Krych, Aaron J.

Abstract The role of capsular repair in the arthroscopic treatment of femoroacetabular impingement remains poorly defined. Some surgeons rarely repair the capsule, whereas others perform repairs routinely. There is little direct clinical evidence to guide surgeon decision making. When capsular repairs are performed, the procedure requires adequate visualization and careful suture placement either to re‐establish the patient's normal capsular volume or to plicate a redundant capsule in a hip with hyperlaxity preoperatively. We present our preferred technique for arthroscopic capsular repair. Technique Video video See video under supplementary data.

Abstract We present our arthroscopic technique for fixation of an unstable osteochondritis dissecans (OCD) lesion. This technique includes arthroscopic evaluation of cartilage and bone quality of the OCD fragment, hinging open the lesion, debridement of fibrous nonunion tissue, reducing the fragment, and obtaining multi‐point compression screw fixation. This technique avoids the morbidity of an open arthrotomy and should be considered when treating an unstable OCD lesion with adequate bone for fixation. Technique Video video See video under supplementary data.

Context: Articular cartilage injuries are common in patients presenting to surgeons with primary complaints of knee pain or mechanical symptoms. Treatment options include comprehensive nonoperative management, palliative surgery, joint preservation operations, and arthroplasty. Evidence Acquisition: A MEDLINE search on articular cartilage restoration techniques of the knee was conducted to identify outcome studies published from 1993 to 2013. Special emphasis was given to Level 1 and 2 published studies. Study Design: Clinical review. Level of Evidence: Level 3. Results: Current surgical options with documented outcomes in treating chondral injuries in the knee include the following: microfracture, osteochondral autograft transfer, osteochondral allograft transplant, and autologous chondrocyte transplantation. Generally, results are favorable regarding patient satisfaction and return to sport when proper treatment algorithms and surgical techniques are followed, with 52% to 96% of patients demonstrating good to excellent clinical outcomes and 66% to 91% returning to sport at preinjury levels. Conclusion: Clinical, functional, and radiographic outcomes may be improved in the majority of patients with articular cartilage restoration surgery; however, some patients may not fully return to their preinjury activity levels postoperatively. In active and athletic patient populations, biological techniques that restore the articular surface may be options that provide symptom relief and return patients to their prior levels of function.

Abstract Purpose Recent advancements in the understanding of hip biomechanics have led to the development of techniques to remove bony impingement and repair and/or preserve the labrum during hip arthroscopy. Although much attention in the literature is devoted to diagnosis and treatment, there is little information about post‐operative rehabilitation. Therefore, the purpose of this review is to (1) provide a five‐phase rehabilitation protocol following arthroscopic treatment for FAI and (2) report clinical and functional outcomes of patients following this protocol at minimum 1‐year follow‐up, in order to provide the surgeon and therapist with a protocol that is supported by clinical data. Methods All consecutive patients undergoing hip arthroscopy and subsequent five‐phase rehabilitation protocol at a single institution from 1 April 2011 to 1 April 2012 were analysed. Inclusion criteria were as follows: no prior ipsilateral hip surgery, completion of the five‐phase rehabilitation protocol, minimum 1‐year follow‐up, and documented outcome scores. Prospective outcomes were assessed with modified Harris hip score (MHHS) and hip outcome score (HOS). Results Fifty‐two patients (19 male and 33 female) met the inclusion criteria with a median age of 42 (range 16–59) years. Mean MHHS, HOS‐ADL, and HOS‐sport scores at a mean 12.5 (range 12–15) months were 80.1 ± 19.9 (0–100), 83.6 ± 19.2 (13.2–100), and 70.3 ± 27.0 (0–100), respectively. Conclusion This five‐phase rehabilitation programme provides a framework where progression from surgery to increasing post‐operative activity level can take place in a predictable manner. Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation. Level of evidence Case series, Level IV.

