Krych, Aaron J.

Objectives: Female athletes are an at-risk population for anterior cruciate ligament (ACL) injury, with rates of injury significantly higher than the general population. Few studies have reported on a second ACL injury for female athletes. The purpose of this study was to (1) report the rate of subsequent ACL injury (ACL graft rupture or contralateral ACL tear) in competitive female soccer players, (2) compare these rates to those of other female athletes of similar competitive level, and (3) determine risk factors for second ACL injury in this athletic population. Methods: The medical record at our institution was reviewed for patients treated with primary ACL reconstruction between 1998 and 2013. Female patients injured during a competitive athletic event were included for further review, and followed for an average of 7.1 years postoperatively (range 1.0 - 17.7 years). Chi-square analysis was used to compare rate of graft rupture and contralateral ACL injury based on pre-operative Tegner score, graft type, and injury side for soccer players vs. other female athletes. Wilcoxon rank-sum test was used to compare rate of subsequent ACL injury to patient age. Results: 337 patients met our inclusion/exclusion criteria (90 soccer players; 247 non-soccer playing athletes) with a mean age of 24.0 years. Of the 337 athletes, 6 were injured during professional competition, 43 were injured during collegiate athletics, 184 during high school play, and 136 during recreational athletics. No patient demographical differences were found at baseline between the soccer group and non-soccer group, including Tegner scores. Overall, 21 soccer players (23.3%) sustained a second ACL injury compared to 21 (8.5%) non-soccer athletes (P < 0.001). Soccer players had significantly more graft ruptures (10.0% vs. 2.0%, P = 0.003) and more contralateral ACL tears (13.3% vs. 6.5%, P = 0.04). Risk factors for ACL graft tear included young age (mean 16.0 vs 24.3 years; P < 0.0001) and higher Tegner Activity Level scores (mean 8.1 vs. 7.4, P = 0.049), but were not risk factors for contralateral ACL injury. Graft selection and injury side showed no statistical significance on graft rupture or contralateral injury. Conclusion: Female soccer players treated with ACL reconstruction had an increased rate of second ACL injury, including graft tear and contralateral ACL injury, compared to a similar group of non-soccer female athletes (23.3% vs. 8.5%, P < 0.001). In addition, young age and higher activity level were risk factors for graft rupture in this population.

Objectives: Arthroscopic treatment for femoroacetabular impingement (FAI) generally has good results, but the outcome can worsen with increasing arthritis, largely defined as joint space narrowing. There remains a subset of hips with maintained joint space but with subchondral edema and cystic change of the acetabulum on MRI, with unknown outcome. Therefore, the purpose of this study was (1) to determine if postoperative outcome was worse for patients with subchondral edema on preoperative MRI compared to a matched control group and (2) to identify risk factors on MRI leading to inferior outcome. Methods: A review of patients who underwent arthroscopic hip surgery for FAI between 2007 and 2013 identified 530 patients. Of these, 39 patients had evidence of subchondral edema or subchondral cyst on the preoperative MRI with maintained joint space on preoperative radiographs. Lesions were characterized by grade, location and type using an established radiographic MRI classification system. A matched cohort of patients without evidence of subchondral edema or cyst was identified, and 2:1 matching was based on patient age, surgeon, surgery year within one year, surgical procedure, Tegner activity score, and Tonnis grade osteoarthritis changes on preoperative x-ray. Outcome was compared using the Hip Outcome Score and Modified Harris Hip Score between the two groups. Risk factors were then analyzed for type of lesion, grade and location of bone marrow lesion. Results: Thirty-nine patients (20 males, 19 females) showed preoperative MRI evidence of subchondral edema, and were followed for a mean of 23 months postoperatively (range, 12 - 60 months). Patients had an average age of 41 years (range, 19 - 67) and a preoperative Tegner score of 3.8 (range, 1 - 9). 87% of patients with subchondral cystic change had evidence of a grade IV full thickness cartilage lesion at the time of hip arthroscopy. Average Modified Harris Hip Scores were inferior for the subchondral group (79.9 ± 18.7) compared to the control group (86.6 ± 12.5; p = 0.027). In addition, Sport sub-scales of the Hip Outcome Score showed significantly lower scores for the subchondral group for both score (69.1 ± 27.0 vs. 79.5 ± 21.4, p = 0.018) and rating (66.7 ± 27.5 vs. 78.0 ± 20.8, p = 0.044). No radiographic risk factors, including type, location, or size of lesion were significant predictors of outcome. Two patients in the subchondral group were later converted to a total hip replacement. Conclusion: The presence of a subchondral acetabular cyst on MRI is indicative of a full thickness cartilage lesion at the time of arthroscopy. These patients have inferior outcomes for arthroscopic treatment of FAI compared to patients with similar age and activity level without MRI subchondral changes. Therefore, we recommend caution with consideration of hip arthroscopy in this patient subset.

