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Purpose The purpose of this meta‐analysis was to determine overall objective graft failure rate, failure rate by graft type (allograft vs autograft reconstruction), instrumented laxity, and patient outcome scores following revision anterior cruciate ligament (ACL) reconstruction. Outcomes of interest were collected for all studies meeting the study inclusion criteria, but lower‐level studies (level III/IV) were not pooled for quantitative synthesis due to high levels of heterogeneity in these study populations. Methods A comprehensive search strategy was performed to identify studies reporting outcomes of revision ACL reconstruction. The primary outcome reported was graft failure. A meta‐analysis comparing rate of failure by graft type was conducted using a random effects model. Studies also reported patient clinical outcome scores, including International Knee Documentation Committee (IKDC), Lysholm, and knee injury and osteoarthritis outcome scores (KOOS) and graft laxity. Results Eight studies with 3,021 patients (56% male, 44% female) with an average age of 30 ± 4 years and mean follow‐up time of 57 months were included. The overall objective failure rate was 6% (95% confidence interval [CI], 1.8%‐12.3%). Mean instrumented laxity as side‐to‐side difference was 2.5 mm (95% CI, 1.9‐3.1 mm). Mean IKDC subjective score was 76.99 (95% CI, 76.64‐77.34), mean KOOS symptoms score was 76.73 (95% CI, 75.85‐77.61), and mean Lysholm score was 86.18 (95% CI, 79.08‐93.28). The proportion of patients with IKDC grade A or B was 85% (95% CI, 77%‐91%). When the available data for failure rate were analyzed by graft type, autograft reconstruction had a failure rate of 4.1% (95% CI, 2.0%‐6.9%), similar to allograft reconstruction at 3.6% (95% CI, 1.4%‐6.7%). Conclusions In this meta‐analysis, revision ACL reconstruction had failure rates similar to autograft or allograft reconstruction. Overall outcome scores for revision reconstruction have improved but appear modest when compared with primary ACL reconstruction surgery. Level of Evidence Meta‐analysis of Level II studies, Level II.

Background: The reported rate of second anterior cruciate ligament (ACL) injuries (20%-30%), including graft failure and contralateral ACL tears, after ACL reconstruction (ACLR) or nonoperative therapy indicates that multiple factors may predispose patients to subsequent ACL injuries. Purpose: To determine the incidence of second ACL injuries in a population-based cohort over a 10-year observation period (2001-2010) and to identify factors that contribute to the risk of second injuries. Study Design: Descriptive epidemiological study. Methods: International Classification of Diseases, 9th Revision (ICD-9) codes relevant to the diagnosis of an ACL tear and the procedure code for ACLR were utilized to search the Rochester Epidemiology Project, a multidisciplinary county database, between the years of 2001 and 2010. The complete medical records for all cases were reviewed to confirm diagnosis and treatment details. A total of 914 unique patients with 1019 acute, isolated ACL tears were identified. These patients were stratified by primary and secondary tears, sex, age, activity level, side of injury, sex × side of injury, and graft type of reconstruction. Results: Second ACL tears were recorded in 141 (13.8%) of the 914 patients diagnosed with an ACL tear in Olmsted County, Minnesota, USA, from 2001 to 2010; 50.4% of these occurred in the contralateral knee. A noncontact mechanism was responsible for 76.4% of all ACL injuries. A second ACL injury was influenced by factors of sex × age group, treatment type × age group, and treatment type × activity level. Nonparametric analysis of graft disruption × graft type demonstrated that a higher prevalence of second ACL tears occurred with allografts compared with hamstring autografts ( P = .0054) and patellar tendon autografts ( P = .0001). Conclusion: The incidence of second ACL tears in this population-based cohort was 13.8%, and half occurred to the ACL of the contralateral knee. Statistically, second ACL injuries differed by sex, occurring in female patients younger than 25 years and male patients aged 26 to 45 years. Allografts continued to be associated with a greater risk of second ACL injuries compared with hamstring and patellar tendon autografts. Nonoperative treatment carried more risk of contralateral tears than ACLR.

Abstract Horizontal cleavage meniscus tears are a common orthopedic injury often treated with partial or total meniscectomy versus repair. This Technical Note presents a technique for all‐inside repair with uniform compression of the superior and inferior leaflets by placement of multiple circumferential compression stitches using an all‐inside self‐retrieving suture passing device. The currently described technique provides several advantages for all‐inside repair of a horizontal cleavage tear: (1) eliminates the need for a posterior incision, (2) minimizes the risk of neurovascular injury, (3) uses standard arthroscopy portals (or small modifications), and (4) requires only a single suture deployment with a self‐retrieving device for each circumferential compression stitch. The resulting circumferential stitch provides uniform compression to the superior and inferior leaflets, promoting meniscal healing. This configuration has been shown to have the highest load to failure of all repair patterns. Technique Video video See video under supplementary data.

