Levy, Bruce A.

Purpose: The goal of this study was to evaluate patient and surgical factors predictive of excellent functional and isokinetic test results 6-months following anterior cruciate ligament (ACL) reconstruction in a group of pediatric patients with open physes. Methods: We retrospectively reviewed the records of all patients 14 years of age or younger that underwent ACL reconstruction from 2000 to 2015. An excellent 6-month outcome was defined as greater than 85% in isokinetic strength and greater than 90% in functional tests when compared to the non-operative extremity. We then utilized univariate and multivariate statistical models to identify patient and/or surgical factors associated with excellent 6-month outcomes. Results: Eighty-six patients (46 male, 42 female) with open physes on preoperative radiographs were included in the study, with a mean age of 13.6 (range, 8.4-14.9), body mass index (BMI) of 22.1 (range, 15.6-36.0), Tegner activity score of 8.8 (6.0-9.0). Thirty-four patients (40%) met the criteria for the excellent 6-month group, which left 52 (60%) in the delayed 6-month group. In univariate analysis, no single preoperative factor correlated with excellent 6-month outcome. The two groups were statistically similar in terms of age, BMI, time to surgery, preoperative arc of motion, presence of concomitant meniscal tear, cartilage damage, graft size, use of a nerve block or tourniquet, operative time, and tourniquet time. Use of a nerve block trended towards delayed outcomes (p = 0.051). Conclusion: Children undergoing ACL reconstruction only have a 40% chance of achieving an excellent rehabilitation result at 6 months. We found no statistically significant patient or surgical characteristics that could predict this outcome. Utilizing a nerve block is a factor which will need to be further evaluated. Significance: Studies in the adult population have identified preoperative patient and surgical factors associated with excellent 6-month isokinetic and functional test results. This pediatric cohort did not find similar results as many of these children were young, healthy and fit. However, the variability of the outcome casts doubts on applying adult rehabilitation protocols to children.

Introduction: It is unknown whether functional and isokinetic testing at 6 months following ACL reconstruction in patients with open-physes correlates with longer term outcomes. The purpose of this study was to compare subsequent ACL rupture risk, knee function, and activity level in patients with open-physes who had excellent 6-month testing to those who did not. Methods: Between the years of 2000 and 2015, 86 patients with open-physes underwent ACL reconstruction and had functional and isokinetic testing performed at 6-months post-operatively. Thirty-four (40%) tested in the excellent range in all categories of both functional and isokinetic testing and were labeled the excellent group. The remaining 52 (60%) patients were labeled the delayed testing group. Data regarding patient, injury, and surgical characteristics were retrospectively collected. The rate of second ACL injury as well as clinical outcome scores were collected postoperatively. Results: Graft rupture rate was 23.4% (n = 8) in the excellent group and 15.4% (n = 8) in the delayed group (p = 0.51). In the excellent group, 20.5% (n = 7) had a contralateral ACL tear versus 11.5% (n = 6) in the delayed group (p = 0.40). Five patients in the excellent group and 4 patients in the delayed group sustained both graft failure and contralateral ACL tear. The overall prevalence of second ACL injury was 29% in the excellent group and 23% in the delayed group. The delayed group returned to sport at an average of 8.8 months whereas the excellent group returned at an average of 6.6 months (p < 0.01). At mean follow up of 3.59 years, the excellent group had a higher Tegner activity level (8.9 versus 8.3) than the delayed group (p < 0.02). Conclusion: Pediatric patients with open-physes who had excellent isokinetic strength and functional testing 6-months postoperatively returned to sport sooner than those who did not. There was no statistical difference in either graft failure or contralateral ACL disruption between these groups. However, both groups had unacceptably high rates of second ACL injury (29% for the excellent group and 23% for the delayed group). Significance: Excellent 6 month return of strength and function was not protective of subsequent ACL disruption, the rate of which remains dismal within this pediatric population. Development of more sensitive functional measures for children could help to change these poor outcomes and guide clinicians when to allow return to sport.

