lawrence score 2 or greater at last radiographic follow-up. Young age and open growth plates were associated with increased incidence of postoperative re-tear (HR: 0.96, CI: 0.93-0.99, p = 0.01). Increased age at diagnosis and BMI ≥ 30 were associated with increased risk of progression to lateral compartment OA on final radiographs. Conclusion: Patients with a surgically treated lateral discoid meniscus tear had a high rate of recurrent meniscus tear at long-term follow-up (60% at 8 years) that was associated with young age. Approximately 48% of surgically treated patients developed symptomatic lateral compartment OA at eight years from initial presentation. The risk of progression to OA increased with older age at diagnosis and BMI ≥ 30.

Background: Little is known about the natural history of a surgically treated symptomatic lateral discoid meniscus. The goals of this study were to describe the rate and factors associated with recurrent lateral meniscal tears and progression to symptomatic lateral compartment osteoarthritis (OA) in patients surgically treated for a symptomatic lateral discoid meniscus. Hypothesis: Patients with surgically treated lateral discoid meniscus have a high incidence of meniscal retear and progression to lateral compartment OA. Study Design: Case series; Level of evidence, 4. Methods: A large geographic database was reviewed to identify and confirm patients presenting with symptomatic lateral discoid meniscus between 1998 and 2015. Charts were reviewed to document treatment and outcomes at a minimum clinical follow-up of 2 years. Results: A total of 59 patients (27 females, 32 males) with a mean age of 25.7 years (range, 4.0-66.0 years) underwent surgical management of a discoid lateral meniscus and were evaluated for a mean of 5.6 years (range, 2.0-23.7 years). Of these, 48 (82%) patients underwent partial lateral meniscectomy, with 24 patients undergoing concurrent saucerization. Eleven (18%) underwent meniscal repair. Tear-free survival following surgery was 41% at 8 years. Progression to symptomatic lateral compartment OA was 50% at 8 years. Young age (hazard ratio, 0.96; 95% CI, 0.93-0.99; P = .01) and open growth plates (hazard ratio, 3.19; 95% CI, 1.15-8.88; P = .03) were associated with increased incidence of postoperative retear. Older age at diagnosis and body mass index ≥30 kg/m 2 were associated with increased risk of progression to lateral compartment OA on final radiographs. Conclusion: Patients with a surgically treated lateral discoid meniscal tear had a high rate of recurrent meniscal tear (59% at 8 years). Approximately 50% of surgically treated patients developed symptomatic lateral compartment OA at 8 years from diagnosis.

