Citations

Objectives: Historically, horizontal cleavage meniscus tears have been debrided with single leaflet preservation, but more recently this has been challenged by repair of these tear types. While circumferential meniscus repair with all-inside and inside-out instrumentation has been described, there remains a paucity of literature regarding the clinical outcomes of this technique. Our purpose was to assess clinical outcomes and reoperation rates of circumferential meniscus repair for horizontal cleavage tears at minimum 2-year follow-up. Methods: Patients with isolated horizontal cleavage tears of the meniscus (Fig. 1a) undergoing primary circumferential meniscus repair (Fig. 1b), including both inside-out and all-inside suturing techniques, at a single institution between 2015 and 2022 were eligible for inclusion and analyzed retrospectively. Arthroscopic images and operative notes were examined to confirm circumferential meniscal repair. Patient demographics, surgery details, and clinical findings were extracted from the institutional electronic medical records. Exclusion criteria consisted of patients not consenting for research, less than 2-years of clinical follow-up, and concurrent ipsilateral repair of a non-horizontal cleavage tear. Patients were not excluded if they had a concomitant anterior cruciate ligament reconstruction (ACLR). Thirty-seven patients met the criteria for inclusion in this study. Knees were analyzed for laterality, number of sutures, suturing technique, concurrent injuries, concurrent procedures, and surgical history. Visual Analogue Scale (VAS) for pain, Tegner, and International Knee Documentation Committee (IKDC) scores were collected at minimum 2-year follow-up and analyzed. Return to sport (RTS) and revision surgery were analyzed. Results: Thirty-seven patients (25 male, 12 female; mean age, 29.4 ± 12.4 years) who underwent circumferential meniscal repair of a horizontal cleavage tear were included in the study and followed for a mean of 6.2 years (range, 2.2-9.3 years, Table 1). There was a total of 38 knees (23 right, 15 left). One patient (3%) had bilateral circumferential meniscal repair surgeries done at separate times. Three (16%) patients failed primary repair and had secondary partial meniscectomy. Similar numbers of circumferential meniscal repairs were performed on lateral and medial menisci, 21 (55%) and 17 (45%), respectively. An average number of 3 ± 2 sutures were used at the time or repair with one of 38 menisci (3%) having a hybrid combination of both all-inside and inside-out suture technique, 24 menisci (63%) had all-inside technique, and 13 menisci (34%) had inside-out technique. Concurrent procedures included 4 ACL reconstructions (3 autograft, 1 allograft), and 8 chondroplasties (4 patella, 2 trochlea, 1 medial femoral condyle, and 1 unspecified, Table 2). At the time of final follow-up, patients reported mean Tegner activity scores of 6.2 ± 2.3, VAS pain with rest of 1.0 ± 2.0, VAS pain with use of 2.5 ± 2.7, and IKDC of 81.6 ± 18.6. When asked, using a VAS Five Point scale, how their knee is currently compared to before their surgery, 14 (74%) feel much better than before surgery, 2 (11%) feel slightly better than before surgery, 1 (5%) feels no change when compared to before their surgery, 2 (11%) feel slightly worse than before surgery, and no one felt much worse than before surgery. Sixteen patients were involved in sports before their surgery. Of those that played sports before their surgery, 14 (88%) returned to sport (Table 3). The most common sports played were hockey (19%), volleyball (19%), tennis (13%), and football (13%). Levels of sport played before surgery included 7 (44%) recreational, 6 (38%) high school, 2 (13%) college, and 1 (6%) club. Levels of sport played after surgery for those who returned to sport included 6 (43%) recreational, 2 (14%) high school, 5 (36%) college, and 1 (7%) club with a significant increase in levels of sport played after surgery ( p ≤ 0.006) compared to before surgery. Conclusions: At an average of 6-years of follow up, there was an 84% success rate of circumferential meniscal repair for horizontal cleavage tears. Most patients who play sports, return to sport and do so at the same or higher level and report successful PROMs. Circumferential meniscal repairs should be considered for patients with horizontal cleavage tears.

