Camp, Christopher L.

Objective The purpose of this systematic review is to determine (1) current reported treatment options for isolated tibial plateau (TP) cartilage lesions, (2) patient reported outcomes following various treatments, and (3) complication rate and survivorship following various treatments. Design A literature search of PubMed, the Cochrane Library, and CINAHL was conducted adhering to PRISMA guidelines. Patients were included if they had TP cartilage lesions treated with surgery. Lesion characteristics, surgical procedure details, patient reported outcomes, complication, and failure rates were collected. Results Thirteen studies yielded 205 knees with TP cartilage lesions treated surgically. Ages ranged from 12 to 77 years. Surgical techniques included 138 treated with osteochondral allograft transplantation (OCA), 37 treated with osteochondral autograft transfer system (OATS), 11 treated with microfracture, 11 treated with an osteochondral scaffold, and 8 treated with autologous chondrocyte implantation (ACI). The patient-reported outcome measures were heterogeneous, but all reported improvements with the notable exception of one study evaluating microfracture. The rate of complications ranged from 0% to 4.6%. Failure rate ranged from 22% to 46% for OCA and 0% to 16% for OATS. No failures were reported for the additional techniques. Conclusions Various surgical techniques have been utilized for the treatment of TP cartilage lesions. Patient-reported outcome measures were heterogeneous, but improvements were reported following all surgical treatments except for microfracture, which resulted in decreased scores at mid-term follow-up. The complication rate was low for all techniques described. However, the failure rate was higher following unicondylar OCA for salvage treatment of posttraumatic deformities.

Objective The purpose of this systematic review was to determine (1) treatment options for bipolar cartilage lesions of the knee, (2) patient-reported outcomes following various surgical treatments, and (3) complication and failure rates following surgery. Design A literature search of PubMed, the Cochrane Library, and CINHAL was performed using PRISMA guidelines. Patients were included if they had bipolar cartilage lesions of the knee treated surgically. Lesion characteristics, surgical technique, patient-reported outcomes, complication rates, failure rates, and survivorship were recorded. Results Fourteen studies yielded 301 knees treated surgically. Patient age ranged from 15 to 74 years. Surgical techniques included 138 autologous chondrocyte implantation (ACI), 156 osteochondral allograft transplantation (OCA), and 7 osteochondral autograft transfer system (OATS). Seven studies reported a concomitant procedure rate that ranged from 0% to 88%. Eight studies reported that both reciprocal lesions received surgical treatment, while 6 studies did not specify. Lesion size ranged from 1 to 41 cm 2 . All reported postoperative improvements in patient-reported outcomes, but the measures were very heterogeneous. There were no major complications and the rate of minor complications ranged from 0% to 50%. Survivorship ranged from 40% to 100% for OCA, 76% to 95% for ACI, and 100% for the 1 study evaluating OATS. Conclusions Bipolar cartilage lesions of the knee typically involve a large surface area and are most commonly treated with ACI or OCA, while OATS may be an option for smaller lesions. Improvements in mid-term patient-reported outcomes were reported for all surgical procedures and they can be performed safely with a low rate of major complications.

Purpose To identify any dose‐dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery. Methods Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow‐up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders. Results A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76‐3.26; P < .0001) and private insurance (OR, 2.53‐2.87; P < .0001) populations. Conclusions A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53‐3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears. Level of Evidence Level III, retrospective cohort study.

Abstract Although we have come a long way, the rapidly expanding field of virtual reality simulation for arthroscopic surgical skills acquisition is supported by only a limited amount of evidence. That said, the good news is that the evidence suggests that simulator experience translates into improved performance in the operating room. If proving this relation is our ultimate goal, more work is certainly needed. In this commentary, a “Task List” is proposed for surgeons and educators interested in using simulators and better defining their role in resident education.