AbstractPurposeThe purpose of this study was to evaluate the utility of multimodal analgesia with fascia iliaca blockade and for acute pain control in patients undergoing hip arthroscopy.MethodsThirty consecutive patients undergoing primary hip arthroscopy were prospectively studied. All patients were treated preoperatively with ultrasound‐guided single injection fascia iliaca blockade and multimodal analgesia. Data collected included post‐operative nausea, numeric rating scale (NRS) pain scores during rest and activity, opioid consumption during the first five days (recorded as tablets of 5 mg hydrocodone/500 mg acetaminophen) and overall patient satisfaction with analgesia.ResultsThis study included 23 female and 7 male patients with a median age of 35 years (range 14–58). No patient required medication for post‐operative nausea. The overall NRS scores were an average of 3.9 on day 0, 3.6 on day 1, 3.4 on day 2, 2.9 on day 3, 3.0 on day 4 and 2.7 on day 5. The average tablets of opioid taken were 1.5 on day 0, 1.2 on day 1, 1.3 on day 2, 1.0 on day 3, 1.1 on day 4 and 0.9 on day 5. Overall, 20 patients rated their post‐operative pain control as very satisfied (67 %), and 10 patients as satisfied (33 %). There were no complications or side effects from the fascia iliaca blockade.ConclusionIn this prospective study, multimodal analgesia with fascia iliaca blockade following hip arthroscopy was safe and effective. The quality of early post‐operative analgesia provided by the fascia iliaca blockade was excellent and resulted in low opioid consumption, high quality of pain relief and high overall patient satisfaction.Level of evidenceProspective case series, Level II.

Objectives: Peroneal nerve injuries are not uncommon with multiligament (ML) knee dislocations. However, there remains little information on outcome of these injuries. Therefore, the purpose of this study was to (1) report the clinical and functional outcomes after ML knee injury with concomitant peroneal nerve palsy, (2) compare recovery and outcome with partial versus complete peroneal nerve injury, (3) compare outcomes to a matched cohort of ML knee injuries without concomitant peroneal nerve palsy. Methods: Patients that underwent surgical reconstruction of a ML knee injury from 1993 to 2010 were reviewed and concomitant nerve injuries were identified, forming the peroneal nerve injury group (PI). Patient demographics, injury mechanism, modified Schenck classification, and peroneal nerve function, treatment, and recovery were documented. Patients were divided into two sub-groups: complete peroneal nerve palsy (CNP) and partial peroneal nerve palsy (PNP). A second group of patients with ML knee injury without peroneal nerve injury were identified, forming the no nerve injury group (NI). The PI and NI groups were matched based on Modified Schenck Classification, age, and gender. Peroneal nerve motor grade was assessed at last clinical follow-up and outcome scores were obtained using the International Knee Documentation Committee (IKDC) and Lysholm forms at a minimum of 2 years post-op. Data was analyzed using univariate and multivariate models to assess for predictive factors between the groups. Results: 27 patients (24 males, 3 females) met inclusion criteria for the PI group (9 CNP and 18 PNP). Treatment for CNP included an AFO for all patients, non-operative (1), neurolysis (2), tendon transfer (3), nerve transfer (1), and combined nerve/tendon transfer (1). One patient in the CNP group required additional surgery, undergoing below knee amputation. Treatment for PNP included non-op (12), neurolysis (4), nerve transfer (1), and combined nerve/tendon transfer (1). 2 patients with incomplete nerve palsy required additional surgery, undergoing an arthrodesis and a total knee arthroplasty. 3 CNP (37.5%) and 15 PNP (83.3%) regained 3/5 or greater tibialis anterior (TA) strength. PNP was associated with increased recovery of 3/5 extensor hallucis longus (EHL) strength (p=0.0093). Outcome scores were obtained for 17 of the remaining patients at a mean 6.6 (range 2-18) years. Univariate analysis revealed no difference between the CNP and PNP groups. Final motor grade of 3/5 did not predict improved outcomes. Not undergoing a tendon transfer procedure predicted better outcomes on the IKDC score (70.5 vs 45.0; p=0.027). All other peroneal nerve interventions were not associated with improved motor or functional outcome. 20 patients formed the NI group. The PI and NI groups were matched on gender (18 M, 2 F), age (mean 30.8 vs 29.5 years), and Modified Schenck Classification (2 KD-I, 10 KD-IIIL, 5 KD-IV, 3 KD-V vs 2, 7, 8, and 3 respectively). In univariate analysis, the PI group had inferior outcomes on both the IKDC (64.5 vs 77.3; p=0.036) and Lysholm (67.1 vs 83.0; p=0.023) scores. Conclusion: Patients with partial peroneal nerve palsy are more likely to regain antigravity EHL strength, but not antigravity TA strength. There is no significant difference in outcomes between partial and complete peroneal nerve palsy. In ML knee injuries, patients with peroneal nerve injury have significantly worse outcomes than similar patients without peroneal nerve injury.