Background Adductor canal block (ACB) is an alternative method to femoral nerve block (FNB) for post-operative analgesia for anterior cruciate ligament reconstruction (ACLR) in pediatric and adolescent patients. Prior studies have suggested that FNB is associated with persistent strength deficits at 6 months after ACLR in this population. Proponents of the ACB consider that this method may result in a decreased incidence of quadriceps strength deficits during post-operative rehabilitation. The purpose of this study was to compare knee strength and function at 6 and 9 months after ACLR in pediatric and adolescent patients who received FNB versus ACB peri-operatively. Methods Patients 18 years or younger who underwent primary ACLR between 2002 and 2017 at a single institution were identified. ACLR was performed with either a patellar tendon autograft or hamstring autograft. A transphyseal ACLR was performed in patients with open physes. All patients participated in a comprehensive rehabilitation program which included isokinetic strength testing and functional testing at 6 and/or 9 months postoperatively. Patients were excluded if they underwent multiligamentous knee reconstruction, concomitant cartilage restoration procedures, did not receive perioperative FNB or ACB, or if they did not complete isokinetic strength and functional testing at 6 or 9 months. The included cohort was separated into FNB group and ACB group for comparison. Isokinetic extension and flexion strength deficits and functional deficits in vertical jump, single hop, and triple hop between the two groups were compared at both time points. A strength deficit of 15% or less and a functional deficit of 10% or less compared to the contralateral side were considered satisfactory. Univariate analysis was performed to assess for differences in patient demographics and surgical variables. A 1:1 matched subgroup analysis between the two groups was performed to account for possible differences in outcomes associated to graft types, concomitant meniscus repair, and BMI. Results Of the 240 patients identified, 85 patients (64 FNB, 21 ACB) with a mean age of 15.9 years (Range: 11-18) met inclusion criteria for comparison at 6 months and 76 patients (40 FNB, 36 ACB) with a mean age of 15.5 years (Range: 12-17) met inclusion criteria for comparison at 9 months. Univariate analysis showed significantly greater deficits at 6 months in the FNB with respect to fast isokinetic flexion strength (7.7% vs. -4.9%; p = .03). There were no differences in slow isokinetic flexion (10.5% vs. 6.8%; p = .79) and fast isokinetic extension (11.9% vs. 13.9%; p = .68) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (19.3% vs. 12.0%; p = .24), but this did not reach statistical significance. This clinical difference in satisfactory scores between the groups with respect to slow isokinetic extension was accentuated with the 1:1 matched outcome trial (23.9% vs. 12.1%; p = .20). With respect to function, there were no differences in deficits for vertical jump (8.4% vs. 4.3%; p = .55), single hop (7.4% vs. 9.3%; p = .65), or triple hop (6.0% vs. 7.1%; p = .77) between the two groups. Univariate analysis showed significant greater deficits at 9 months in the FNB with respect to slow isokinetic flexion strength (9.6% vs. 0.4%; p = .01). There were no differences in fast isokinetic flexion (-0.2% vs. 0.7%; p = .87) and fast isokinetic extension (6.0% vs. 2.7%; p = .51) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (17.3% vs -14.0%, p = .19), but this did not reach statistical significance. With respect to function, there were no differences in deficits for vertical jump (5.2% vs. 6.5%, p = .85), single hop (7.7% vs. 6.2%; p = .79), or triple hop (1.9% vs. 3.9%; p = .35) between the two groups. Conclusion Because previous studies have shown a significant delay in return of strength with FNB, ACB began to be employed at our center for post-operative pain control following ACLR in pediatric and adolescent patients. This study showed that pediatric and adolescent patients treated with FNB as a method of post-operative analgesia after ACLR had significantly greater deficits in fast isokinetic flexion at 6 months and slow isokinetic flexion at 9 months compared to those who received ACB. These differences may or may not have clear clinical relevance. However, patients treated with FNB showed clinically relevant greater deficits in slow isokinetic extension strength at 6 and 9 months postoperatively compared to those who received ACB if 85% strength return is used as criteria to return to sport. Pediatric and adolescent patients could benefit from undergoing perioperative analgesia with ACB instead of FNB, but comparison between these two methods of regional anesthesia may require a prospective trial. Level of Evidence Retrospective cohort study, Level IV [Table: see text][Table: see text]