Objectives: Value based decision making regarding nonoperative management vs. early surgical stabilization for first-time anterior shoulder instability (ASI) events remains controversial. Thus, the purpose of this study was to perform 1) a systematic review of the current literature and 2) a Markov model-based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI. Methods: A Markov Chain Monte Carlo probabilistic model (Figure 1) was developed to evaluate the outcomes and costs of 1,000 simulated patients (average age » 20 years old) with first-time ASI undergoing nonoperative management vs. ABR. Utility values, recurrence rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality-adjust life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Probabilities of recurrence as well as the utility of each treatment strategy were obtained from the literature search as described above. Probabilities were pooled across studies to obtain a weighted average for both nonoperative treatment and ABR. Similarly, studies reporting scores on the Western Ontario Shoulder Instability Index (WOSI) scale were utilized to approximate shoulder-related quality of life after each treatment strategy and outcome. Costs for each treatment strategy and transition state in the model were considered from the payer perspective (commercial or government) and obtained from institutional data at a large, academic medical center. Results: The Markov model with Monte Carlo microsimulation demonstrated average (± standard deviation) costs for nonoperative management and ABR of $38,649 ± 10,521 and $43,052 ± 9,352, respectively. Total QALYS acquired over the 10-year time horizon were 7.7 ± 0.4 and 8.4 ± 0.5 for nonoperative management and ABR, respectively. The ICER comparing ABR to nonoperative management was found to be just $5,725/QALY, which falls substantially below the $50,000 willingness-to-pay (WTP) threshold (Figure 2). The mean number of recurrences were 2.6 ± 0.3 and 1.2 ± 0.2 for patients initially assigned to the nonoperative and ABR treatment groups, respectively. Out of 1,000 samples run over 1,000 trials, ABR was the optimal strategy in 98.7% of cases, with nonoperative management the optimal strategy in 1.3% of cases (Figure 3). Conclusions: The primary findings of this systematic review and cost-effectiveness analysis were as follows: 1) when compared to nonoperative management, arthroscopic Bankart repair (ABR) substantially reduces the risk of recurrent dislocations, 2) ABR results in greater shoulder function and higher WOSI scores than does nonoperative management, and 3) despite substantially higher upfront costs, ABR proved to be more cost-effective than an initial trial of nonoperative management, which can be attributed to both fewer recurrent dislocations and greater utility over the long-term.

Objectives: The role of femoral version (FV[MOU1] ) in the pre-arthritic hip pain remains increasingly recognized, including in femoroacetabular impingement (FAI). Increased femoral version or decreased femoral version may play a role in hip biomechanics contributing to hip instability or impingement, respectively. The purpose of this study was to compare the outcomes of hip arthroscopy for FAI across different femoral version groups in a multicenter prospective cohort study. Methods: A prospective multicenter cohort study of 677 FAI patients undergoing primary hip arthroscopy was performed. The current study included 603 patients with low-dose CT performed preoperatively for measurement of femoral version from the larger cohort. Inclusion criteria were patients aged 14-45 years with idiopathic FAI. Exclusion criteria were previous ipsilateral hip procedures, associated disorders, or Tönnis 2 or greater osteoarthritis. Femoral version was measured on low-dose computed tomography (CT) utilizing the Yoshioka oblique method and was broken into five subgroups: <5° (decreased FV), 6-15° (normal FV), 16-25° (mildly increased FV), 26-35° (moderately increased FV), 35°+ (severely increased FV). Patient-reported outcomes (PROs) were measured at a minimum one-year follow-up. The modified Harris hip score (mHHS) was assessed relative to the minimal clinically important difference (MCID) of 8 and patient acceptable symptom state (PASS) of 74. Additional PROs included the HOOS Pain and Sports/Recreation subscores and the iHOT-12 score. Composite failure was defined as a reoperation for persistent symptoms or a failure to achieve either the mHHS MCID or PASS. Independent t-test (Mann-Whitney U) and ANOVA were utilized to compare groups. Results: Males had statistically lower femoral version than females (14.0° vs 18.0°; p<0.001). In females, 38.0% had mildly increased FV, 17.9% had moderately increased FV, and 3.6% had severely elevated FV. This is compared to 27.6%, 9.2%, and 1.8% in males, respectively (all p<0.001). Decreased FV was present in 7.1% of males, compared to 5.9% of females. Increased or decreased femoral versions appear to have similar outcomes to normal version when evaluated by PROs or outcome states. In fact, mildly increased and moderate increased FV group demonstrated the best outcomes. Changes in HOOS pain and sports subscores were significantly higher for these groups. Severely increased FV, >35°, was only present in 2.8% of patients but did demonstrate a higher rate of composite failure (15.4%) compared to moderately increased FV (3.1%). The decreased FV group had a composite failure of 10.4% compared to normal femoral version, 16-25° (10.2%). Conclusions: In a patient cohort undergoing hip arthroscopy for FAI, significant differences in FV between males and females were present. Overall, in a multicenter prospective cohort study, the outcomes of hip arthroscopy for FAI did not seem to differ between increased or decreased femoral versions but were superior in mild to moderately increased FV. Future research with longer-term follow-up is still needed to definitively establish the longevity of outcomes of hip arthroscopy relative to FV.

