Krych, Aaron J.

Abstract In the standard approach to hip arthroscopy, access to the joint is achieved using fluoroscopic guidance to enter the central compartment of the hip using the Seldinger technique, penetrating the capsule with a needle and subsequently cannulating and obtaining direct visualization of the joint. In such a way, arthroscopists then proceed with accessory portal creation and capsulotomy, as desired, under direct intra‐articular visualization. In cases with severe pincer morphology or coxa profunda, it may not be possible to safely access the central compartment under fluoroscopic guidance due to significant lateral overcoverage of the femoral head. We present an outside‐in arthroscopic approach for accessing the hip joint in such patients, allowing for safe visualization, osseous pincer resection, and improved central compartment access while minimizing the risk to cartilage and labral tissue. Technique Video video See video under supplementary data.

Case: A 20-year-old woman presented with a unipolar, 1.8 × 1.8-cm osteochondral defect of the left acetabulum. Osteochondral allograft transplantation was performed using a medial tibial plateau allograft resulting in excellent clinical outcomes across 4 different outcome scores and maintenance of the joint space at 4.3 years postoperatively. Conclusion: Although previous literature has demonstrated long-term clinical success of osteochondral allograft transplantation in knee, excellent clinical outcomes can also be obtained in the hip. Thus, osteochondral allograft transplantation may be a viable treatment option for adolescents and young adults with concomitant cartilage and subchondral bone hip defects.

Abstract Purpose The demographic and radiological risk factors of subchondral insufficiency fractures of the knee (SIFK) continue to be a subject of debate. The purpose of this study was to associate patient‐specific factors with SIFK in a large cohort of patients. Methods Inclusion criteria consisted of patients with SIFK as verified on magnetic resonance imaging (MRI). All radiographs and MRIs were reviewed to assess characteristics such as meniscus tear presence and type, subchondral oedema presence and location, location of SIFK, mechanical limb alignment, osteoarthritis as assessed by Kellgren–Lawrence grade and ligamentous injury. A total of 253 patients (253 knees) were included, with 171 being female. The average body mass index (BMI) was 32.1 ± 7.0 kg/m 2 . Results SIFK was more common in patients with medial meniscus tears (77.1%, 195/253) rather than tears of the lateral meniscus (14.6%, 37/253) ( p < 0.001). Medial meniscus root and radial tears of the posterior horn were present in 71.1% (180/253) of patients. Ninety‐one percent (164/180) of medial meniscus posterior root and radial tears had an extrusion ≥3.0 mm. Eighty‐one percent (119/147) of patients with SIFK on the medial femoral condyle and 86.8% (105/121) of patients with SIFK on the medial tibial plateau had a medial meniscus tear. Varus knees had a significantly increased rate of SIFK on the medial femoral condyle in comparison to valgus knees ( p = 0.016). Conclusion In this large cohort of patients with SIFK, there was a high association with medial meniscus root and radial tears of the posterior horn, meniscus extrusion ≥3.0 mm as well as higher age, female gender and higher BMI. Additionally, there was a particularly strong association of medial compartment SIFK with medial meniscus tears. As SIFK is frequently undiagnosed, identifying patient‐specific demographic and radiological risk factors will help achieve a prompt diagnosis. Level of Evidence Level IV.

Purpose To (1) analyze trends in the publishing of statistical fragility index (FI)–based systematic reviews in the orthopaedic literature, including the prevalence of misleading or inaccurate statements related to the statistical fragility of randomized controlled trials (RCTs) and patients lost to follow‐up (LTF), and (2) determine whether RCTs with relatively “low” FIs are truly as sensitive to patients LTF as previously portrayed in the literature. Methods All FI‐based studies published in the orthopaedic literature were identified using the Cochrane Database of Systematic Reviews, Web of Science Core Collection, PubMed, and MEDLINE databases. All articles involving application of the FI or reverse FI to study the statistical fragility of studies in orthopaedics were eligible for inclusion in the study. Study characteristics, median FIs and sample sizes, and misleading or inaccurate statements related to the FI and patients LTF were recorded. Misleading or inaccurate statements—defined as those basing conclusions of trial fragility on the false assumption that adding patients LTF back to a trial has the same statistical effect as existing patients in a trial experiencing the opposite outcome—were determined by 2 authors. A theoretical RCT with a sample size of 100, P = .006, and FI of 4 was used to evaluate the difference in effect on statistical significance between flipping outcome events of patients already included in the trial (FI) and adding patients LTF back to the trial to show the true sensitivity of RCTs to patients LTF. Results Of the 39 FI‐based studies, 37 (95%) directly compared the FI with the number of patients LTF. Of these 37 studies, 22 (59%) included a statement regarding the FI and patients LTF that was determined to be inaccurate or misleading. In the theoretical RCT, a reversal of significance was not observed until 7 patients LTF (nearly twice the FI) were added to the trial in the distribution of maximal significance reversal. Conclusions The claim that any RCT in which the number of patients LTF exceeds the FI could potentially have its significance reversed simply by maintaining study follow‐ups is commonly inaccurate and prevalent in orthopaedic studies applying the FI. Patients LTF and the FI are not equivalent. The minimum number of patients LTF required to flip the significance of a typical RCT was shown to be greater than the FI, suggesting that RCTs with relatively low FIs may not be as sensitive to patients LTF as previously portrayed in the literature; however, only a holistic approach that considers the context in which the trial was conducted, potential biases, and study results can determine the merits of any particular RCT. Clinical Relevance Surgeons may benefit from re‐examining their interpretation of prior FI reviews that have made claims of substantial RCT fragility based on comparisons between the FI and patients LTF; it is possible the results are more robust than previously believed.