Background: First-time lateral patellar dislocation is a common orthopaedic injury. The purposes of this study were to (1) evaluate the incidence of first-time lateral patellar dislocation in a geographically-determined population, (2) report trends over time in the incidence of dislocation, and (3) describe the rate of surgical treatment. Hypothesis: The rate of patellar dislocation is highest among adolescent patients. Study Design: Cohort study. Level of Evidence: Level 3. Methods: The study population included 609 individuals identified through a multidisciplinary geographic cohort county database who were diagnosed with first-episode lateral patellar dislocation between 1990 and 2010. The complete medical records were reviewed to confirm the diagnosis and to evaluate details of injury and treatment. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 US population. Poisson regression analyses were performed to examine incidence trends by age, sex, and calendar period. Results: The overall age- and sex-adjusted annual incidence of patellar dislocation was 23.2 (95% CI, 21.2-24.9) per 100,000 person-years. The annual incidence was similar between male and female patients and highest among adolescents aged 14 to 18 years (147.7/100,000 person-years). The mean age at dislocation was 21.4 ± 9.9 years, and 331 patients (54.4%) were female. During the study period, there was a significant decline in the incidence of patellar dislocation among men aged 19 to 25 years ( P = 0.002) and girls aged 14 to 18 years ( P = 0.025). Eighty patients received surgical treatment during the study period, including 66 patients (10.8%) for recurrent instability and 14 patients (2.3%) for acute osteochondral injury. Conclusion: With an annual incidence of 23.2 per 100,000 person-years, lateral patellar dislocation is a frequently encountered orthopaedic injury. The incidence of dislocation among adolescent patients in this cohort is higher than previously reported. Despite a decrease in the annual incidence of dislocation in adolescent girls, the overall incidence of patellar dislocation remained relatively constant over a 21-year observation period. Clinical Relevance: This study demonstrates that the incidence of patellar dislocation in adolescents is greater than previously reported.

Abstract Lateral meniscus tears are commonly encountered by orthopaedic surgeons. Despite efforts to repair and preserve the meniscus, meniscectomy is occasionally required to treat irreparable tears. The resulting lateral meniscus deficiency leads to increased tibiofemoral contact pressures and ultimately early osteoarthritic changes in the knee. Lateral meniscal allograft transplant (LMAT) has been proposed as a way to restore the lateral meniscus–deficient knee to its native form. Although several techniques for LMAT have been proposed, osseous fixation has demonstrated increased stability, improved outcomes, and improved long‐term survival. This article presents a technique for LMAT using bone plugs and standard arthroscopic portals. Technique Video video See video under supplementary data.

Objectives: Osteochondritis dissecans (OCD) is a disorder of subchondral bone that commonly affects the knee.The purpose of this study is to (1) evaluate the rate of arthritis and knee arthroplasty in a population-based cohort of patients with OCD lesions treated non-operatively and (2) evaluate factors that may predispose patients to knee osteoarthritis and arthroplasty. Methods: 86 patients (mean age 21.4 years) with OCD lesions treated nonoperatively were identified between 1976 and 2014. Information related to the diagnosis, laterality of lesion, details of treatment, and progression to arthritis was obtained from the medical record. Factors predictive of arthritis and arthroplasty (age, gender, body mass index, and lesion location) were examined. Results: At a mean follow-up of 12.6 (±9.8) years from diagnosis, 13 patients (15%) were diagnosed with arthritis corresponding to a cumulative incidence of 5.0% at 5 years, 10.0% at 10 years, 20.0% at 25 years, and 30.0% at 35 years. The cumulative incidence of arthroplasty was 1.0% at 5 years, 3.0% at 10 years, 8.0% at 25 years, and 8.0% at 35 years. BMI greater than 25 kg/m 2 (HR 15.4, 95% CI: 1.9, 124.5) and patellar OCD lesions (HR 15.0, 95% CI: 1.3, 345.3) were associated with arthritis. Conclusion: Arthritis following nonoperative treatment of OCD lesions is a challenging problem with an estimated 30% cumulative incidence at 35 years after diagnosis. In contrast, the long-term rate of arthroplasty is low. BMI greater than 25 kg/m 2 and patellar OCD lesions are predisposing factors for arthritis. Older age at diagnosis was associated with a greater risk of arthritis and knee arthroplasty.