Objectives: Traumatic lateral patellar dislocation is frequently associated with cartilage lesions, particularly of the patella and lateral femoral condyle (LFC). Multiple treatment options to address these chondral lesions including debridement, microfracture, cartilage restoration with allo- or autograft, and osteotomies can be utilized at the index patellar stabilization surgery, or in a staged fashion. However, these additional procedures are not without increased morbidity and long-term benefit has not been well elucidated. In patients with traumatic chondral lesions associated with patellofemoral instability (PFI), meniscal coverage of the lesion and intervention to eliminate further patellar instability may be all that is required for a successful outcome. Thus rendering the increased time, morbidity, and cost of chondral procedures unjustified in this setting. The purpose of this study was to assess outcomes of patients with LFC chondral lesions after traumatic patellar dislocations and whether meniscus coverage of the lesion on magnetic resonance imaging (MRI) has an impact on patient outcomes. Methods: A retrospective chart review was performed to compare outcomes for patients with LFC lesions following acute patellar dislocation treated surgically at a single institution. MRI, operative reports, and intraoperative imaging were reviewed to assess for LFC lesions. Size of the LFC lesion and evaluation of meniscus coverage was measured in the coronal plane on T2 MRI sequences (Figure 1). Patient charts were reviewed to follow postoperative rehabilitation and clinical course. Patient reported outcome measures (PROMs) were obtained using the International Knee Documentation Committee (IKDC) score, Lysholm Knee score, Visual Analog Scale (VAS), and Tegner Activity score. Results: A total of 228 patients underwent surgical stabilization for patellar instability from 2001 to 2022, 81 of which had an LFC lesion identified on MRI and confirmed intraoperatively. Seven of these patients underwent a concomitant cartilage restoration procedure (3 internal fixation of osteochondral fragment, 2 microfracture, 1 osteochondral allograft, and 1 MACI) and they were excluded from the study leaving 74 patients. In assessing meniscus coverage of the chondral lesion, 10 of these lesions had no meniscus coverage, 8 had 1-50% coverage, and 56 had 51-100% coverage. The average size of the chondral lesion was 7.1 ± 2.9 mm and the majority were in the anterior one-third of the LFC. Average follow up from the index surgery was 7.6 years (range, 2.2-15.2 years). During this time frame, 12 patients had subsequent knee surgeries, none of which were to address the LFC lesion (Table 2). Postoperatively, nearly all patients reported improvement in their pain with an average VAS pain decrease of 3.7 points. There were no significant differences in PROMs in patients with meniscus coverage versus those without (Table 2). At the time of final follow-up, four patients had radiographic evidence of knee osteoarthritis (OA) within the lateral compartment, and one underwent a total knee arthroplasty (TKA). The patient that underwent a TKA had no meniscal coverage of their chondral lesion at the time of their index procedure. Conclusions: Cartilage lesions secondary to traumatic lateral patellar dislocation are common; however, appropriate management of these lesions remains unclear. The present findings suggest that not surgically addressing chondral lesions in patients with overlying meniscus coverage can allow for high functional outcomes and minimal pain after patellar stabilization procedures. Although only four patients progressed to radiographic evidence of OA, long term data will be valuable to understand whether overlying meniscus coverage is also protective against the development of OA and progression to TKA.