Background: Patients with isolated anterior cruciate ligament (ACL) reconstruction have demonstrated an increased risk of ACL graft failure and lower patient-reported outcome (PRO) scores when increased posterior tibial slope (PTS) is present. However, there is a paucity of literature evaluating the effect of PTS on outcomes after combined bicruciate multiligamentous knee reconstruction. Purpose: To determine whether differences exist for graft failure rates or PRO scores based on PTS after combined bicruciate multiligamentous knee reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent combined ACL and posterior cruciate ligament (PCL) reconstruction between 2000 and 2020 at our institution were identified. Exclusion criteria were age <18 years, knee dislocation grade 5 injuries, concomitant osteotomy procedures, and <2 years of clinical follow-up. Demographic and outcomes data were collected from our prospectively gathered multiligamentous knee injury database. Lysholm and International Knee Documentation Committee (IKDC) scores were analyzed in relation to PTS. Outcomes were compared for patients with a PTS above and below the mean for the total cohort, PTS >12° versus <12°, positive versus negative Lachman test at follow-up, and positive versus negative posterior drawer test at follow-up. Results: A total of 98 knees in 98 patients were included in the study, with a mean clinical follow-up of 5.1 years (median, 4.6 years; range, 2-16 years). The mean PTS was 8.7° (range, 0.4°-16.9°). Linear regression analysis showed no significant correlation between PTS and IKDC or Lysholm scores. Patients with a PTS above the mean of 8.7° trended toward lower IKDC ( P = .08) and Lysholm ( P = .06) scores. Four patients experienced ACL graft failure and 5 patients experienced PCL graft failure. There were no differences in graft failure rates or PRO scores for patients with a PTS >12°. Patients with a positive Lachman test trended toward higher PTS (9.6° vs 8.5°, P = .15). Conclusion: In this series of bicruciate multiligamentous knee reconstructions at midterm follow-up, no differences in graft failures, complications, reoperations, revisions, or PRO scores based on PTS were identified. Patients with a positive Lachman test were found to have a slightly higher PTS, although this did not reach statistical significance.

Abstract Acetabular labral tears are commonly diagnosed in patients with hip or groin pain, most of which occur anterosuperiorly. In some cases, operative intervention in the form of arthroscopic labral repair may be necessary to restore labral function. Posterolateral tears can be technically challenging when using traditional modified anterior portal and anterolateral (AL) portal access owing to a suboptimal drill trajectory. In this article, we describe the establishment of a posterolateral (PL) portal 1 to 2 cm posterior to the tip of the greater trochanter, mirroring the distal‐to‐proximal trajectory of the AL portal and entering the capsulotomy at the 10‐o'clock position. This method highlights that the PL portal is used for drilling and anchor placement, whereas the remaining work is performed through the AL portal. This avoids the use of any shavers or burrs in the PL portal near important neurovascular structures, including the sciatic nerve. Addressing posterolateral labral tears in the 9‐ to 11‐o'clock position using a PL portal can enhance labral fixation, thereby mitigating the risk of suboptimal repairs that can negatively impact postoperative outcomes. Technique Video video See video under supplementary data.

