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Background: Meniscal repair is desirable over resection to prevent post-meniscectomy arthritis, especially in young and active patients. However, long-term data is currently lacking following meniscus repair, particularly in the pediatric population. Purpose: To report long-term follow-up of isolated meniscus tears treated by meniscal repair in a pediatric population, and to compare those results to previous mid-term follow-up data reported. We hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Methods: Patients less than 18 that had a meniscal repair procedure performed between 1990 and 2005 were included. Concomitant ACL reconstructions were excluded from the present study. At the time of final follow-up, recurrent meniscus tear, reoperation rates, and IKDC and Tegner scores were determined. Wilcoxin signed ranks tests were performed to calculate the differences in clinical outcome for the 3 time points (pre-operative, average 7 years post-op, and average 18 years post-op) and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At an average follow-up of 18 years (range 13.2 - 25.9 years), 34 patients with 35 isolated meniscus repairs (4F: 30 M) with an average age of 16 (9.9 - 18.7) were included in this study. Of the 35 knees (34 patients), none had “failed” or re-injured their affected meniscus since mid-term follow-up in 2008. The average IKDC score was 92.1 which was found to be significantly increased when compared to both preoperative IKDC 64.7 (P<.0001) and mid-term IKDC scores, 89.8 (p=.02). However, the average Tegner score (6.5) was significantly lower than both pre-operative 8.28 (p<.0001) and the mid-term Tegner average 8.25 (p<.0001). Patients with a meniscus re-tear and subsequent partial meniscectomy had lower IKDC scores than clinically successful repairs (88.9 vs 94.0), but this did not reach statistical significance (p=.09). There was no correlation for Tegner or IKDC values with 1) rim width, 2) current age, 3) time elapsed since surgery, or 4) time from injury to surgery. There were also no differences in Tegner or IKDC scores when comparing; medial versus lateral, left versus right, tear types, surgical repair technique, or male vs female. Conclusion: This study demonstrates very good clinical long-term outcomes following meniscal repair in a pediatric population.

PurposeBevacizumab improves progression-free survival but not overall survival in patients with metastatic breast cancer. E5103 tested the effect of bevacizumab in the adjuvant setting in patients with human epidermal growth factor receptor 2–negative disease.Patients and MethodsPatients were assigned 1:2:2 to receive placebo with doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel (arm A), bevacizumab only during AC and paclitaxel (arm B), or bevacizumab during AC and paclitaxel followed by bevacizumab monotherapy for 10 cycles (arm C). Random assignment was stratified and bevacizumab dose adjusted for choice of AC schedule. Radiation and hormonal therapy were administered concurrently with bevacizumab in arm C. The primary end point was invasive disease–free survival (IDFS).ResultsFour thousand nine hundred ninety-four patients were enrolled. Median age was 52 years; 64% of patients were estrogen receptor positive, 27% were lymph node negative, and 78% received dose-dense AC. Chemotherapy-associated adverse events including myelosuppression and neuropathy were similar across all arms. Grade ≥ 3 hypertension was more common in bevacizumab-treated patients, but thrombosis, proteinuria, and hemorrhage were not. The cumulative incidence of clinical congestive heart failure at 15 months was 1.0%, 1.9%, and 3.0% in arms A, B, and C, respectively. Bevacizumab exposure was less than anticipated, with approximately 24% of patients in arm B and approximately 55% of patients in arm C discontinuing bevacizumab before completing planned therapy. Five-year IDFS was 77% (95% CI, 71% to 81%) in arm A, 76% (95% CI, 72% to 80%) in arm B, and 80% (95% CI, 77% to 83%) in arm C.ConclusionIncorporation of bevacizumab into sequential anthracycline- and taxane-containing adjuvant therapy does not improve IDFS or overall survival in patients with high-risk human epidermal growth factor receptor 2–negative breast cancer. Longer duration bevacizumab therapy is unlikely to be feasible given the high rate of early discontinuation.

Objective Osteochondritis dissecans (OCD) is a knee disorder of predominately pediatric populations. Because of low incidence, it has traditionally been difficult to study OCD. The purpose of this study was to report long-term outcomes of skeletally immature OCD lesions and determine risk factors for persistent knee pain at final follow-up. Design A geographic database of more than 500,000 patients was reviewed to identify patients with knee OCD. Clinical course including operative management, persistent knee pain, and total knee arthroplasty (TKA) were analyzed through review of radiographs, magnetic resonance images, and physician notes. Results A total of 95 skeletally immature patients (70 male, 25 female, mean age 12.5 ± 2.0 years) were followed for a mean of 14 years (range, 2-40 years). Fifty-three patients were treated operatively and 42 were treated nonoperatively. At final follow-up, 13 patients noted persistent knee pain, 8 treated operatively versus 5 treated nonoperatively. Risk factors for knee pain were female gender, patellar lesions, and unstable lesions. Four patients (8%) treated operatively and 2 patients (5%) treated nonoperatively developed symptomatic osteoarthritis at a mean of 28.6 years following diagnosis. Three patients underwent TKA at a mean age of 52 years, significantly younger than that observed for primary TKA at our institution ( P = 0.004). Conclusions Skeletally immature OCD patients have promising histories, with an estimated 14% risk of persistent knee pain, 6% symptomatic osteoarthritis, and 3% conversion to TKA at 14 years’ mean follow-up. Females, patellar lesions, and unstable lesions demonstrated increased persistent knee pain risk. Patients with OCD undergo TKA at a significantly younger age than the general population.

