Krych, Aaron J.

Objective To report radiographic and magnetic resonance imaging findings, patient-reported outcomes, and complications and/or reoperations following nonarthroplasty surgical intervention for focal glenohumeral cartilage defects. Design A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Patients were included if they possessed a chondral defect of the humeral head, glenoid, or both, which had been treated with a joint preserving nonarthroplasty procedure. Risk of bias assessment was performed using the Methodological Index for Non-Randomized Studies scoring system. Study demographics, surgical technique, imaging findings, patient-reported outcomes, complications, failures, and reoperations were collected. Results Fourteen studies with 98 patients (100 shoulders) met the inclusion criteria. Patient ages ranged from 7 to 74 years. The nonarthroplasty surgical techniques utilized included microfracture (67 shoulders), osteochondral transplantation (28 shoulders), chondrocyte transplantation (4 shoulders), and internal fixation (1 shoulder). The rates of radiographic union and progression of osteoarthritis ranged between 90% to 100% and 57% to 100%, respectively. Visual analog scores ranged from 0 to 1.9 at final follow-up. Mean postoperative ASES (American Shoulder and Elbow Surgeons) shoulder scores ranged from 75.8-100. Mean postoperative CSS (Constant Shoulder Score) scores ranged from 83.3-94. Mean postoperative SSV (Subjective Shoulder Value) ranged from 70% to 99%. Failure and reoperation rates ranged between 0% to 35% and 0% to 30%, respectively, with the most common reoperation being conversion to prosthetic arthroplasty. Conclusions In this systematic review, nonarthroplasty surgical techniques demonstrated acceptable rates of radiographic healing, improved patient reported outcomes, minimal complications, and low rates of failure or reoperation. Joint preserving techniques are likely viable options to prolong function of the native shoulder and provide short- to midterm pain relief in young and highly active patients. Level of Evidence Level IV.

AbstractThe meniscal ossicle is observed in clinical practice, yet there currently is limited information on its potential clinical significance. The purpose of this study was to assess the clinical presentation, imaging findings, and clinical treatment and outcomes of a series of patients identified as having a meniscal ossicle. An institutional database was reviewed to identify knees with a meniscal ossicle. Clinical presentation, magnetic resonance imaging (MRI), treatment, and outcomes were analyzed. Radiographs were graded using Kellgren–Lawrence (KL) scores. MRIs were reviewed for the presence and location of meniscal ossicles and additional knee pathology. Knee arthroplasty rates were recorded with the remaining patients contacted to obtain final International Knee Documentation Committee (IKDC) and Tegner's scores. Failure was defined as conversion to arthroplasty or failing IKDC score (< 75.4). Forty-five meniscal ossicles in 45 patients (26 males and 19 females) with a mean age of 51 years (standard deviation [SD] = 19.0) were included. Pain was the most common presenting symptom (89%). Forty-two patients (93%) had an associated meniscus root tear on MRI. Eighteen percent of patients that did not have an ossicle on initial imaging subsequently developed an ossicle. Mean KL grades progressed significantly from baseline of 1.84 (SD = 1.0) to 2.55 (SD = 0.93 p < 0.01) on final follow-up. Thirty-nine percent of baseline radiographs showed KL grades of less than 2 compared with only 15% of follow-up radiographs (p = 0.04). Mean IKDC score obtained for patients ≤ 60 at an average follow-up of 3.1 years (SD = 3.2) was 65.2 (SD = 19.0). Eight out of 45 patients (18%) had progressed to total knee arthroplasty (TKA) by latest available follow-up. Sixty-two percent of patients met failure criteria at latest available follow-up. The meniscal ossicle is most commonly found in the posterior horn or root of the medial meniscus and is highly suggestive to be sequelae of a posterior root tear. Therefore, the presence of a meniscal ossicle should alert the orthopaedic surgeon to the high likelihood of the patient having a meniscus root tear. These patients have shown to have poor clinical outcomes and worsening arthritis.

Purpose To report the rate of radiographic union, patient‐reported outcomes, complications, and reoperations after internal fixation of unstable osteochondritis dissecans (OCD) in the skeletally mature knee. Methods A literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines. Patients were included if they were skeletally mature and underwent internal fixation of an unstable OCD lesion of the knee. Risk of bias assessment was performed using the Methodological Index for Non‐randomized Studies scoring system. Surgical technique, rate of union, patient‐reported outcomes, complications, and reoperations were collected. Results Thirteen studies resulted in 148 patients (150 knees) for inclusion. Patient age ranged from 14 to 45 years. Numerous fixation procedures were used, including biodegradable devices (rods, pins, nails, and screws), metal screws, Kirschner wire, and autologous bone sticks. Overall, reported outcome measures were heterogeneous in nature. The rate of radiographic healing ranged from 67% to 100% across 6 studies. Improved subjective results and Hughston criteria on final follow‐up ranged from 83% to 100% across 4 studies each. Mean postoperative Lysholm scores ranged from 42 to 98 in studies that reported them. Both complication and reoperation rates ranged from 0% to 44%. The most commonly performed reoperations were loose body excision and cartilage resurfacing procedures. Conclusions A variety of surgical techniques are available for treatment of unstable OCD lesions in the skeletally mature knee. In this systematic review, internal fixation of the native fragment showed acceptable rates of radiographic union and improved patient‐reported outcomes relative to other techniques. Level of Evidence Level IV, systematic review of level III‐IV studies.

