Song, Bryant M.

Objectives: Background: Although they are common, there remains a paucity of data regarding traumatic anterior shoulder dislocations (ASI) associated with anteroinferior glenoid rim fractures (AGRF) in older patients. Purpose: To describe the incidence of AGRF in this population following ASI, identify risk factors for AGRF, compare treatment strategies, and compare clinical outcomes of patients with and without an associated AGRF. Methods: An established geographic medical record system was used to identify patients >50 years of age with ASI between 1994 and 2016. Patients with radiographic evidence of AGRF were identified and matched 1:1 to patients without AGRF. Comparative analysis was conducted to determine differences between groups. Results: Overall, 186 patients were identified with a mean follow-up of 10.4 years (range, 2.0 – 25.4). Of these, 42 (22.6%) had AGRF and were matched to 42 control patients without AGRF. Average age was 58.9 and 58.2 years for the AGRF and control groups, respectively. Rates of surgical intervention (29% vs. 43%), recurrent instability (14% vs. 17%), progression of osteoarthritis (34% vs. 39%), and conversion to arthroplasty (2% vs. 5%) were similar between AGRF and control cohorts. Control patients were more likely to report recurrent pain (p=.046). For patients with AGRF, increased bone fragment size (OR 1.1) and increased BMI (OR 1.2) correlated with an increased risk for surgery. The cut-off value for surgery in patients with AGRF was a fragment size ≥33% of the glenoid width. Conclusions: In patients ≥ 50 years at presentation of ASI, 22.6% presented with an associated AGRF. Increased fragment size and greater patient BMI were significant factors associated with undergoing surgical intervention; however, most patients did not require surgery. Patients without AGRF were more likely to report recurrent pain, possibly due to a higher prevalence of rotator cuff derangement. Overall, the presence of an AGRF did not portend a worse prognosis as treatment strategies and long-term outcomes in terms of recurrent instability, progression of osteoarthritis, and conversion to arthroplasty were similar between patients with and without AGRF at the time of ASI diagnosis.

Objectives: Anterior shoulder instability (ASI) is a well-studied topic in young patients, however there is a dearth of knowledge about older patients with this pathology. The goals of this study were to describe patient demographics, injury characteristics and outcomes in patients >50 years old with anterior shoulder instability along with historical trends in diagnosis and treatment. Methods: An established geographic database was used to identify 179 patients who experienced new onset anterior shoulder instability after the age 50 between 1994-2016. Mean age was 59.7 years, mean BMI was 31.3 and 54.2% were female. The dominant arm was involved in 62.2% of instability events. 26.8% of our study population were laborers and 50% reported current or former smoking habits. The primary etiology for ASI involved trauma in 96.6% of cases. Comparative analysis was performed to identify differences between age groups. Mean follow up time was 11 years. Results: The overall incidence of ASI in our study population was 28.8/100,000 person years with the highest incidence in the age cohort 60-64 at 38.9/100,000 person years. At initial presentation, 73% of all patients were found to have a lesion apparent on either XR or MRI. Rotator cuff tears were found in 92.4% of all patients undergoing MRIs. 26.2% ultimately progressed to surgery at a mean time of 1.57 years after injury. 53% of all surgical procedures involved a rotator cuff repair whereas only 25% were performed for instability. In terms of historical trends, the one-year rate of obtaining an MRI after an ASI event has increased from 10% in the late 1990s to 46% in 2015-16. Similarly, the one-year rate of performing surgery has increased from 5.1% to 47% from 1994-1999 to 2015-2016. Conclusions: In our cohort, patients over the age of 50 with ASI were found to often have concomitant pathology on imaging, however only ¼ of all patients required surgery. Although the rate of ASI has stayed relatively stable over the last 20 years, the rate of obtaining an MRI and of surgical management has increased. [Figure: see text]