Purpose To (1) determine the incidence of symptomatic venous thromboembolic events (VTEs) after knee arthroscopy and arthroscopy‐assisted procedures at a single institution and (2) determine associated risk factors for VTEs in these patients. Methods The records of patients who underwent knee arthroscopy at a single institution between 1988 and 2008 were reviewed. Chemoprophylaxis was not routinely used. Confirmed VTEs occurring within 4 weeks after the index arthroscopy procedure were included. A 2:1 matched control group was generated to include patients in whom knee arthroscopy was performed by the same surgeon either on the same day or immediately before each case resulting in a VTE. Preoperative and perioperative data were collected with respect to demographic data, medical history, medications, and surgical and anesthesia data. Univariate and multivariate analyses were performed. Results During the study period, 12,595 patients underwent knee arthroscopy. Among these patients, 43 cases of VTEs (35 deep venous thromboses [DVTs], 5 pulmonary embolisms [PEs], and 3 DVTs that progressed to PEs) occurred, resulting in an incidence of 0.30% (95% confidence interval [CI], 0.22% to 0.41%) for DVT, 0.06% (95% CI, 0.03% to 0.12%) for PE, and 0.34% (95% CI, 0.25% to 0.46%) for VTEs overall. Factors associated with an elevated risk of symptomatic postoperative VTEs included a history of malignancy ( P = .01; odds ratio [OR], 6.3), a history of VTEs ( P = .02; OR, 5.2), or the presence of more than 2 classic risk factors for VTEs ( P = .01; OR, 13.6). Conclusions In this study, symptomatic VTEs were rare and occurred infrequently, with an incidence of 0.34% (95% CI, 0.25% to 0.46%), after knee arthroscopy and arthroscopy‐assisted cases in the absence of routine chemoprophylaxis. Patients with a history of VTEs, a history of malignancy, or 2 or more classic risk factors are at increased risk of VTEs after knee arthroscopy, and chemoprophylaxis should be considered in these select patients. Level of Evidence Level III, case‐control study.

Objectives: Intra-articular (IA) anesthetic injection is commonly performed as a diagnostic test in the setting of femoroacetabular impingement (FAI). Currently, there is a paucity of data correlating post-injection pain relief and outcomes after hip arthroscopy for FAI. The purpose of this study is to determine whether the amount of pain relief after IA injection predicts clinical and functional outcomes following hip arthroscopy. We hypothesize that increased pain relief (>50%) will correlate with better outcomes after surgery. Methods: The records of patients undergoing hip arthroscopy for FAI at our institution between April 2007 and April 2012 were reviewed. We identified patients who underwent IA injection and subsequent hip arthroscopy. Inclusion criteria were: ultrasound or fluoroscopic guided intra-articular anesthetic injection performed at our institution, prospectively documented pre- and post-injection Numerical Rating Scale (NRS) pain scores, no prior ipsilateral hip surgery, and minimum 1 year follow-up. Pre-operative radiographs were reviewed and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome scores. Results: 99 hips in 96 patients met our inclusion criteria and included 71 females (74%) and 25 males (26%) with a mean age of 37.5 ± 14.0 years. 26 patients had Tonnis grade 0, 55 had grade 1, and 18 had grade 2 (0 grade 3). Mean pain relief after IA injection was 73.6 ± 36.1 (range 0-100) percent. 26 patients (26%) had ≤50% pain relief while 73 (74%) had >50% pain relief. Outcome scores were obtained at a mean 14.9 months. Mean MHHS, HOS-ADL, and HOS-Sport scores were 79.2 ± 17.3, 82.6 ± 17.3, and 67.4 ± 28.2, respectively. There was no statistical correlation between percent pain relief and MHHS, HOS-ADL, or HOS-Sport scores. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. While patients that received >50% pain relief by IA injection were more likely to achieve positive results (MHHS >70) with a likelihood ratio of 1.23 (95% CI 0.92-1.53), this was not significant. Multivariate regression analysis demonstrated no significant predictors of outcome, including age, gender, Tonnis grade, percent relief with IA injection, number of months postoperatively, or type of surgery. Conclusion: In patients undergoing hip arthroscopy for FAI, our data indicates that the amount of pain relief from IA injection is a poor predictor of short term outcome, even when adjusting for chondral degeneration. While anesthetic injections can be an important diagnostic tool in select patients, correlation of the clinical history, physical examination, and imaging findings are fundamental. In addition, outcome following hip arthroscopy remains multifactorial.