Purpose To use a national database to determine (1) the incidence of joint infection after elbow arthroscopy, (2) identify independent patient‐related risk factors for infection, and (3) determine the influence of concomitant intra‐articular corticosteroid injection on infection risk. Methods The 100% Medicare Standard Analytic Files were queried to identify patients who underwent elbow arthroscopy from 2005 to 2012. Postoperative elbow infections occurring within 6 months of surgery were identified using both International Classification of Diseases, 9th Revision codes for postoperative infection and Current Procedural Terminology codes for the surgical treatment of a postoperative infection. Patients were excluded if their initial arthroscopic procedure was performed for infection. A multivariate binomial logistic regression analysis was then used to evaluate patient‐related risk factors for postoperative infection. Results Of the 2,704 elbow arthroscopy cases identified, 42 (1.55%) developed a postoperative infection. The annual incidence of infections did not increase significantly over the course of the study ( P = .374). A number of patient demographics and medical comorbidities significantly increased the risk of infection. The most notable factors included age ≥ 65 years (odds ratio [OR] 2.38, P = .006), body mass index > 40 (OR 1.97, P = .024), tobacco usage (OR 1.80, P = .046), alcohol usage (OR 4.01, P < .001), diabetes mellitus (OR 2.10, P = .015), inflammatory arthritis (OR 2.81, P < .001), hypercoagulable disorder (OR 2.51, P = .015), and intra‐articular corticosteroid injection at the time of arthroscopy (OR 2.79, P = .006). Conclusions The annual number of elbow arthroscopies performed in the United States has increased steadily; however, the postoperative infection rate remained consistently low at 1.55%. There are a number of patient‐specific risk factors that increase this risk with OR ranging from 1.97 to 4.01. Similarly, patients who receive an intra‐articular corticosteroid injection at the time of surgery are nearly 3 times (OR 2.79) more likely to develop a postoperative infection. Level of Evidence Level III, case‐control study.

Abstract As our knowledge and technology advance, the indications for elbow arthroscopy continue to grow rapidly. During this expansion, a number of new portals have been described and reported using variable nomenclature and location descriptions. Accordingly, a comprehensive review of these portals is warranted. Given the concern for potential iatrogenic injury to surrounding neurovascular structures, a discussion of these critical nerves and vessels is also timely. In this work, we review pertinent surface anatomy; portal nomenclature, locations, and utility; and review distances to the nearest structures at risk. Technique Video video See video under supplementary data.

Abstract The field of elbow arthroscopy has evolved significantly since the procedure was first introduced more than 30 years ago. As our knowledge and understanding grows, numerous technical modifications have been made to improve the safety and efficacy of elbow arthroscopy. One of the most significant modifications is the change from the supine hanging position to the supine‐suspended position with the use of a mechanical arm holder. Currently, the supine‐suspended and lateral decubitus positions are the 2 most commonly used techniques. In this work, we discuss the history of the supine position, provide key points for proper patient positioning, and detail the steps of diagnostic elbow arthroscopy. It is our hope that this work will serve as an up‐to‐date review and summary of the most critical components of this procedure for emerging elbow arthroscopists. Technique Video video See video under supplementary data.

Abstract In recent years, arthroscopy has gained popularity as a preferred treatment of a multitude of pathologies affecting the elbow. Since its initial description in 1985, many modifications have been made as our knowledge and technology have advanced. Currently, the majority of arthroscopic procedures are performed in either the lateral decubitus or supine suspended position. In this work, we discuss the history, patient positioning, and key steps for performing elbow arthroscopy in the lateral decubitus position. In addition to key steps, a number of strengths and limitations of this set up are discussed in detail. When properly executed, elbow arthroscopy can be performed in a safe and efficient manner with minimal risk to patients. Technique Video video See video under supplementary data.

Purpose The purpose of this study was to determine failure rates, functional outcomes, and risk factors for failure after revision anterior shoulder stabilization surgery in high‐risk adolescent athletes. Methods Adolescent athletes who underwent primary anterior shoulder stabilization were reviewed. Patients undergoing subsequent revision stabilization surgery were identified and analyzed. Failure rates after revision surgery were assessed by Kaplan‐Meier analysis. Failure was defined as recurrent instability requiring reoperation. Functional outcomes included the Marx activity score; American Shoulder and Elbow Surgeons score; and University of California, Los Angeles score. The characteristics of patients who required reoperation for recurrent instability after revision surgery were compared with those of patients who required only a single revision to identify potential risk factors for failure. Results Of 90 patients who underwent primary anterior stabilization surgery, 15 (17%) had failure and underwent revision surgery (mean age, 16.6 years; age range, 14 to 18 years). The mean follow‐up period was 5.5 years (range, 2 to 12 years). Of the 15 revision patients, 5 (33%) had recurrent dislocations and required repeat revision stabilization surgery at a mean of 50 months (range, 22 to 102 months) after initial revision. No risk factors for failure were identified. The Kaplan‐Meier reoperation‐free estimates were 86% (95% confidence interval, 67% to 100%) at 24 months and 78% (95% confidence interval, 56% to 100%) at 48 months after revision surgery. The mean final Marx activity score was 14.8 (range, 5 to 20); American Shoulder and Elbow Surgeons score, 82.1 (range, 33 to 100); and University of California, Los Angeles score, 30.8 (range, 16 to 35). Conclusions At 5.5 years' follow‐up, adolescent athletes had a high failure rate of revision stabilization surgery and modest functional outcomes. We were unable to convincingly identify specific risk factors for failure of revision surgery. Level of Evidence Level IV, retrospective therapeutic case series.