Objectives: The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted with a lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair, but no long-term, comparative studies are available in the literature. Methods: A total of 55 patients (58 knees) with recurrent lateral instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. Exclusion criteria included prior or concomitant tibial tubercle osteotomy or trochleoplasty, and follow-up less than 8 years. Pre- and post-operative demographic, surgical, imaging and clinical data were recorded for each patient. Results: MPFL repair was performed on 26 patients (29 knees; 14 females, 15 males) at a mean age of 19.1 years. MPFL reconstruction was performed on 29 patients (29 knees; 18 females, 11 males) at a mean age of 18.2 years. Mean follow-up was 12.0 years (range 8.3-18.9). The reconstruction group had a significantly lower rate of recurrent dislocation compared to the repair group (14% vs 41%, p=0.019) at final follow up. There were no differences in the number of pre-operative dislocations (greater than or less than 3), degree of patellar facet chondromalacia, TT-TG distance, or Tegner scores. The reconstruction group had significantly more time from injury to surgery compared to the repair group (median, 1,460 days vs 627 days, p =0.007). There were no differences in post-operative Tegner, Lysholm or Kujala scores at final follow-up. Additionally, there were no differences in return to play rates (repair 80.8% vs reconstruction 75.0%, p=0.610) or reoperation rates (repair 20.7% vs reconstruction 13.8%, p=0.487). Conclusions: Repair of the MPFL leads to nearly 3-fold higher rate of recurrent patellar dislocation (41% vs. 14%) at long term follow-up compared to MPFL reconstruction. However, MPFL repair and reconstruction provide similar clinical results, return to play rates and reoperation rates. [Table: see text][Table: see text]

Purpose To 1) evaluate the clinical efficacy of arthroscopic posterior capsular release for improving range of motion (ROM) in cases of recalcitrant flexion contracture and 2) determine patient‐reported outcomes (PROs) postoperatively. Methods Retrospective chart review was performed to identify patients who underwent arthroscopic posterior capsular release due to persistent extension deficit of the knee despite comprehensive nonoperative physical therapy between 2008 and 2021. Knee ROM and PROs (International Knee Documentation Committee [IKDC], Tegner, and visual analog scale [VAS]) were collected at final follow‐up. Results Overall, 22 patients were included with a median age of 37 years (interquartile range [IQR]: 20.5‐44.3). Of these, 8 (36%) were male and 14 (64%) were female, and average follow‐up was 3.7 ± 3.3 years. The most common etiology was knee flexion contracture after anterior cruciate ligament (ACL) reconstruction (59%). All patients failed a minimum of 3 months of nonoperative management. Prior to operative intervention, 100% of patients received physical therapy, 64% received extension knee bracing or casting, and 36% received corticosteroid injection. Median preoperative extension was 15° (IQR: 10‐25) compared to 2° (IQR: 0‐5) postoperatively ( P < .001). At final follow‐up, median extension was 0° (IQR: 0‐3.5). Postoperative VAS pain scores at rest (2 vs 0; P = .001) and with use (5 vs 1.8; P = .017) improved at final contact, and most (94%) patients reported maintaining their extension ROM. Patients with ACL‐related extension deficit reported better IKDC (81 vs 51.3; P = .008), Tegner (5.8 vs 3.6; P = .007), and VAS pain scores (rest: 0.2 vs 1.8; P = .008; use: 1.3 vs 5; P = .004) compared to other etiologies. Conclusion Arthroscopic posterior capsular release for recalcitrant flexion contracture provides an effective means for reducing pain and restoring terminal extension. The improvement in extension postoperatively was maintained for most (94%) patients at final follow‐up with a 14% reoperation rate.