Background: Osteochondritis dissecans (OCD) is a disorder of unknown origin that can affect knees in skeletally mature and immature patients. Surgical management is an important cornerstone of treatment for unstable OCD lesions. Purpose: To determine the (1) healing rate after internal fixation of unstable OCD between skeletally immature and mature knees, (2) risk factors for failure, and (3) patient-reported outcomes among healed patients. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective cohort study was conducted with patients who underwent internal fixation of unstable knee OCD lesions from 2000 to 2015. Skeletal immaturity was defined as open or partially open physes. Healing was assessed through clinical findings and imaging. Definitive reoperation for the same OCD lesion was classified as failure. Results: Among 87 patients included, 66 (76%) had healed lesions at ≥2 years postoperatively, while 21 (24%) failed. Skeletal maturity made no significant difference in failure rate (risk ratio, 0.68; 95% CI, 0.29-1.72; P = .40). For skeletally immature patients, lateral versus medial condylar location conferred an increased hazard of 18.2 (95% CI, 1.76-188.07; P < .01). Multivariate analysis factoring in skeletal maturity showed that lateral condylar location was an independent risk factor for failure (hazard ratio, 4.25; 95% CI, 1.47-19.85; P < .01). Mean patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) increased significantly after surgery, except the KOOS symptoms score for the skeletally mature group. Final scores (mean ± SD) were as follows at a mean follow-up of 60 months (range, 24-166): IKDC, 83.5 ± 20.2; KOOS pain, 89.7 ± 14.1; KOOS symptoms, 87.4 ± 18.4; KOOS activities of daily living, 93.9 ± 12.7; KOOS sports, 80.7 ± 25.9; KOOS quality of life, 78.9 ± 23.1. Conclusion: Skeletally immature and mature patients heal at comparable rates after internal fixation of OCD lesions, resulting in functional and subjective improvement. Lateral femoral condylar lesion location is an independent risk factor for failure.

AimsIt has been suggested that mobile-bearing total knee arthroplasty (TKA) might lead to better outcomes by accommodating some femorotibial rotational mismatch, thereby reducing contact stresses and polyethylene wear. The aim of this study was to determine whether there is a difference between fixed- and mobile-bearing versions of a contemporary TKA with respect to durability, range of movement (ROM) and function, ten years postoperatively.Patients and MethodsA total of 240 patients who were enrolled in this randomized controlled trial (RCT) underwent a primary cemented TKA with one of three tibial components (all-polyethylene fixed-bearing, modular metal-backed fixed-bearing and mobile-bearing). Patients were reviewed at a median follow-up of ten years (IQR 9.2 to 10.4).ResultsThere was no difference in durability, as measured by survivorship free of revision for any reason, nor in mean maximal ROM at ten years (p = 0.8). There was also no difference in function, as measured by Knee Society (KS) function scores (p = 0.63) or the prevalence of patellar tilt (p = 0.12).ConclusionIn this clinical RCT, the mobile-bearing design of TKA was found to be reliable and durable, but did not provide better maximum knee flexion, function or durability ten years postoperatively compared with a posterior-stabilized, fixed-bearing design incorporating either an all-polyethylene or a modular-metal-backed tibial component. Cite this article: Bone Joint J 2018;100-B:925–9.

Background: There are limited data comparing the outcomes of all-inside versus inside-out meniscal repair techniques. Purpose: To assess failure rates and clinical outcomes after the surgical repair of bucket-handle meniscal tears utilizing either an all-inside or inside-out technique. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with bucket-handle meniscal tears undergoing all-inside or inside-out repair at a single institution between 2003 and 2013 were analyzed. A total of 28 mensici repaired utilizing second-generation all-inside suturing devices and 42 menisci repaired using an inside-out technique were eligible for inclusion. Rigorous propensity matching was performed on the basis of age, sex, tear laterality, rim width, and concomitant anterior cruciate ligament reconstruction (ACLR), resulting in a total of 40 patients equally distributed between the 2 repair techniques for comparison. Retear-free survival as well as preoperative and postoperative International Knee Documentation Committee (IKDC) and Tegner scores and physical examination findings were subsequently analyzed. Results: Twenty patients who underwent all-inside repair (14 male; mean age, 23.7 ± 6.7 years) were successfully propensity matched to 20 patients who underwent inside-out meniscal repair (15 male; mean age, 22.5 ± 7.6 years), with a mean retear-free follow-up of 4.4 years (range, 2.5-7.4 years). Four (20%) all-inside repairs and 4 (20%) inside-out repairs failed over the course of follow-up ( P > .999), with a mean time to failure of 2.7 years (range, 1.3-4.4 years) and 5.0 years (range, 0.8-7.5 years), respectively ( P = .25). Increasing patient age trended toward a decreased clinical retear rate, independent of the repair technique (hazard ratio, 0.86; P = .056). There were no significant differences in the Tegner scores, IKDC scores, or range of motion between the groups as a whole or when subcategorizing by age, sex, body mass index, tear complexity, rim width, isolated versus concomitant ACLR, or medial- versus lateral-sided repair. There were no complications in the all-inside group, while there was a 10% rate of minor complications in the inside-out group ( P = .49). Conclusion: Overall, satisfactory clinical outcomes are achievable at short-term to midterm follow-up with both inside-out and all-inside repair techniques of bucket-handle meniscal tears in rigorously matched patients with similar meniscal tear patterns.