Background: Lateral meniscal oblique radial tears (LMORTs) are the most common type of lateral meniscal tears and occur concomitantly with anterior cruciate ligament (ACL) tears in up to 12% of cases. Four types of LMORTs have been classified in the literature based on proximity to the meniscal root and extent of the tear. Type 1 and 2 LMORTs represent partial and complete posterior root tears less than 10 mm from the root insertion. Type 3 and 4 LMORTs are partial and complete posterior radial meniscus tears greater than 10 mm from the root insertion. Indications: Type 3 and 4 LMORTs can and should be addressed with an all-inside side-to-side repair at the time of ACL reconstruction. LMORTs that are not repaired at the time of ACL reconstruction can contribute to persistent instability and meniscal extrusion. Technique Description: Diagnostic arthroscopy is performed to evaluate the posterior aspects of both the medial and lateral meniscus. The medial leaflet is commonly flipped into the notch and scarred to ACL remnant. After identifying and isolating the medial leaflet, an arthroscopic suture passer is used to pass a suture from inferior to superior through the medial leaflet. A second suture is passed from inferior to superior through the lateral leaflet. This is used to shuttle the suture pass through the medial leaflet to the bottom of the meniscus, where it can be tied in a horizontal mattress fashion. The sutures are tied down with aide of an arthroscopic knot pusher. A second set of sutures is passed and used to shuttle a second suture that would be tied posterior to the first suture, again in a horizontal mattress fashion. This allows reduction of the fragments in apposition across the tear. Postoperatively, patients are allowed range of motion from 0° to 90° and to toe touch weightbearing for the first 4 weeks. Patients are advanced to weightbearing as tolerated at 5 weeks. Typical return to sport ranges from 6 to 9 months postoperatively. Results: Results have been published for 2-year outcomes of type 3 and 4 LMORT repairs and have demonstrated persistent improved patient-reported outcomes as well as healing rates that are greater than 80% and in some series approach nearly 100%. Discussion/Conclusion: Arthroscopic all-inside side-to-side surgical repair is a durable and reliable treatment option for patients presenting for ACL reconstruction with concomitant type 3 or 4 LMORT. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: While posterior medial meniscus root (PMMR) techniques have evolved, there remains a need to both optimize repair strength and improve resistance to cyclic loading. Hypothesis: Adjustable tensioning would lead to higher initial repair strength and reduce displacement with cyclic loading compared with previously described transtibial pull-out repair (TPOR) fixation techniques. Study Design: Controlled laboratory study. Methods: A total of 56 porcine medial menisci were used. Eight intact specimens served as a control for the native meniscus. For the others, PMMR tears were created and repaired with 6 different TPOR techniques (8 in each group). Fixed PMMR repairs were executed using 4 different suture techniques (two No. 2 cinch sutures, two cinch tapes, two No. 2 simple sutures, and two No. 2 sutures in a Mason-Allen configuration) all tied over a cortical button. Adjustable PMMR repairs using Mason-Allen sutures were fixed with an adjustable soft tissue anchor fixation tensioned at either 80 N or 120 N. The initial force, stiffness, and relief displacement of the repairs were measured after fixation. Repair constructs were then cyclically loaded, with cyclic displacement and stiffness measured after 1000 cycles. Finally, the specimens were pulled to failure. Results: The PMMR repaired with the 2 cinch sutures fixed technique afforded the lowest ( P < .001) initial repair load, stiffness, and relief displacement. The adjustable PMMR repairs achieved a higher initial repair load ( P < .001) and relief displacement ( P < .001) than all fixed repairs. The 2 cinch sutures fixed technique showed an overall higher cyclic displacement ( P < .028) and was completely loose compared with the native meniscus functional zone. Repairs with adjustable intratunnel fixation showed displacement with cyclic loading similar to the native meniscus. With cyclic loading, the Mason-Allen adjustable repair with 120 N of tension showed less displacement ( P < .016) than all fixed repairs and a stiffness comparable to the fixed Mason-Allen repair. The fixed Mason-Allen technique demonstrated a higher ultimate load ( P < .007) than the adjustable Mason-Allen techniques. All repairs were less stiff, with lower ultimate failure loads, than the native meniscus root attachment ( P < .0001). Conclusion: Adjustable TPOR led to considerably higher initial repair load and relief displacement than other conventional fixed repairs and restricted cyclic displacement to match the native meniscus function. However, the ultimate failure load of the adjustable devices was lower than that of a Mason-Allen construct tied over a cortical button. All repair techniques had a significantly lower load to failure than the native meniscus root. Clinical Relevance: Knotless adjustable PMMR repair based on soft anchor fixation results in higher tissue compression and less displacement, but the overall clinical significance on healing rates remains unclear.