Background: Wrestling is a physically demanding sport, with young athletes prone to anterior cruciate ligament (ACL) injuries. There is a paucity of data evaluating the results of ACL reconstruction (ACLR) in this cohort. Purpose: To assess return to sport (RTS), patient-reported outcomes, reoperation rates, and graft survival after ACLR in a large cohort of competitive wrestlers at midterm follow-up. Study Design: Case series; Level of evidence, 4. Methods: We identified all competitive wrestlers (club, high school, collegiate, or professional) with a history of an ACLR at a single institution between 2000 and 2019. Graft failure was defined as a retear (as determined via clinical or advanced imaging evaluation) and/or revision ACLR. All patients were contacted for determination of reinjury rates; current sport status; and pain visual analog scale, International Knee Documentation Committee, and Tegner activity scores. Results: Included were 107 knees in 103 wrestlers, with a median follow-up time of 5.9 years (interquartile range [IQR], 3.9-10.3 years). The median age was 17 years (IQR, 15-18 years), with 106 (99%) male patients, and the distribution of bone–patellar tendon–bone (BTB) and hamstring tendon (HT) autografts was 64 (60%) and 43 (40%), respectively. At final follow-up, 80% of athletes were able to RTP at a median of 280 days (IQR, 212-381 days). Graft failure occurred in 14 (13%) knees at a median time of 1.8 years (IQR, 0.7-5.3 years) after the index ACLR. BTB autograft demonstrated a lower failure rate compared with HT autograft (8% vs 21%; P = .044) and was associated with better survival compared with HT autograft up to 15 years after the index ACLR (90.4% vs 76.3%; P = .030). When compared by graft diameter, HT autografts of at least 7.5 mm were not associated with a lower graft failure than BTB constructs of all sizes ( P = .205). Conclusion: Return to competitive wrestling was observed in 80% of athletes after ACLR, with 14% of wrestlers experiencing graft failure. BTB autograft was associated with better survival than HT autograft.

Background: Prospective evaluation of clinical outcomes after posterior meniscal root repair utilizing a transtibial pullout technique is limited, and factors that may contribute to outcomes are unclear. Hypothesis: It was hypothesized that there would be an overall significant improvement in outcomes after root repair and that differences in clinical outcomes would correlate with age, body mass index (BMI), sex, and meniscal extrusion. Study Design: Case-control study; Level of evidence, 3. Methods: Consecutive patients undergoing transtibial medial or lateral meniscal root repair were enrolled prospectively at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) were obtained to assess for meniscal healing, quantification of extrusion, articular cartilage grade, and subchondral bone changes. Patient-reported outcomes including International Knee Documentation Committee (IKDC) scores, Tegner activity scale, and visual analog scale (VAS) for pain were collected preoperatively and 2 years postoperatively. Patients were then subdivided by clinical and demographic characteristics to determine factors associated with clinical outcomes. Results: Included were 45 patients (29 female, 16 male; mean age, 42.3 ± 12.9 years; mean BMI, 31.6 kg/m 2 ) who underwent 47 meniscal root repairs (29 medial and 16 lateral; 2 had both). Significant improvements at 2-year follow-up were seen in IKDC score (41.1 vs 78.4; P < .001), Tegner activity level (3 vs 4; P < .001), and VAS pain (2.8 vs 0.7; P < .001). BMI, preoperative malalignment, cartilage status, and progressive meniscus extrusion (Δ = 0.7 mm) did not have a negative impact on IKDC and Tegner scores 2 years postoperatively. Age greater than or equal to 50 years and extrusion pre- and postoperatively were associated with decreased Tegner scores. Progressive meniscal extrusion was associated with a decreased overall improvement in Tegner scores. Conclusion: Transtibial root repair for medial and lateral posterior meniscal root tears demonstrated significantly improved clinical outcomes at 2 years postoperatively. Increased age, increased BMI, cartilage status, and meniscal extrusion did not have a negative impact on short-term functional outcomes (IKDC), but age greater than or equal to 50 years and extrusion negatively influenced patient activity level (Tegner). Registration: NCT03037242 ( ClinicalTrials.gov identifier).