Background Adductor canal block (ACB) is an alternative method to femoral nerve block (FNB) for post-operative analgesia for anterior cruciate ligament reconstruction (ACLR) in pediatric and adolescent patients. Prior studies have suggested that FNB is associated with persistent strength deficits at 6 months after ACLR in this population. Proponents of the ACB consider that this method may result in a decreased incidence of quadriceps strength deficits during post-operative rehabilitation. The purpose of this study was to compare knee strength and function at 6 and 9 months after ACLR in pediatric and adolescent patients who received FNB versus ACB peri-operatively. Methods Patients 18 years or younger who underwent primary ACLR between 2002 and 2017 at a single institution were identified. ACLR was performed with either a patellar tendon autograft or hamstring autograft. A transphyseal ACLR was performed in patients with open physes. All patients participated in a comprehensive rehabilitation program which included isokinetic strength testing and functional testing at 6 and/or 9 months postoperatively. Patients were excluded if they underwent multiligamentous knee reconstruction, concomitant cartilage restoration procedures, did not receive perioperative FNB or ACB, or if they did not complete isokinetic strength and functional testing at 6 or 9 months. The included cohort was separated into FNB group and ACB group for comparison. Isokinetic extension and flexion strength deficits and functional deficits in vertical jump, single hop, and triple hop between the two groups were compared at both time points. A strength deficit of 15% or less and a functional deficit of 10% or less compared to the contralateral side were considered satisfactory. Univariate analysis was performed to assess for differences in patient demographics and surgical variables. A 1:1 matched subgroup analysis between the two groups was performed to account for possible differences in outcomes associated to graft types, concomitant meniscus repair, and BMI. Results Of the 240 patients identified, 85 patients (64 FNB, 21 ACB) with a mean age of 15.9 years (Range: 11-18) met inclusion criteria for comparison at 6 months and 76 patients (40 FNB, 36 ACB) with a mean age of 15.5 years (Range: 12-17) met inclusion criteria for comparison at 9 months. Univariate analysis showed significantly greater deficits at 6 months in the FNB with respect to fast isokinetic flexion strength (7.7% vs. -4.9%; p = .03). There were no differences in slow isokinetic flexion (10.5% vs. 6.8%; p = .79) and fast isokinetic extension (11.9% vs. 13.9%; p = .68) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (19.3% vs. 12.0%; p = .24), but this did not reach statistical significance. This clinical difference in satisfactory scores between the groups with respect to slow isokinetic extension was accentuated with the 1:1 matched outcome trial (23.9% vs. 12.1%; p = .20). With respect to function, there were no differences in deficits for vertical jump (8.4% vs. 4.3%; p = .55), single hop (7.4% vs. 9.3%; p = .65), or triple hop (6.0% vs. 7.1%; p = .77) between the two groups. Univariate analysis showed significant greater deficits at 9 months in the FNB with respect to slow isokinetic flexion strength (9.6% vs. 0.4%; p = .01). There were no differences in fast isokinetic flexion (-0.2% vs. 0.7%; p = .87) and fast isokinetic extension (6.0% vs. 2.7%; p = .51) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (17.3% vs -14.0%, p = .19), but this did not reach statistical significance. With respect to function, there were no differences in deficits for vertical jump (5.2% vs. 6.5%, p = .85), single hop (7.7% vs. 6.2%; p = .79), or triple hop (1.9% vs. 3.9%; p = .35) between the two groups. Conclusion Because previous studies have shown a significant delay in return of strength with FNB, ACB began to be employed at our center for post-operative pain control following ACLR in pediatric and adolescent patients. This study showed that pediatric and adolescent patients treated with FNB as a method of post-operative analgesia after ACLR had significantly greater deficits in fast isokinetic flexion at 6 months and slow isokinetic flexion at 9 months compared to those who received ACB. These differences may or may not have clear clinical relevance. However, patients treated with FNB showed clinically relevant greater deficits in slow isokinetic extension strength at 6 and 9 months postoperatively compared to those who received ACB if 85% strength return is used as criteria to return to sport. Pediatric and adolescent patients could benefit from undergoing perioperative analgesia with ACB instead of FNB, but comparison between these two methods of regional anesthesia may require a prospective trial. Level of Evidence Retrospective cohort study, Level IV [Table: see text][Table: see text]

Background: Previous studies on periacetabular osteotomy (PAO) reported complication and reoperation rates of 5.9% and 10%, respectively. Hip arthroscopy is increasingly utilized as an adjunct procedure to PAO to precisely treat associated intra-articular pathology. The addition of this procedure has the potential of further increasing complication rates. Purpose: To determine the rates of complication and reoperation of combined hip arthroscopy and PAO for the treatment of acetabular deformities and associated intra-articular lesions. Study Design: Case series; Level of evidence, 4. Methods: Using a prospective database, the authors retrospectively reviewed 248 hips (240 patients) that underwent combined hip arthroscopy and PAO between 2007 and 2016. Data were collected at scheduled follow-up visits at approximately 1 month, 3 to 4 months, and 1 and 2 years after surgery. Mean follow-up from surgery was 3 years (range, 1-8 years). A total of 220 PAOs were done for symptomatic acetabular dysplasia, 18 for symptomatic acetabular retroversion, and 10 for combined acetabular dysplasia and acetabular retroversion. Central compartment arthroscopy was performed for treatment of intra-articular chondrolabral pathology in all cases. Select cases underwent femoral head-neck junction osteochondroplasty either arthroscopically before the PAO or through an open approach after it. Complications were graded according to the modified Dindo-Clavien complication scheme, which was validated for hip preservation procedures. Reoperations (excluding hardware removal) were recorded. Results: Grade III complications occurred among 7 patients (3%) while there were no grade IV complications. Grade III complications included deep infection (n = 3), wound dehiscence (n = 1), hematoma requiring exploration (n = 1), symptomatic heterotopic ossification requiring excision (n = 1), and deep venous thrombosis (n = 1). There were 13 reoperations (5%), and 3 were repeat hip arthroscopy. Univariate Cox hazard models were used to estimate the relative risk factors for complication and reoperation. Increased age (per decade) showed over twice the increased likelihood for complications (hazard ratio, 2.5; 95% CI, 1.67-3.74). Also, preoperative diagnosis of acetabular retroversion, not acetabular dysplasia, showed >3 times the increased risk of reoperation (hazard ratio, 3.05; 95% CI, 1.41-6.61). Conclusion: The rate of complications reported is comparable (3%) with previously published complication rates of PAO without hip arthroscopy. In this cohort, increasing age and diagnosis of acetabular retroversion were associated with higher complication and reoperation rates.