Background: Patellofemoral instability (PFI) is a condition that leads to recurrent dislocation events and is typically secondary to extensor mechanism malalignment and rotational deformities. To correct malalignment, a tibial tubercle osteotomy (TTO) can be performed; however, an understanding of the associated complications, recurrence rates, and potential for reoperation is necessary. Purpose: To systematically review the literature to determine the incidence of postoperative complications, rate of recurrent instability, and all-cause reoperation rate after TTO for PFI. Study Design: Systematic review; Level of evidence 4. Methods: The Cochrane Database of Systematic Reviews, PubMed, Embase, MEDLINE, and CINAHL were queried for studies that reported complications after TTO. No date limits were applied. A total of 1050 studies were identified. Complications were categorized into “minor” and “major” groups using a modified Clavien-Dindo Classification. A meta-analysis was conducted to examine complication rates, recurrent instability, and all-cause reoperation, utilizing a DerSimonian and Laird random-effects model. A meta-analysis for recurrent instability was subgrouped according to follow-up periods of ≤2 years and >2 years. Results: A total of 38 studies were included, comprising 1546 patients, representing 1733 knees. The study dates ranged from 1989 to 2024, and the level of evidence ranged from 2 to 4. The weighted mean age at surgery was 24.1 years (range, 20-54 years), and 67% of patients were women. The weighted mean follow-up of all studies was 4.2 years. Overall, 197 minor complications, 39 major complications, 90 recurrent instability events, and 275 reoperations were identified. The minor complication rate was 9% (range, 0%-65% [95% CI, 6%-13%]). The major complication rate was 3% (range, 0%-10% [95% CI, 3%-4%]). Seven studies had a ≤2-year follow-up, and the remaining 31 studies had a >2-year follow-up. The recurrent instability rate was 3% in studies with ≤2 years of follow-ups (range, 0%-26% [95% CI, 1%-13%]). In studies with >2 years of follow-up, the recurrent instability rate was 8% (range, 0%-31% [95% CI, 6%-12%]). The all-cause reoperation rate was 16% (range, 0%-54% [95% CI, 11%-21%]). Conclusion: This systematic review and meta-analysis identified the incidence of complications (17%), the rate of recurrent instability (3%-8%), and the all-cause reoperation rate (16%) after TTO. TTO, performed alone or in combination with medial patellofemoral ligament reconstruction for the treatment of PFI, reliably improved clinical outcome scores in the setting of variable complication rates. Interestingly, rates of recurrent instability increased over time, and most reoperations were undertaken for hardware removal rather than revision patellar stabilization surgery.

Purpose To compare clinical and functional outcomes (including range of motion, clinical laxity, reoperation/revision rates, and patient‐reported outcome measures) of combined anterior cruciate ligament/posterior cruciate ligament reconstruction (ACLR/PCLR) with and without suture tape (ST) augmentation via a propensity‐matched cohort analysis. Methods A retrospective review was performed to identify all patients who underwent simultaneous primary ACLR/PCLR between 2001 and 2022. A 1:1 propensity match was performed using patient sex, Schenck classification grade, age ±8 years, and body mass index ±10 to produce 2 cohorts: ACLR/PCLR with and without (control) ST augmentation. Clinical outcomes (visual analog scale [VAS], range of motion, Tegner activity scale, Lysholm score, and International Knee Documentation Committee subjective score) were analyzed. Results The propensity match produced a final cohort of 50 ACLR/PCLR patients: 25 with ST augmentation and 25 nonaugmented controls. Most patients had a KD3M injury (12 in each cohort), and no significant differences were noted in concomitant neurovascular, meniscal, or chondral injuries between the groups. Forty patients (80%) completed follow‐up at a mean of 4.7 years for the ST cohort and 8.5 years for the control cohort ( P > .05). Postoperative ST versus control values for outcome measures including VAS at rest (0.9 vs 1.5; P = .71), VAS with use (3.0 vs 2.2; P = .24), International Knee Documentation Committee (75.7 vs 76.3; P = .37), Lysholm (81.8 vs 77.6; P = .91), and Tegner activity (4.8 vs 5.4; P = .37) scores showed no differences ( P > .05 for all). There were no differences in excessive postoperative clinical laxity between ST and control cohorts (ST n = 1 vs control n = 2, Lachman 2+, P = .140; ST n = 3 vs control n = 1, posterior drawer 2+, P = .122). The total number of patients who underwent reoperation was 7 of 25 (28%) for the ST cohort and 8 of 25 (32%) for the control cohort ( P = .76). Conclusions Concomitant ACLR/PCLR utilizing ST augmentation showed similarly satisfactory postoperative clinical outcomes at a minimum 2‐year follow‐up compared to a matched cohort without ST. The use of an independent ST did not limit motion or increase the incidence of complications or revision surgery. Level of Evidence Level III, retrospective comparative case series.

Abstract Meniscus allograft transplant (MAT) can provide meaningful improvement in patient outcomes in those who are otherwise meniscus deficient. A common finding in the setting of a failed MAT is meniscus extrusion. Meniscus centralization is a technique performed to reduce the meniscus to its intra‐articular location and has been shown to improve postoperative pain and function in patients with an extruded meniscus. Prior techniques have been described for meniscus centralization in the setting of a meniscus root tear or with the use of single tension devices that are tensioned after meniscocapsular fixation. We present a minimally invasive technique for meniscus centralization that can be performed in conjunction with MAT using a centralization stabilization suture and re‐tensionable root‐fixation subchondral anchors that can be secured prior to meniscocapsular fixation. Technique Video video See video under supplementary data.