Purpose The purposes of this study were to identify patient characteristics and risk factors for overnight admission following outpatient hip arthroscopy and to develop a machine learning algorithm that can effectively identify patients requiring admission following elective hip arthroscopy. Methods A retrospective review of a prospectively collected national surgical outcomes database was performed to identify patients who underwent elective outpatient hip arthroscopy from 2006 to 2018. Patients admitted overnight postoperatively were identified as those with length of stay of 1 or more days. Models were generated using random forest (RF), extreme gradient boosting (XGBoost), adaptive boosting (AdaBoost), elastic net penalized logistic regression, and an additional model was produced as a weighted ensemble of the four final algorithms. Results Overall, 1,276 patients were included. The median age was 43 years, and 64.2% (819) were female. Of the included patients, 109 (8.5%) required an overnight stay following elective outpatient hip arthroscopy. The most important factors for inpatient admission were increasing operative time, general anesthesia, age extremes, male gender, greater body mass index (BMI), American Society of Anesthesiologists classification >1, and the following preoperative lab values outside of normal ranges: sodium, platelet count, hematocrit, and leukocyte count. The ensemble model achieved the best performance based on discrimination assessed via internal validation (area under the curve = .71), calibration, and decision curve analysis. The model was integrated into a Web‐based open‐access application able to provide both personalized predictions and explanations. Conclusion A machine learning algorithm developed based on preoperative features identified increasing operative time, age extremes, greater BMI, sodium, hematocrit, platelets, and leukocyte count as the most important variables associated with inpatient admission with fair validity.

Objectives: There is a paucity of literature regarding outcomes of anterior shoulder instability (ASI) in throwers and overhead athletes (OHA). The purpose of this study was to report the pathology, treatment strategies, and outcomes of ASI in throwers and overhead athletes utilizing an established US geographic population-based cohort. Methods: An established geographic database of more than 500,000 patients was used to identify athletes <40 years of age with ASI between 1994 and 2016. Medical records were reviewed to obtain demographics, type of sport, surgical details, and clinical outcomes. Patients were contacted after final clinical follow-up for patient reported outcomes (PRO). The Western Ontario Shoulder Instability (WOSI) score, return to sport at previous level of performance (RPP), rate of return to play (RTP) and time to RTP were recorded. Statistical analysis was performed comparing throwers to non-throwers and OHA to non-overhead athletes (NOHA). Results: The study population consisted of 171 patients, 114 NOHA and 57 OHA. Of the OHA, 40 were throwers. The mean follow-up was 14.7 ± 5.6 years for PRO’s and 11.7 ± 7.3 years for last clinical evaluation. No difference in overall instability events was seen in either group. Throwers were more likely to present with subluxations while non-throwers were more likely to present with frank dislocations. NOHA and non-throwers were more likely than OHA and throwers to have a history of trauma related to ASI, respectively ( P = <.001, P = .002). Throwers were more likely to undergo an open surgical procedure (45%) than non-throwers (15%) ( P = .038). The rate of recurrent instability between groups was similar. Throwers returned to sport at a lower rate than non-throwers, however this did not reach significance (64% vs 83%, P = .100). Throwers and OHA reported similar WOSI scores, RPP and time to RTP grouped by surgical or conservative management compared to non-throwers and NOHA, respectively. Conclusions: In a US cohort of patients, throwers and OHA had a similar number of instability events compared to non-throwers and NOHA, respectively. Non-throwers and NOHA were more likely to present with frank dislocation which is supported by the significantly higher rates of trauma in both groups. Notably, the WOSI score, RPP, rate of RTP and time to RTP showed no difference between throwers and OHA when compared to their non-throwing and NOHA counterparts.