Background: Increased posterior tibial slope (PTS) leads to a relative anterior translation of the tibia on the femur. This is thought to decrease the stress on posterior cruciate ligament (PCL) reconstruction (PCLR) grafts. Purpose/Hypothesis: The purpose of this study was to analyze the effect of PTS on knee laxity, graft failure, and patient-reported outcome (PRO) scores after PCLR without concomitant anterior cruciate ligament reconstruction (ACLR). It was hypothesized that patients with higher PTS would have less knee laxity, fewer graft failures, and better PROs compared with patients with lower PTS. Study Design: Case-control study; Level of evidence, 3. Methods: All patients who underwent PCLR between 2001 and 2020 at a single institution were identified. Patients were excluded if they underwent concomitant or prior ACLR or proximal tibial osteotomy, were younger than 18 years, had <2 years of in-person clinical follow-up, and did not have documented PRO scores (Lysholm score and International Knee Documentation Committee [IKDC] score). Data were collected retrospectively from a prospectively gathered database. PTS measurements were recorded from perioperative lateral knee radiographs. A linear regression model was created to analyze PTS in relation to PRO scores. Patients with a grade 1 (1-5 mm) or higher posterior drawer were compared with those who had a negative posterior drawer. Results: A total of 37 knees met inclusion criterion; the mean age was 30.7 years at the time of surgery. The mean clinical follow-up was 5.8 years. No significant correlation was found between either the Lysholm score or the IKDC score and the PTS. Twelve knees (32.4%) had a positive posterior drawer at final follow-up. The mean PTS in knees with a positive posterior drawer was 6.2°, whereas that for knees with a negative posterior drawer was 8.3° ( P = .08). No significant differences in PRO scores were identified for knees with versus knees without a positive posterior drawer. No documented graft failures or revisions were found. Conclusion: No significant differences were found in PROs or graft failure rates based on PTS at a mean of 5.8 years after PCLR. Increased tibial slope trended toward being protective against a positive posterior drawer, although this did not reach statistical significance.

Background: Osteochondral allograft transplantation (OCAT) is an accepted knee joint–preserving treatment strategy for focal osteochondral lesions that is often conducted in combination with meniscal allograft transplantation (MAT). Despite its frequent and simultaneous utilization, there remains a lack in the literature reporting on outcomes and failure rates after concomitant procedures. Purpose: To determine (1) the midterm clinical success rate after OCAT+MAT in comparison with a matched-pair cohort undergoing isolated OCAT, (2) whether patient-specific and procedural variables influence the risk of failure, and (3) patient-reported outcome measures over time. Study Design: Cohort study; Level of evidence, 3. Methods: A single-center matched-pair cohort study was conducted investigating outcomes in patients who underwent OCAT of the medial or lateral femoral condyle with and without MAT between 2004 and 2020. Patients were matched 1:1 by age (±5 years), sex (male or female), body mass index (±5), and grouped Kellgren and Lawrence grade (grades 0-1 or 2-4). The minimum follow-up time was 2 years. Radiographic variables (International Cartilage Regeneration & Joint Preservation Society [ICRS] grade and Kellgren and Lawrence grade) were assessed preoperatively and at follow-up. Subjective patient-reported outcome measures (Lysholm score, Knee injury and Osteoarthritis Outcome Score [KOOS] including subscores, International Knee Documentation Committee [IKDC] score, and visual analog scale score) were collected preoperatively and at follow-up. Clinical failure was defined as revision surgery for graft failure or conversion to total knee arthroplasty. Patient-reported, clinical, and radiographic outcomes were compared between groups. Results: In total, 66 patients (33 treated with isolated OCAT, 33 treated with OCAT+MAT; 57.6% male) with a mean age of 26.3 years (range, 18-62 years) were followed for a mean of 5.6 years (minimum, 2 years; range, 24-218 months). The 2 cohorts showed no difference in Kellgren and Lawrence grade postoperatively ( P = .59). There was a significantly higher ICRS grade detected at follow-up in the OCAT+MAT group (2.81 ± 1.10) compared with the OCAT group (2.04 ± 0.96) ( P < .05). There were no statistically significant differences between the groups regarding reoperation rate (OCAT: n = 6; OCAT+MAT: n = 13; P = .116), time to reoperation (OCAT: 46.67 ± 47.27 months vs OCAT+MAT: 28.08 ± 30.16 months; P = .061), and failure rate (OCAT: n = 4 [12.1%] vs OCAT+MAT: n = 5 [15.2%]; P = .66). In the OCAT+MAT group, an increase of tibial slope by 1° conferred a 1.65-fold increase in the hazard for failure over decreased slope (hazard ratio, 1.65; 95% CI, 1.10-2.50; P < .05). The overall survival rate was 86% at a mean follow-up of 5.6 years. Patient-reported outcome scores were significantly improved at the final follow-up compared with preoperative status. No significant differences were seen between groups with respect to subjective IKDC, Lysholm, Tegner, and KOOS results, except for the KOOS Symptoms subscale score, which was significantly higher in the OCAT+MAT group than in the OCAT group (mean difference, 14.6; P < .05) and did exceed the minimal clinically important difference threshold of 10.7. Conclusion: Midterm results after isolated OCAT and OCAT+MAT show high rates of healing and sustainable subjective improvement of knee function and quality of life. However, it should be noted that the difference in reoperation rate and time to reoperation between the groups is arguably clinically important and that lack of statistical significance may be because of low power. These results imply that isolated OCAT is an efficient joint-preserving treatment that can be combined with MAT in well-selected patients with meniscal insufficiency without negative influence on global clinical outcomes.