AbstractCardiac implantable electronic devices (CIED) are utilized in increasing number and in heterogeneous populations. With excellent training, checklists, and “muscle memory,” the implantation procedure is generally very safe and efficient. Nevertheless, significant and potentially life‐threatening complications can occur.

Background: A symptomatic discoid lateral meniscus is an uncommon orthopaedic abnormality, and the majority of information in the literature is limited to small case series. Purpose/Hypothesis: The purpose of this study was to determine the incidence of symptomatic discoid menisci in a geographically determined population and to describe treatment trends over time. The hypothesis was that the incidence of symptomatic discoid menisci would be highest among adolescent patients, and thus, the rate of surgical treatment would be high compared with nonoperative treatment. Study Design: Descriptive epidemiology study. Methods: The study population included 79 patients in Olmsted County, Minnesota, identified through a geographic database, who were diagnosed with a symptomatic discoid lateral meniscus between 1998 and 2015. The complete medical records were reviewed to confirm the diagnosis and evaluate the details of injury and treatment. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 United States population. Results: The overall annual incidence of symptomatic discoid lateral menisci was 3.2 (95% CI, 2.5-3.9) per 100,000 person-years; 12.6% of the patients in the cohort had bilateral symptomatic discoid lateral menisci. The overall annual incidence was similar between male (3.5 per 100,000 person-years) and female patients (2.8 per 100,000 person-years). The highest incidence of symptomatic discoid lateral menisci was noted in adolescent male patients aged 15-18 years (18.8 per 100,000 person-years). A majority (72.2%) of patients presented with a symptomatic tear of the discoid meniscus. The remaining patients presented with mechanical symptoms, including catching/locking or effusion, with no demonstrable meniscus tear on imaging or diagnostic arthroscopic surgery. Additionally, 20.0% of patients were observed to have peripheral instability of the meniscus at the time of diagnostic arthroscopic surgery. The mean age of those with peripheral instability was significantly younger than of those who did not have peripheral instability. Sixty patients (75.9%) received surgical treatment during the study period, including 49 (81.7%) patients who underwent partial lateral meniscectomy and 11 (18.3%) patients who underwent lateral meniscus repair in addition to saucerization. Conclusion: With an overall annual incidence of 3.2 per 100,000 person-years, a symptomatic discoid meniscus is an uncommonly encountered orthopaedic abnormality. However, the incidence of symptomatic discoid lateral menisci is highest in adolescent male patients. Because of the high rate of meniscus tears in patients presenting with symptoms, the majority are treated surgically.

Abstract A varus‐producing distal femoral osteotomy (DFO) is an effective technique for the treatment of lateral patellar instability (LPI) in patients with concomitant moderate to severe valgus malalignment. Patellar maltracking and subluxation are corrected via neutralization of some of the laterally directed forces on the patella due to the valgus deformity. This can be accomplished with a distal femoral lateral opening‐wedge or medial closing‐wedge osteotomy and medial soft tissue stabilization. A medial closing‐wedge osteotomy offers the advantages of immediate weight bearing and a single incision in cases requiring patellofemoral soft tissue stabilization. In this article, we describe our preferred operative technique for a medial closing‐wedge DFO using a femoral locking plate and medial patellofemoral ligament imbrication for the correction of LPI. Technique Video video See video under supplementary data.