Objectives: Medial meniscus posterior root tears (MMPRTs) are recognized as a source of pain and dysfunction, but treatment options remain a clinical challenge. Currently, outcomes are unknown following partial meniscectomy for these lesions. To determine (1) the efficacy of partial meniscectomy to treat MMPRTs compared to a matched group of non-operatively treated MMPRTs, and (2) risk factors for worse clinical and radiographic outcome. Methods: This retrospective comparative study was performed to include 27 patients with MMPRTs that were treated with arthroscopic partial meniscectomy (PMM) and a minimum 2-year follow-up. These patients were then matched by age, gender, and BMI to a group of 27 patients with MMPRTs treated non-operatively (control group). Demographic data, radiographic findings, final Tegner and IKDC scores were obtained and compared between the two groups. Risk factors for worse clinical and radiographic outcome in the PMM group alone, including age, sex, BMI, initial K-L grade, subchondral edema, and insufficiency fracture on MRI were determined. Results: Overall, 54 patients were included in the study. 27 patients (10M: 17F) with a mean age of 55±9 and a mean BMI of 32.8±5.3 were treated with PMM and followed for a mean of 5.5±2 years (range 2.3-9.3 years). In the PMM group, final median Tegner score was 3, mean IKDC scores were 67.8±20, median KL grades on weight-bearing AP films demonstrated progressive arthritis (median grade 1 to 2, p=0.001) and more patients had grade II or higher arthritis at final follow-up than baseline (91.3% vs. 36% p<0.01. Overall, 14 of the 27 patients (52%) treated operatively progressed to total knee arthroplasty at a mean of 54.3 months. When comparing the PMM and control groups, there was no significant difference in final median Tegner scores, mean IKDC, median K-L grades, progression to arthroplasty, or overall failure rate. Following PMM, female patients had lower final IKDC scores (74.6±16.7 vs. 44.00±2.8, p=0.02) compared to males, as well as a higher rate of arthroplasty (70.6% vs, 20.0%, p=0.009). Higher BMI correlated with lower IKDC scores (r=-0.91, p=0.01) and meniscal extrusion was associated with higher rate of arthritis at final follow-up (100% vs. 57%, p=0.02). Conclusion: Partial meniscectomy for a MMRT provides no benefit in halting arthritic progression. Patients who undergo arthroscopic debridement for MMPRTs still progress to significant arthritis, poor clinical outcomes and a high arthroplasty rate (52%) at over 5-year follow-up. Compared to a non-operative control group, there was no benefit in any subjective or objective outcome measures from the arthroscopic partial meniscectomy. Female patients, higher BMI, and presence of meniscus extrusion were associated with worse outcomes and a higher rate of subsequent knee arthroplasty.

Objectives: Osteochondritis dissecans (OCD) is a disorder of subchondral bone that causes adverse effects on the overlying cartilage and commonly affects the knee. The purpose of this study is to (1) evaluate the rate of arthritis and knee arthroplasty in a population-based cohort of patients with OCD lesions treated operatively and (2) evaluate factors that may predispose patients to knee osteoarthritis and arthroplasty. Methods: 221 patients (mean age 26.1 ± 13.6 years) with OCD lesions treated operatively were identified between 1976 and 2014 and followed for a mean of 16.3 (±11.4) years from diagnosis. Information related to the diagnosis, laterality of lesion, details of treatment, and progression to arthritis was obtained from the medical record. Surgical treatment was classified as palliative (fragment excision) or restorative (lesion drilling, fragment fixation, osteochondral allograft or autograft). Factors predictive of arthritis and arthroplasty were examined. Results: In the palliative group, the cumulative incidence of arthritis was 12.0% at 5 years, 17.0% at 10 years, 26.0% at 15 years, 39.0% at 20 years, and 70% at 30 years. The cumulative incidence of arthroplasty was 2.0% at 5 years, 4.0% at 10 years, 4.0% at 15 years, 10.0% at 20 years, and 32.0% at 30 years. In the restorative group, the cumulative incidence of arthritis was 3.0% at 5 years, 7.0% at 10 years, 16.0% at 15 years, 25.0% at 20 years, and 51% at 30 years. The cumulative incidence of arthroplasty was 0.0% at 5 years, 0.0% at 10 years, 3.0% at 15 years, 6.0% at 20 years, and 11.0% at 30 years. BMI greater than 25 kg/m 2 (HR 3.3, 95% CI: 1.6, 7.0), older age at diagnosis (HR 4.9, 95% CI: 1.8, 17.3) and fragment excision (HR 2.3, 95% CI: 1.2, 4.6) were predictive of arthritis. Conclusion: OCD patients treated with fragment excision have a high rate of arthritis and knee arthroplasty at long-term follow-up. In contrast, patients treated with fragment repair or osteochondral restoration have lower rates of arthritis and arthroplasty. BMI greater than 25 kg/m 2 , older age at diagnosis, and fragment excision were predictive of arthritis.