Background: Meniscal repair is desirable over resection to prevent postmeniscectomy arthritis, especially among young and active patients. However, long-term data are currently lacking following isolated meniscal repair, particularly in the pediatric population. Purpose/Hypothesis: To report long-term follow-up of isolated meniscal tears treated by meniscal repair in a pediatric and adolescent population and to compare those results with previous midterm follow-up data reported. The authors hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Forty-four patients aged ≤18 years undergoing repair of an isolated meniscal tear (without concomitant anterior cruciate ligament injury) between 1990 and 2005 were included. At the time of final follow-up, recurrent tear, reoperations, and International Knee Documentation Committee (IKDC) and Tegner scores were determined. With logistic regression, the overall failure among tear types was calculated. Wilcoxon rank sum analysis 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 a mean follow-up of 17.6 years (range, 13.1-25.9 years), 32 patients with 33 isolated meniscal repairs (29 male, 3 female) with a mean age of 16.1 years (range, 9.9-18.7 years) at surgery were included in this study. At early follow-up, the overall failure rate was 14 of 33 (42%); complex tears (80%) and bucket-handle tears (47%) had higher overall failure rates when compared with simple tears (18.2%), although only complex tears had a significantly higher failure rate. However, no further failures occurred since midterm follow-up with any tear type. At final follow-up, the mean IKDC score was 92.3, which was significantly increased when compared with preoperative (65.3, P < .0001) and midterm (90.2, P = .01) scores. The mean Tegner score (6.5) was significantly lower than both preoperative (8.3, P < .0001) and midterm (8.4, P < .0001) scores. There was no difference in Tegner or IKDC score for patients with successful versus failed repair. Conclusion: In conclusion, while there was a high early failure rate, this study demonstrated overall good to excellent long-term clinical outcomes after isolated meniscal repair in an adolescent population, even for those requiring reoperation. 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 as compared with other tear types.

Background: Surgical reconstruction of the anterior cruciate ligament (ACL) is one of the most common orthopaedic procedures, with an estimated 100,000 to 175,000 procedures performed annually. Recently, the all-inside reconstruction technique has come into favor and is theorized to be superior to the complete tibial tunnel technique. Purpose: To compare clinical and patient-reported outcomes (PROs) for hamstring autograft ACL reconstruction (ACLR) performed with an all-inside versus a complete tibial tunnel technique. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent hamstring autograft ACLR via either an all-inside approach (femoral and tibial sockets) or a complete tibial tunnel approach (femoral socket and full-length, transtibial tunnel) at a single institution between July 2011 and July 2015 were reviewed. Demographic information, preoperative comorbidities, surgical details, physical examination findings, and follow-up outcomes were extracted from the medical record. Physical examination data included pivot-shift, Lachman, and range of motion examinations, whereas PROs included the Tegner activity scale, Lysholm score, and International Knee Documentation Committee (IKDC) score at a minimum of 2 years after surgery. Return to sport and risk factors for failure were analyzed. Results: A total of 82 patients (mean ± SD age, 25.8 ± 10.2 years) who underwent all-inside reconstruction (median PRO follow-up, 30.1 months; range, 24.7-72.9 months) and 54 patients (mean ± SD age, 21.1 ± 7.3 years) who underwent complete tibial tunnel reconstruction (median PRO follow-up, 25.8 months; range, 23.9-74.5 months) met the inclusion criteria. PRO scores at latest follow-up were comparable between the all-inside versus the complete tibial tunnel groups (Lysholm score, 93.8 vs 94.4, P = .621; IKDC score, 93.5 vs 93.3, P = .497; Tegner activity score, 6.4 vs 6.8, P = .048). Complications (including graft failure) were experienced by 20% of patients in the all-inside group compared with 24% in the complete tibial tunnel group ( P = .530). Graft failure before the final follow-up was experienced by 10% of patients in the all-inside group compared with 19% in the complete tibial tunnel group ( P = .200). Mean return to sport was 12.5 months in the all-inside group versus 9.9 months in the complete tibial tunnel group ( P = .028). Conclusion: All-inside and complete tibial tunnel hamstring autograft ACLR resulted in excellent physical examination findings and PROs at minimum 2-year follow-up. Both techniques successfully restored knee stability and patient function.

Abstract In 2018, the best available evidence has failed to show any significant clinical or functional difference between autograft and allograft for posterior cruciate ligament reconstruction. Autograft patients may have higher complication rates. Both groups show good functional outcome after reconstruction.