Background: Treatment decisions in patients with anterior cruciate ligament (ACL) injuries are influenced by multiple factors, such as the desire to return to sports or symptomatic instability. Identifying the differential treatment effect of ACL reconstruction (ACLR) compared with nonoperative management on a patient-specific level can inform surgical decision-making. Hypothesis: Unsupervised machine learning can identify distinct patient subgroups based on outcome achievement after ACL injury, and ACLR will exert a protective effect on the development of posttraumatic osteoarthritis (PTOA) over nonoperative management. Study Design: Cohort study; Level of evidence, 3. Methods: A longitudinal populational registry identified patients with ACL injuries from 1990 to 2016 with a minimum 7.5-year follow-up. An unsupervised random forest algorithm was utilized to develop and validate patient subgroups. Treatment effects of ACLR on outcomes were analyzed using a machine learning causal inference estimator. Patient subgroup membership was incorporated into a multivariable logistic regression to identify factors predictive of optimal outcomes. Results: A total of 923 patients (785 primary ACLR, 138 nonoperative) were included. The random forest algorithm arrived at an optimal partition of 2 subgroups, with 653 patients in the optimal outcome subgroup (368 male [56.4%]; mean age, 26.0 ± 10.2 years; mean body mass index [BMI], 26.5 ± 4.30) and 270 patients in the suboptimal outcome subgroup (152 male [56.3%]; mean age, 35.0 ± 10.1 years; mean BMI, 30.5 ± 5.54). The latter group demonstrated significantly increased rates of secondary meniscal injury, development of symptomatic PTOA, and progression to total knee arthroplasty (TKA) at the final follow-up (all P < .01). In the optimal outcome subgroup, ACLR had significantly protective treatment effects on the risk of secondary meniscal injury (average treatment effect [ATE], 61%), contralateral ACL injury (ATE, 8%), symptomatic PTOA (ATE, 16%), and progression to TKA (ATE, 6%) (all P < .01). Conversely, in the suboptimal outcome subgroup, ACLR only protected against symptomatic PTOA (ATE, 11%) and progression to TKA (ATE, 8%) (both P < .01). Conclusion: Two clinically meaningful subgroups were identified from retrospectively collected data and found to experience differential treatment responses after ACL injuries. ACLR decreased the rate of development of PTOA and TKA in both subgroups but was not as effective in preventing secondary meniscal injuries or contralateral ACL injuries in patients who were older, heavier, or had concomitant medial meniscus injuries.

Abstract Anterior cruciate ligament reconstruction (ACLR) using bone–patellar tendon–bone autograft remains one of the most common autografts used, and there is significant evidence to support its title as the “gold standard.” There are nuances and technical challenges associated with every step of an ACLR, which always leave room for improvement. The purpose of this Technical Note is to provide reproducible, technical pearls where errors are commonly encountered during ACLR. In this article, we detail 10 technical pearls that surgeons should consider to enhance operative workflow and optimize success during ACLR with a bone–patellar tendon–bone autograft. Technique Video video See video under supplementary data.

Purpose To develop an expert consensus statement on the diagnosis, management, and rehabilitation of medial meniscal root tears (MMRTs) using a modified Delphi technique. Methods A working group developed statements on MMRT diagnosis, nonoperative management, surgical indications, surgical management, alignment, and rehabilitation using modified Delphi techniques. Fifty‐six experts were surveyed over 3 rounds to reach consensus, with agreement measured on a 5‐point Likert scale. Statements were included, revised, or excluded on the basis of predefined thresholds (≥75% agreement, <20% disagreement). Experts suggested revisions or new statements in the first 2 rounds, and final consensus statements were included. Results All 56 experts completed 3 survey rounds. Experts agreed that root tears may occur with no known history of trauma, typically in older patients, and that it should be diagnosed with an magnetic resonance imaging. In symptomatic patients with MMRTs without advanced osteoarthritis should be repaired using an anatomic transtibial pull‐out technique (performing a pie‐crusting technique can be helpful for visualization). Nonoperative management is advised for patients with advanced osteoarthritis. High tibial osteotomy may be considered for significant varus malalignment during MMRT repair. The only statement without consensus was the management of asymptomatic MMRTs with mild medial compartment cartilage wear, indicating ongoing debate. Conclusions Overall, 98% of statements reached consensus. There is agreement that magnetic resonance imaging is the gold standard for diagnosis. Symptomatic MMRTs without advanced osteoarthritis should be repaired early using an anatomic transtibial pull‐out technique. End‐stage knee osteoarthritis warrants nonoperative management of MMRTs, and a structured postoperative protocol with limited weightbearing and range of motion is essential after repair. No agreement was reached on managing asymptomatic MMRTs in patients without significant medial compartment degeneration. Meniscal centralization sutures may help in cases of substantial extrusion, but their routine use is debated. Level of Evidence Level V, consensus of expert opinion.