Objectives: Hip arthroscopy is becoming more advanced and commonly performed. However, significant controversy exists regarding whether high grade acetabular cartilage lesions should be treated with debridement or microfracture. In addition, patients treated with microfracture are subject to extended partial weight-bearing rehabilitation in order to mitigate risk of subchondral plate fracture and protect fibrocartilage tissue formation. The purpose of this study was to determine the mid-term patient-reported outcomes and failure rate and patient-reported outcomes of Grade 3 and 4 acetabulum labrum articular disruption (ALAD) lesions managed with microfracture or debridement. Methods: Primary arthroscopic labral repair cases at two centers from November 2008 to April 2016 were reviewed in patients aged < 55 years with unipolar ALAD Grade 3 and 4 pathology. Patients undergoing microfracture and debridement were compared using visual analog pain scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score - Sports Specific Subscale (HOS-SSS) to determine predictors of outcomes and failure. Results: 127 hips in 123 patients (47 M, 76 F, mean age 34.7 ± 11.1) undergoing debridement (n = 95) or microfracture (n = 32) were followed for a mean of 4.9 years (range 2.0 - 8.5). Patients undergoing debridement achieved 3.5 point mean improvements in VAS (p < 0.01), 20.9 point improvements in mHHS (p < 0.01), and 25.5 point improvements in HOS-SSS (p < 0.01), which was statistically similar to that observed in microfracture patients (p ≥ 0.19). Five-year survival free of revision surgery was 83.0% in the debridement group and 85.6% in the microfracture group (p = 0.85). Cartilage treatment technique was found not to be predictive of revision risk during both univariate (p = 0.84) and multivariate (p = 0.84) analysis. Conclusion: Patients undergoing debridement of high grade unipolar acetabular cartilage lesions demonstrate similar patient reported outcome scores and revision rates compared to patients undergoing microfracture. These outcomes support debridement of acetabular lesions in order to optimize recovery while maintaining established positive outcomes following hip arthroscopy. [Table: see text]

Objectives: Participation in National Collegiate Athletic Association (NCAA) football is at an all-time high. This population experiences a substantial injury burden with many of these injuries affecting the upper extremities. The NCAA has adopted a data-driven decision-making process when providing recommendations for protecting player safety. The purpose of this study was to describe the epidemiology of hand and wrist injury in NCAA football in an effort to provide meaningful data for tailoring effective injury prevention strategies. Methods: An epidemiologic study utilizing the NCAA Injury Surveillance Program (NCAA-ISP) database was performed to investigate rates and patterns of hand and wrist injury in NCAA varsity football teams participating in the NCAA-ISP from 2009 to 2014. Descriptive statistics were used to present demographic data. Injury rates were calculated per 1000 athlete-exposures (AEs) using statistical cross-referencing between injury-level and event-level data. Injury mechanism and severity, as measured by time-loss from play, were determined and compared between exposure factors such as player position, player seniority, and practice versus game setting. Results: 725 hand and wrist injuries were captured in 899,225 AEs. The observed practice hand and wrist injury rate was 0.51 injuries per thousand AEs, which was significantly lower than the game injury rate of 3.60 (p < 0.01). Comparing player demographics for injuries sustained during practice as opposed to game time revealed significant differences based on player year, player position, activity performed at the time of injury, and mechanism of injury (p < 0.01, Figure 1). Player-on-player contact was the most common injury mechanism reported with blocking being the most common activity at injury. Of all sustained injuries, 71.4% resulted in no time loss from competition whereas 9.8% of injuries resulted in greater than 7 days of time loss. On average, fracture resulted in the greatest time loss from competition (8.3 ± 24.0 days for injuries sustained in practice setting, 7.7 ±15.8 days for injuries sustained in game setting). When comparing injury by location, hand injury resulted in greater time loss (3.7 ± 15.1, 4.4 ± 13.8) than to nail/subungual (0±0, 0±0), finger (1.6 ± 6.7, 1.1 ± 4.2), and wrist injury (1.2 ± 3.8, 1.8 ± 4.9). Conclusion: This study characterizes the incidence of NCAA football hand and wrist injuries in both practice and game settings and demonstrates the relatively low rate of injuries leading to loss of playing time. Hand and wrist injury was found to be significantly more common in games when compared to practice. Offensive linemen were the most commonly affected players in the cohort, with most injuries occurring during game time compared to practice. This study provides valuable prognostic data regarding expected time loss from play on a per injury pattern basis. Further investigation on specific injury subtypes and expected time loss as a result of these injures would provide trainers, players, and coaches with useful information on an expected post-injury recovery and rehabilitation timeline. [Figure: see text]