Objectives: Patellar dislocation can occur in isolation or be associated with chronicinstability. The goals of this study are to describe the rate and factors associated with additional patellar instability events (ipsilateral recurrence and contralateral dislocation), as well as the incidence of patellofemoral arthritis among skeletally immature patients following patellar dislocation. Methods: The study included a population-based cohort of 232 skeletally immature patients who experienced a first-time lateral patellar dislocation between 1990 and 2010. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. Subjects were followed for a mean of 12.1 years to determine the rate of subsequent patellar dislocation (ipsilateral recurrence or contralateral dislocation) as well as clinically significant patellofemoral arthritis. Results: 104 patients had ipsilateral recurrent patellar dislocation. The cumulative incidence of recurrent dislocation was 11% at 1 year, 21.1% at 2 years, 37.0% at 5 years, 45.1% at 10 years, 54.0 % at 15 years, and 54.0% at 20 years. Patella alta (HR: 10.6, 95% CI: 3.6, 36.1), increased TT-TG distance (HR 18.7, 95% CI: 1.7, 228.2), and trochlear dysplasia (HR 23.7, 95% CI: 1.0, 105.2) were associated with recurrence. Similarly, 18 patients (7.8%) had contralateral patellar dislocation. The cumulative incidence of patellofemoral arthritis was 0% at 2 years, 1.0% at 5 years,2.0% at 10 years, 10.1% at 15 years, 17%% at 20 years, and 39.0% at 25 years. Osteochondral injury was associated with arthritis (HR 25.7, 95% CI: 6.2, 143.8). Conclusion: Skeletally immature patients have a high rate of recurrent patellarinstability that is associated with structural abnormalities such as patella alta and trochlear dysplasia. In contrast, the rate of subsequent contralateral dislocation is low. Osteochondral injury is associated with arthritis after patellar dislocation, but the overall incidence of symptomatic arthritis with advanced radiographic changes in pediatric patients is low at 12-year follow-up.

Background: Osteochondritis dissecans (OCD) is a disorder of subchondral bone that commonly affects the knee. Purpose: To (1) evaluate the rate of arthritis and knee arthroplasty in a population-based cohort of patients with OCD lesions treated nonoperatively and (2) evaluate factors that may predispose patients to knee osteoarthritis and arthroplasty. Study Design: Case series; Level of evidence, 4. Methods: Eighty-six patients (mean age, 21.4 years) with OCD lesions treated nonoperatively were identified between 1976 and 2014. Information related to the diagnosis, laterality of lesion, details of treatment, and progression to arthritis was obtained from the medical record. Factors predictive of arthritis and arthroplasty (age, sex, body mass index [BMI], and lesion location) were examined. Results: At a mean ± SD follow-up of 12.6 ± 9.8 years from diagnosis, 13 patients (15%) were diagnosed with arthritis, corresponding to a cumulative incidence of 5.0% at 5 years, 10.0% at 10 years, 20.0% at 25 years, and 30.0% at 35 years. The cumulative incidence of arthroplasty was 1.0% at 5 years, 3.0% at 10 years, 8.0% at 25 years, and 8.0% at 35 years. BMI at diagnosis greater than 25 kg/m 2 (hazard ratio [HR], 15.4; 95% CI, 1.9-124.5), patellar OCD lesions (HR, 15.0; 95% CI, 1.3-345.3), and diagnosis as an adult (HR, 21.7; 95% CI, 2.7-176.3) were factors associated with an increased risk of arthritis. Conclusion: Arthritis after nonoperative treatment of OCD lesions is a challenging problem, with an estimated 30% cumulative incidence at 35 years after diagnosis. In contrast, the long-term rate of arthroplasty is low. BMI at diagnosis greater than 25 kg/m 2 and patellar OCD lesions are predisposing factors for arthritis. Diagnosis of OCD as an adult was associated with a greater risk of arthritis.