Background: Avulsion fractures involving the tibial eminence are considered equivalent in terms of the cause to anterior cruciate ligament (ACL) tears; however, there are limited data comparing the outcomes of adolescent patients undergoing surgical fixation of a tibial eminence fracture (TEF) with those undergoing ACL reconstruction. Purpose: To compare the clinical outcomes, subsequent ACL injury rates, and activity levels between adolescent patients who underwent TEF fixation with patients with midsubstance ACL tears who required acute reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: This study included a group of patients with TEFs treated with surgical fixation matched to a group of similar patients with ACL tears treated with reconstruction between the years 2001 and 2015. Data regarding the initial injury, surgical intervention, ACL/ACL graft injury rates, and physical examination findings were recorded. Clinical and functional outcomes were obtained using a physical examination, the International Knee Documentation Committee (IKDC) subjective score, the Lysholm score, and the Tegner activity score. Results: Sixty patients with a mean follow-up of 57.7 months (range, 24-206 months) were included; 20 patients (11 male, 9 female; mean age, 11.9 years [range, 7-15 years]) who underwent surgical fixation for a TEF were matched to a group of 40 patients (23 male, 17 female; mean age, 12.5 years [range, 8-5 years]) who underwent reconstruction for ACL tears. The TEF group demonstrated significantly lower postoperative IKDC scores (TEF group, 94.0; ACL group, 97.2; P = .04) and Lysholm scores (TEF group, 92.4; ACL group, 96.9; P = .02). The TEF group returned to sport 119 days sooner ( P < .01), but there was no difference in postoperative Tegner scores (TEF group, 7.3; ACL group, 7.6; P = .16). The TEF group demonstrated increased postoperative anterior laxity ( P = .02) and a higher rate of postoperative arthrofibrosis ( P = .04). There was no difference in subsequent ACL injuries ( P = .41). Conclusion: Both groups demonstrated quality outcomes at a minimum 2-year follow-up. Patients with TEFs demonstrated lower mean clinical outcome scores compared with patients with ACL tears, but the differences were less than reported minimal clinically important difference values. Additionally, the TEF group experienced more postoperative anterior laxity and had a higher rate of postoperative arthrofibrosis. There was no difference in the rate of subsequent ACL injuries. The TEF group returned to sport sooner than the ACL group, but the postoperative activity levels were similar.

Background: Studies have shown good and excellent clinical and radiographic results after meniscal repair. Limited published information exists on the long-term outcomes, however, especially in a pediatric and adolescent population. Purpose: To determine long-term results of meniscal repair and concomitant anterior cruciate ligament (ACL) reconstruction in a pediatric and adolescent population. Specifically, the aims were to determine the clinical success rate of meniscal repair with concomitant ACL reconstruction, compare results with midterm outcomes, and analyze risk factors for failure. Study Design: Case series; Level of evidence, 4. Methods: Cases of meniscal repair with concomitant ACL reconstruction between 1990 and 2005 were reviewed among patients aged ≤18 years. Patient demographics, injury history, and surgical details were recorded, and risk factors for failure were analyzed. Physical examination findings and clinical outcomes at latest available follow-up were collected. Subjective knee outcomes were compared with midterm results. Descriptive statistics and univariate analysis were used to evaluate the available data. Results: Forty-seven patients (30 females, 17 males) with a mean age of 16 years (SD, 1.37) and a mean follow-up of 16.6 years (SD, 3.57) were included in this study. Overall, 13 patients (28%) failed meniscal repair and required repeat surgery at the time of final follow-up. Of the 13 failures, 9 underwent a subsequent meniscectomy; 2, meniscectomy and revision ACL reconstruction; 1, meniscal repair and revision ACL reconstruction; and 1, meniscal repair and subsequent meniscectomy. Mean International Knee Documentation Committee scores improved from 47.9 preoperatively to 87.7 postoperatively ( P < .01), and the mean score at long-term follow-up (87.7) did not significantly differ from that at the midterm follow-up (88.5) at a mean 7.4 years ( P = .97). Mean Tegner Activity Scale scores improved from 1.9 preoperatively to 6.3 postoperatively ( P < .01) and decreased from 8.3 at preinjury to 6.3 at final long-term follow-up ( P < .01). Conclusion: In conclusion, the long-term overall clinical success rate (failure-free survival) was 72% for repair of pediatric and adolescent meniscal tears in the setting of concomitant ACL reconstruction. Patients reported excellent knee subjective outcome scores that remained favorable when compared with midterm follow-up.