Background: Multiligament knee injuries (MLKIs) can also involve the medial patellofemoral ligament (MPFL), but there is a paucity of information regarding prevalence and relevance of MPFL involvement in this setting. Purpose: (1) To identify the prevalence of MPFL injury in MLKIs, (2) to determine whether an MPFL tear results in symptomatic patellar instability, and (3) to report clinical and functional outcomes of patients with and without MPFL tears after MLKI surgical reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The records of all patients who underwent surgical reconstruction of MLKI (defined as a grade 3 injury of ≥2 ligaments) at a single institution from 2007 to 2010 were reviewed. Age, sex, knee dislocation classification (according to Schenck), and MRI findings were documented. All preoperative MRI scans were reviewed by an experienced musculoskeletal radiologist to determine the presence or absence of MPFL involvement. If an MPFL tear was present, its anatomic location and severity as well as the presence of patellar or lateral femoral condyle bone bruises were documented. Inclusion criteria included (1) MLKI treated at a single institution, (2) presence of MPFL tear on preoperative MRI, and (3) minimum 2-year clinical follow-up. Patellar instability symptoms were assessed with the Kujala Knee Questionnaire. Functional outcomes were measured using the International Knee Documentation Committee (IKDC) score. IKDC scores were compared between patients who sustained MLKIs with and without MPFL tears. There were 21 patients in each group. Results: Over the 4-year study period, 30 of 51 patients (59%) treated surgically for a MLKI had MRI evidence of an MPFL tear. Nine were lost to follow-up, leaving 21 patients for review. There were 13 complete (62%), 5 high-grade partial (24%), and 3 partial (14%) MPFL tears. Sixteen of 21 tears (76%) occurred at the proximal third, with the remainder exhibiting diffuse signal abnormality consistent with tearing throughout the length of the MPFL. The superficial medial collateral ligament was involved in all patients. In no case was the MPFL repaired or reconstructed. At mean follow-up of 3.6 years (range, 2.0-5.7 years), only 1 of 21 patients (5%) complained of patellofemoral instability symptoms whereas 20 of 21 patients (95%) did not experience patellar subluxation or dislocation. No significant difference was found when IKDC scores were compared between patients with and without an MPFL tear (mean ± SD, 65.5 ± 22.9 vs 79.4 ± 16.1; P = .07). Conclusion: MPFL tears occur frequently in patients with MLKI but rarely cause instability. In the majority of cases, MPFL tears do not need to be addressed at the time of surgery.

Abstract Tibial plateau fractures present a difficult range of fractures to treat. Arthroscopy allows for a less invasive option when compared with arthrotomy. Furthermore, visualization of the articular surface arthroscopically can allow for a precise reduction and assessment of any concomitant injuries to the articular cartilage and meniscus. By use of arthroscopy, unicondylar lateral plateaus were traditionally approached through a laterally based metaphyseal window. However, in carefully selected patients and fracture patterns, a medially based, arthroscopic‐assisted approach can create long bony tunnels for subchondral support and allow for greater ease in fracture reduction. We present our technique using a medial approach for arthroscopic‐assisted fixation of lateral tibial plateau fractures. Technique Video video See video under supplementary data.

Abstract Meniscal root injuries can compromise knee function and lead to early degenerative changes if not appropriately treated. Numerous techniques have been described; however, the technical difficulties in performing these repairs are well known. Furthermore, the relative strengths of various repair techniques have been examined. This article describes a single–working portal meniscal root repair technique using a double‐locking loop suture configuration with a novel suture‐passing device that offers a strong, reproducible repair construct. Technique Video video See video under supplementary data.

Objectives: Arthroscopy is being used more frequently as a treatment for intra-articular hip pathology due to femoroacetabular impingement (FAI). Prior to surgery, intra-articular anesthetic injection is commonly performed as a diagnostic test to localize the source of pain. Currently, there is a paucity of data correlating post-injection pain relief and functional outcomes after hip arthroscopy for FAI. The purpose of this study is to determine whether the amount of pain relief after preoperative intra-articular anesthetic injection predicts clinical and functional outcomes following hip arthroscopy with minimum one year follow-up. We hypothesize that increased pain relief (>50%) will correlate with better outcomes after surgery. Methods: The records of patients undergoing hip arthroscopy for FAI at our institution between April 2007 and April 2012 were reviewed. We identified patients who underwent pre-operative intra-articular anesthetic injection and subsequent hip arthroscopy. Inclusion criteria were: ultrasound or fluoroscopic guided intra-articular anesthetic injection performed at our institution, documented pre- and post-injection Numerical Rating Scale (NRS) pain scores, no prior ipsilateral hip surgery, and minimum 1 year follow-up. Pre-operative radiographs were reviewed and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome scores. Results: 57 hips in 55 patients met our inclusion criteria and included 37 females (67%) and 18 males (33%) with a mean age of 42.6 ± 14.7 (range 15-68) years. 8 patients had Tonnis grade 0, 35 had Tonnis grade 1, and 14 had Tonnis grade 2. Mean pain relief after intra-articular injection was 74.4 ± 31.9 (range 0-100) percent. 13 patients (23%) had ≤50% pain relief while 44 (77%) had >50% pain relief. Outcome scores were obtained at a mean 25.5 (range 12- 60) months. Mean MHHS, HOS-ADL, and HOS-Sport scores were 82.1 ± 17.4 (range 42.9-100), 85.0 ± 16.6 (range 39.7-100), and 71.8 ± 28.1 (range 11.1-100) respectively. There was no correlation between percent pain relief and MHHS, HOS-ADL, or HOS-Sport scores. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. When adjusting for Tonnis grade there was no correlation between percent relief and any of the outcome scores measured. Conclusion: In patients undergoing hip arthroscopy for FAI, our data indicates that the amount of pain relief from intra-articular anesthetic injection does not correlate with minimum 1 year clinical and functional outcomes even when adjusting for Tonnis grade. Although pain relief did not predict outcomes in our study, we still believe it is a useful diagnostic tool to localize the source of pain in patients considering hip arthroscopy.