Purpose To report the outcomes for combined tibial tubercle osteotomy (TTO) and medial patellofemoral ligament (MPFL) reconstruction and assess for potential risk factors for recurrent instability and/or poor outcomes. Methods The medical record at our institution was reviewed for patients treated with MPFL reconstruction and TTO for recurrent lateral patellar instability from 1998 to 2014. Preoperative imaging was assessed for trochlear dysplasia according to the Dejour classification (high grade = B, C, D) and the presence of patella alta using the Caton‐Deschamps ratio (>1.2). The indication for combined MPFL reconstruction and TTO was MPFL insufficiency and a lateralized tibial tubercle. Outcomes were determined by recurrent instability, return to sport, and Kujala and International Knee Documentation Committee (IKDC) scores. Results Thirty knees in 28 patients (14 M, 14 F) with a mean age of 22.6 ± 9.1 years (range, 13‐51 years) were included with a mean follow‐up of 48 ± 28 months (24‐123 months). Seventy‐three percent (22/30) had high‐grade trochlear dysplasia, and 63% (19/30) had patella alta. One patient had a postoperative dislocation and 1 had a subluxation event. The Caton‐Deschamps ratio decreased by a mean of 0.2 ( P = .001), leaving 30% with postoperative patella alta. The mean postoperative scores were as follows: Tegner = 5 ± 2, Kujala = 89 ± 16 (45‐100), and IKDC = 85 ± 17 (44‐100). Eighty‐three percent (15/18) returned to their preoperative sport. Female gender was a risk factor for lower IKDC (77.3 vs. 92.6, P = .01) and Kujala (82.2 vs. 95.0, P = .03) scores. Medialization greater than 10 mm was directly correlated to lower IKDC ( P = .02) and Kujala ( P = .01) scores. Conclusions The combination of MPFL reconstruction and TTO in patients with trochlear dysplasia results in low recurrence of instability. Patients on average had good subjective outcomes and were able to return to sport. Female gender and tibial tubercle medialization greater than 10 mm were associated with worse outcomes. Level of Evidence Level IV, therapeutic case series.

Background: As the number of cartilage restoration procedures is increasing, so is the number of revision procedures. However, there remains limited information on the reasons for failure of primary cartilage restoration procedures. Purpose: To determine the common modes of failure in primary cartilage restoration procedures to improve surgical decision making and patient outcomes. Study Design: Case series; Level of evidence, 4. Methods: Patients who presented for revision after failed cartilage repair surgery were evaluated for factors contributing to failure of the primary procedure. All revision cases performed by a single surgeon at a tertiary center for failed cartilage restoration over a 6-year time frame were identified. In all cases, the medical records, preoperative radiographs, and magnetic resonance imaging scans were reviewed by 2 experienced cartilage surgeons. The cause for failure was categorized as malalignment, meniscal deficiency, graft or biologic failure, or instability. Univariate and descriptive statistics regarding patient demographics, index procedure, lesion location and size, and mechanism of failure were analyzed. Results: A total of 59 cases in 53 patients (32 male, 21 female) met the inclusion criteria. The mean patient age at the time of revision was 27.6 years, and the mean body mass index was 28.4 kg/m 2 . Failed index surgical procedures included 35 microfractures (59%), 12 osteochondral allograft transplantations (20%), 10 osteochondral autograft transfers (17%), 2 nonviable osteochondral allografts (3%), and 2 particulated juvenile chondral allografts (3%). The mean lesion size was 4.4 cm 2 . Reasons for failure included 33 cases with untreated malalignment (56%), 16 with graft failure (27%), 11 with untreated meniscal deficiency (19%), and 3 with untreated instability (5%); 4 cases demonstrated multiple reasons for failure. Conclusion: The most commonly recognized reason for failure was untreated malalignment. While biologic and graft failures will occur, the majority of failures were attributed to untreated background factors such as malalignment, meniscal deficiency, and instability. The stepwise approach of considering and addressing alignment, meniscal volume, and stability remains essential in cartilage restoration surgery.