Objectives: TT-TG distance is a commonly used measurement for surgical decision-making in patients with patellofemoral malalignment and instability. This measurement has historically been performed utilizing axial CT scans. More recently, MRI has been proposed as an equivalent test for measurement of TT-TG distance. We sought to determine the reliability of TT-TG measurements on both MRI and CT, and to determine whether the measurements can be used interchangeably. Methods: All patients diagnosed with patellar instability who had received both CT and MRI of the knee between 2003 and 2011 were included (n=59 knees in 54 patients). Two fellowship trained musculoskeletal radiologists measured the TT-TG distances for each patient by CT and MRI in a randomized, blinded fashion for a total of 236 measurements. Inter-observer reliability was calculated between radiologists for both imaging modalities and inter-methods reliability was calculated between the two imagining modalities. The results are reported using intraclass correlation coefficients (ICC) and Bland Altman analysis (BAA). Results: The 59 knees had a mean TT-TG distance of 16.9 mm (range: 8.3-25.8) by CT and 14.7 mm (range: 1.5-25.1) by MRI. Eighteen patients (31%) had a TT-TG ≥ 20 mm by CT, and only 9 (15%) had a TT-TG ≥ 20 mm by MRI. Inter-observer reliability between the radiologists was considered excellent for both CT and MRI (ICC = 0.777 and 0.843 respectively). When comparing CT to MRI, however, the ICC was considered only fair for each of the two raters (0.532 and 0.539). A total of 11 patients (19%) had a TT-TG ≥ 20 mm on CT preoperatively and underwent distal realignment by tibial tubercle osteotomy (TTO). In this surgical subgroup, the mean TT-TG on CT was 22.5 mm (range 19.8-25.8) while the mean TT-TG on MRI was only 18.7 mm (range 14.4-22.8). Conclusion: TT-TG distance can be measured with excellent inter-rater reliability on both MRI and CT scans; however, the values derived from these two tests may not be interchangeable. This observation should be taken into consideration when MRI is used for surgical planning since MRI may underestimate TT-TG distance when compared to CT.

Abstract Labral repair has become an essential technique in the arthroscopic surgical management of femoroacetabular impingement. Several clinical studies suggest that labral repair results in superior patient outcomes in comparison to labral debridement alone. The repair procedure requires accurate evaluation of labral tissue quality, precise placement of sutures and anchors, and careful re‐tensioning of the labrum. We present our preferred technique for labral repair. Technique Video video See video under supplementary data.

Abstract Appropriate identification and precise resection of the pincer lesion are integral parts of the arthroscopic surgical treatment of femoroacetabular impingement. Preoperative radiographic planning of the bone resection, as well as executing the plan intraoperatively using both fluoroscopic and arthroscopic cues, is critical to adequately removing the pincer lesion. We present our surgical technique of removing the impinging bone by defining the focal acetabular rim overcoverage, accessing the pincer lesion with labral detachment, and then performing acetabular rim resection. Technique Video video See video under supplementary data.

Background: Tibial tubercle–trochlear groove distance (TT-TG) is a commonly used measurement for surgical decision making in patients with patellofemoral malalignment and instability. This measurement has historically been performed utilizing axial computed tomography (CT). More recently, magnetic resonance imaging (MRI) has been proposed as an equivalent method, but this has not yet been fully validated. Purpose: To determine the reliability of TT-TG distance measurements on both MRI and CT and to determine whether the measurements are interchangeable with one another. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: All patients with patellar instability who underwent both CT and MRI of the knee from 2003 to 2011 were included (n = 59 knees in 54 patients). Two fellowship-trained musculoskeletal radiologists measured the TT-TG distances for each patient by CT and MRI in a randomized, blinded fashion. Interobserver reliability was calculated between radiologists for both imaging modalities, and intermethod reliability was calculated between the 2 imaging modalities. The results are reported using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Results: The 59 knees had a mean TT-TG distance of 16.9 mm (range, 8.3-25.8 mm) by CT and 14.7 mm (range, 1.5-25.1 mm) by MRI. Interobserver reliability between the radiologists was considered excellent for both CT and MRI (ICC = 0.777 and 0.843, respectively). When comparing CT to MRI, the ICC was considered only fair for each of the raters (0.532 and 0.539). Eleven patients (19%) had a TT-TG distance of ≥20 mm on CT preoperatively and underwent distal realignment by tibial tubercle osteotomy. In this surgical subgroup, the mean TT-TG distance was 22.5 mm (range, 19.8-25.8 mm) by CT and only 18.7 mm (range, 14.4-22.8 mm) by MRI for a mean difference of 3.80 mm ( P < .001). Conclusion: The TT-TG distance can be measured with excellent interrater reliability on both MRI and CT; however, the values derived from these 2 tests may not be interchangeable. This observation should be taken into consideration when MRI is used for surgical planning because MRI may underestimate the TT-TG distance when compared with CT.