Objectives: The current literature lacks evidence to guide treatment of isolated lateral meniscus tears in young patients. Accordingly, the purpose of this study was to describe our institutional experience in young patients with lateral meniscus tear with regard to i) treatment trends in meniscectomy and repair ii) long-term patient reported and radiographic outcomes, and iii) failure rates and associated patient and treatment factors. Methods: Patients <26 years of age who underwent surgery for lateral meniscus tears between 2001 and 2017. Patients with ligamentous injury or prior surgeries in the same knee were excluded. Records were reviewed to obtain patient demographics, injury characteristics, surgical details, reoperation rates, repeat imaging, and patient outcome scores. Statistical analysis compared treatment trends over time. Patient reported outcomes (PROs), imaging outcomes, and failure rates were compared by treatment modality. Failure was defined as reoperation, symptomatic osteoarthritis, or IKDC <75. Simple logistic regressions were calculated to predict failure and IKDC based on treatment, type of tear, location of tear, or amount of meniscus removed. Results: 226 knees in 217 patients were identified with average clinical follow-up of 3.2 years. Our cohort consisted of 158 male patients, and average age was 17.4 years (7-25). 138 patients (144 knees) were treated with meniscectomy (partial to complete) (64%) and 79 patients (82 knees) were treated with repair (36%). Repair rates compared to meniscectomy (any degree) increased over time with 63% of lateral meniscus tears from 2013-2017 treated with repair compared to 23% from 2001 -2004 ( P = <.0001). IKDC scores in the meniscectomy group increased from 76.3 ± 9.1 pre-operatively to 97.2 ± 3.9 post-operatively ( P = <.0001) and increased in the repair group from 71.0 ± 11.5 pre-operatively to 97.4 ± 4.1 post-operatively ( P = <.0001).The change in IKDC score was greater in repair (26.0 ± 12.3) than meniscectomy (21.1 ± 9.8) ( P = .002). Reoperation rates in meniscectomy (20%) and repair (20%) were similar ( P = .910). Pre-operative IKDC scores were lower in the repair group ( P = .001), but final IKDC scores were similar ( P = 0.695). Symptomatic OA was noted in 17 patients in the meniscectomy group (22%) and 5 patients in the repair group (11%) ( P = .121). The failure rate was similar between meniscectomy (35%) and repair (28%) ( P = .307). Regression equations evaluating treatment modality, type and location of tear, and amount of meniscus removed did not reach significance in predicting IKDC or failure. Conclusions: In this cohort of young patients with isolated lateral meniscus tears, rate of repair increased over time. IKDC scores improved more in the repair group compared to the meniscectomy patients, however IKDC scores obtained at final follow-up were similar. Rates of symptomatic OA, reoperation, and failure were similar between groups. Treatment modality, type and location of tear, and amount of meniscus removed were not predictive of final IKDC or failure.

Background: Meniscal tears are common in active patients, but treatment trends and surgical outcomes in young patients with lateral meniscal tears are lacking. Purpose: To evaluate treatment trends, outcomes, and failure rates in young patients with lateral meniscal tears. Study Design: Cohort study; Level of evidence, 3. Methods: Patients aged ≤25 years treated surgically for isolated lateral meniscal tears from 2001 to 2017 were identified. Treatment trends were compared over time. International Knee Documentation Committee (IKDC) scores and failure rates were compared by treatment modality (meniscectomy vs meniscal repair). Failure was defined as reoperation, symptomatic osteoarthritis, or a severely abnormal IKDC score. Univariate regression analyses were performed to predict failure and IKDC scores based on treatment, type and location of tear, or extent of meniscectomy. Results: Included were 217 patients (226 knees) with a mean age of 17.4 years (range, 7-25 years); of these patients, 144 knees (64%) were treated with meniscectomy and 82 knees (36%) with meniscal repair. Treatment with repair increased over time compared with meniscectomy ( P < .001). At a minimum 2-year follow-up (mean, 6.1 ± 3.9 years), 107 patients (110 knees) had IKDC scores, and analysis indicated that although scores in both groups improved from pre- to postoperatively (repair: from 69.5 ± 13.3 to 97.4 ± 4.3; meniscectomy: from 75.7 ± 9.0 to 97.3 ± 3.9; P < .001 for both), improvement in IKDC score was greater after repair (27.9 ± 13.9) versus meniscectomy (21.6 ± 9.4) ( P = .005). Included in the failure analysis were 184 patients (192 knees) at a mean follow-up of 8.4 ± 4.4 years. The rates of reoperation, symptomatic osteoarthritis, and failure were not significantly different between the meniscectomy and repair groups. Conclusion: An increase was seen in the rate of isolated lateral meniscal tear repair in young patients. IKDC score improvement was greater after repair than meniscectomy, although postoperative IKDC scores were similar. Symptomatic arthritis, reoperation, and failure rates were similar between groups; however, there was a trend for increased arthritis symptoms in patients treated with meniscectomy, especially total meniscectomy. Treatment modality, type and location of tear, and amount of meniscus removed were not predictive of final IKDC scores or failure.