Objectives: Traditional pitching statistics (ERA, WHIP, etc) have been used as surrogates for pitcher performance without being validated. Even amongst healthy pitchers, the normal variability of these parameters has not yet been established. The purpose of this study was to determine the normal variability of basic and advanced pitching statistics in non-injured Major League Baseball (MLB) pitchers. It is our hope that this work will serve as the foundation for the identification and implementation of validated, pitcher dependent statistical measures that can be used to assess return to play performance following injury. Methods: Publicly available data from MLB Statcast and Pitch/Fx databases was used to analyze all non-injured MLB pitchers during 2015 and 2016 seasons who pitcher greater than 100 innings each season without injury. Traditional and advanced baseball pitching statistics were analyzed. The variability of each parameter was assessed by computing coefficient of variation (CV) between individual pitchers and across all pitchers. A CV below 10 is typically indicative of a relatively constant parameter, and parameters with a CV > 10 are generally considered inconsistent and unreliable. Results: A total of 118 pitchers met all inclusion criteria. For each of these healthy pitchers, 38 basic/traditional parameters and 17 advanced parameters were analyzed. Of the traditional pitcher statistics, only 1 (3%) demonstrated a CV value < 10 (average fastball velocity [FBv]; CV 1.5) (Figure 1). In advanced statistics, 9 of 17 (53%) variables demonstrated acceptable consistency as evidenced by a CV value < 10 (Figure 2). Release position from plate (release_pos_y) along with velocity from the plate (vy0) where the two most constant advanced parameters. When separated by pitch type, these two parameters were the most constant (lowest CV) in every pitch type. Conclusion: The validity and variability of baseball statistics as surrogate markers for performance after injury/surgery have not yet been evaluated. It is critical that baseball statistics undergo proper vetting prior to being used to assess recovery. This study reveals average fastball velocity and release position from the plate to be the least variable basic and advanced baseball statistics in MLB pitchers. In total, only 10 of the 55 statistics analyzed demonstrated acceptable consistency and reliability. This study can be further used to determine the minimum time that each of these variables needs to be followed to ensure an appropriate sample size is obtained to detect significant differences in pre- and post- injury performance. [Figure: see text][Figure: see text]

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.

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.

Objectives: Following ACL reconstruction, objective measurements of functional testing are often incorporated into the decision-making process with regard to clearance for return to sport (RTS), in order to reduce the risk of second ACL injury. However, there is limited data to assess the predictive value of functional testing to risk of second ACL injury. Therefore, the purpose of this study was to determine whether performance on functional testing following primary ACL reconstruction can predict second ACL injuries. Methods: Patient records were retrospectively analyzed for individuals who presented with an ACL injury at a single institution from 1990-2010. A total of 335 patients who underwent primary ACL reconstruction, had functional testing at the six month ± one month time point postoperatively, and had a minimum of two year post-operative follow-up were included in this study. Functional testing included vertical jump, single leg hop, and triple leg hop. Functional testing is represented as a measure of limb symmetry and was calculated as the involved limb divided by the uninvolved limb providing a percentage relative to the uninvolved limb. Statistical analysis was performed to determine the significance of functional test limb symmetries between those with and without a secondary tear by sex, then by age. Unpaired T-tests with an alpha level less than 0.05 was performed with JMP 13 (SAS Institute Inc., Cary, NC). Group distributions as well as effect sizes were calculated. Results: 335 patients with a mean age of 25 (SD 9.76) at an average time of 9.05 years (SD 3.54) of follow-up after ACL reconstruction met inclusion criteria and underwent statistical analysis (females= 150, male= 185). Of the cohort, 53 patients (18%) experienced second tears (female= 26, male= 27) at an average time of 44.19 months (6.03- 168.4) following ACL reconstruction with 34 occurring on the contralateral side and 19 on the ipsilateral side. Results at six month post ACL reconstruction indicate a significant difference between those who experienced a second ACL injury and those who didn’t with respect to single hop limb symmetry (95% ±7% vs.90% ± 12%, P<0.01). Triple hop limb symmetry was also significantly different between those who suffered a second ACL tear and those who did not (94% ± 6% vs. 90% ±11%, P<0.01). No significant differences were found in limb symmetry of vertical jump. When data was analyzed by sex, significant differences were found in females in the single hop limb symmetry (96% ± 8%, vs. 89% ± 14%, P<0.05) as well as triple hop limb symmetry (95% ± 5% vs. 90% ± 12%, P< 0.05). No significant differences were found in vertical jump for neither females nor males. No significant differences were found when data was categorized by age or sex and age. Conclusion: Overall, at an average of 9.05 years follow-up, 18% of a young and active population of primary ACL reconstructions had a second ACL injury. Contralateral ACL injuries were observed at an increased frequency relative to subsequent ipsilateral ACL tears. Patients with greater limb symmetry on single hop or triple hop functional testing at 6 months are at an increased risk for second ACL tears. When functional testing is used for return-to-sport decisions, physicians should caution patients about the risk of subsequent ACL injury for high performing patients.

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.