Background: The preoperative assessment of cartilage lesions is critical to surgical planning and decision making. The accurate radiographic determination of acetabular cartilage damage has remained elusive for modern imaging modalities, including magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). While risk factors have been individually described, no multivariable system exists for predicting high-grade cartilage damage. Purpose: To determine the preoperative predictors of grade 3 to 4 acetabular labrum articular disruption (ALAD) lesions. Study Design: Case-control study; Level of evidence, 3. Cohort study (diagnosis); Level of evidence, 1. Methods: Retrievable radiographs were reviewed from primary hip arthroscopic procedures performed at 2 high-volume institutions between December 2007 and April 2017. The predictive value of demographic and radiographic factors for the intraoperative documentation of ALAD grade 3 to 4 damage was analyzed and entered into a multivariable model, and a statistically guided scoring system for the damage risk was created using the Akaike information criterion. The scoring system was then prospectively validated on 167 patients who underwent primary hip arthroscopy between April 2017 and February 2018. Results: A total of 652 primary hip arthroscopic procedures in 614 patients (390 female, 224 male; mean age, 33.2 ± 12.5 years; mean body mass index, 26.9 ± 5.5 kg/m 2 ) from 2007 to 2017 were analyzed. Male sex (odds ratio [OR], 3.11; P < .01), age ≥35 years (OR, 1.96; P < .01), cam morphology (alpha angle >55°) (OR, 2.96; P < .01), and Tönnis grade 1 to 2 (grade 1: OR, 4.14; P < .01, and grade 2: OR, 9.29; P < .01) were univariate risk factors for intraoperatively documented high-grade damage. A multivariable scoring system, the Rapidly Assessed Predictor of Intraoperative Damage (RAPID) score (0-5 points), was generated based on sex, Tönnis grade, and cam morphology. Patients with increasing RAPID scores had an increasing risk of damage, with a 10.5% risk for those with 0 points and an 88.0% risk for those with 5 points ( P < .01). The area under the curve was 0.75 for the study group and 0.76 for the validation group ( P = .94). Conclusion: While preoperative MRI has diagnostic value for hip arthroscopic surgery, the RAPID score provides added benefit as a readily employable, in-clinic system for predicting high-grade cartilage damage. The discriminatory value of the RAPID score compares favorably with previous MRI and MRA studies. This information will help the clinician and patient plan for high-grade damage and identify potential targets for cartilage treatment.

Background: A symptomatic discoid lateral meniscus is an uncommon orthopaedic abnormality, and the majority of information in the literature is limited to small case series. Purpose/Hypothesis: The purpose of this study was to determine the incidence of symptomatic discoid menisci in a geographically determined population and to describe treatment trends over time. The hypothesis was that the incidence of symptomatic discoid menisci would be highest among adolescent patients, and thus, the rate of surgical treatment would be high compared with nonoperative treatment. Study Design: Descriptive epidemiology study. Methods: The study population included 79 patients in Olmsted County, Minnesota, identified through a geographic database, who were diagnosed with a symptomatic discoid lateral meniscus between 1998 and 2015. The complete medical records were reviewed to confirm the diagnosis and evaluate the details of injury and treatment. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 United States population. Results: The overall annual incidence of symptomatic discoid lateral menisci was 3.2 (95% CI, 2.5-3.9) per 100,000 person-years; 12.6% of the patients in the cohort had bilateral symptomatic discoid lateral menisci. The overall annual incidence was similar between male (3.5 per 100,000 person-years) and female patients (2.8 per 100,000 person-years). The highest incidence of symptomatic discoid lateral menisci was noted in adolescent male patients aged 15-18 years (18.8 per 100,000 person-years). A majority (72.2%) of patients presented with a symptomatic tear of the discoid meniscus. The remaining patients presented with mechanical symptoms, including catching/locking or effusion, with no demonstrable meniscus tear on imaging or diagnostic arthroscopic surgery. Additionally, 20.0% of patients were observed to have peripheral instability of the meniscus at the time of diagnostic arthroscopic surgery. The mean age of those with peripheral instability was significantly younger than of those who did not have peripheral instability. Sixty patients (75.9%) received surgical treatment during the study period, including 49 (81.7%) patients who underwent partial lateral meniscectomy and 11 (18.3%) patients who underwent lateral meniscus repair in addition to saucerization. Conclusion: With an overall annual incidence of 3.2 per 100,000 person-years, a symptomatic discoid meniscus is an uncommonly encountered orthopaedic abnormality. However, the incidence of symptomatic discoid lateral menisci is highest in adolescent male patients. Because of the high rate of meniscus tears in patients presenting with symptoms, the majority are treated surgically.