Outcomes Following Repair of Achilles Midsubstance Tears: Percutaneous Knotless Repair vs Open Repair

BACKGROUND

Optimum treatment for acute Achilles tendon rupture results in high mechanical strength, low risk of complications, and return to preinjury activity level. Percutaneous knotless repair is a minimally invasive technique with promising results in biomechanical studies, but few comparison clinical studies exist. Our study purpose was to compare functional outcomes and revision rates following acute Achilles tendon rupture treated between percutaneous knotless repair and open repair techniques.

METHODS

Patients 18 years or older with an acute Achilles tendon rupture, treated by a single surgeon with either open repair or percutaneous knotless repair, and more than 2 years after surgery were assessed for eligibility. Prospective clinical data were obtained from the data registry and standard electronic medical record. Additionally, the patients were contacted to obtain current follow-up questionnaires. Primary outcome measure was Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL). Secondary outcome measures were FAAM sports, 12-Item Short Form Health Survey (SF-12), Tegner activity scale, patient satisfaction with outcome, complications, and revisions. Postoperative follow-up closest to 5 years was used in this study.

RESULTS

In total, 61 patients were included in the study. Twenty-four of 29 patients (83%) in the open repair group and 28 of 32 patients (88%) in the percutaneous knotless repair group completed the questionnaires with average follow-up of 5.8 years and 4.2 years, respectively. We found no significant differences in patient-reported outcomes or patient satisfaction between groups (FAAM ADL: 99 vs 99 points, P = .99). Operative time was slightly longer in the percutaneous knotless repair group (46 vs 52 minutes, P = .02). Two patients in the open group required revision surgery compared to no patients in the percutaneous group.

CONCLUSION

In our study, we did not find significant differences in patient-reported outcomes or patient satisfaction by treating Achilles tendon midsubstance ruptures with percutaneous knotless vs open repair.

LEVEL OF EVIDENCE

Level IlI, retrospective cohort study.

Syndesmotic Suture Button Fixation Results in Higher Tegner Activity Scale Scores When Compared to Screw Fixation: A Multicenter Investigation

BACKGROUND

Suture buttons and metal screws have been used and compared in biomechanical, radiographic, and clinical outcome studies for syndesmotic injuries, with neither implant demonstrating clear superiority. The aim of this study was to compare clinical outcomes of both implants.

METHODS

Patients who underwent syndesmosis fixation at 2 separate academic centers from 2010 through 2017 were compared. Thirty-one patients treated with a suture button and 21 patients treated with screws were included. Patients in each group were matched by age, sex, and Orthopaedic Trauma Association fracture classification. Tegner Activity Scale (TAS), Foot and Ankle Ability Measure (FAAM), patient satisfaction score, surgical failure, and reoperation rates were compared.

RESULTS

Patients who underwent suture button fixation had significantly higher TAS scores than those who underwent screw fixation (p < 0.001). There was no significant difference in FAAM ADL scores between cohorts (p = 0.08). Symptomatic hardware removal rates were similar (3.2% suture button cohort vs 9.0% in screw cohort). One patient (4.5%) underwent revision surgery secondary to syndesmotic malreduction after screw fixation, for a reoperation rate of 13.5%.

CONCLUSION

Patients with unstable syndesmotic injuries treated with suture button fixation had higher mean TAS scores compared to patients treated with screws. Foot and Ankle Ability Measure and ADL scores in these cohorts were similar.Level of Evidence: Level 3 Retrospective Matched Case-Cohort.

Reliability and Validity of the Knee Injury and Osteoarthritis Outcome Score in Patients Undergoing Unicompartmental Knee Arthroplasty

BACKGROUND

The Knee Injury and Osteoarthritis Outcome Score (KOOS) was developed to document outcomes from knee injury, including the impact of osteoarthritis on knee function. The purpose of this study is to determine the reliability and validity of the KOOS subscales for evaluating outcomes following unicompartmental knee arthroplasty (UKA).

METHODS

KOOS Pain, Activities of Daily Living (ADL), Sport, Symptoms, and Quality of Life (QoL) scores collected from 172 patients who underwent UKA were used in the analysis. KOOS subscales were tested for reliability and validity of scores through a Rasch model analysis.

RESULTS

KOOS Sport, KOOS ADL, and KOOS QoL had good evidence of reliability with acceptable person reliability, person separation, and item reliability. For overall scale functioning, KOOS Pain, Symptoms, and ADL all had 1 question that did not have an acceptable value for infit or outfit mean square value. Questions in KOOS Sport and QoL all had acceptable values. There was a positive, linear relationship between the Short-Form 12 Physical Component Summary and the KOOS subscales which indicated good evidence of convergent validity. These associations were also seen when the cohort was separated in medial and lateral UKA.

CONCLUSION

Two of the 5 KOOS subscales (KOOS Sport and KOOS QoL) were considered adequate in measuring outcomes, as well as reliability. The KOOS ADL had borderline values; however, it had adequate infit and outfit values. The KOOS Pain and Symptom score performed poorly in this analysis. For documenting outcomes following UKA, this study supports the use of KOOS ADL, Sport, and QoL.

Syndesmotic Suture Button Fixation Results in Higher Tegner Activity Scale Scores When Compared to Screw Fixation: A Multicenter Investigation

Category:

Ankle

Introduction/Purpose:

Injuries of the syndesmosis may occur in isolation or association with rotational ankle fractures. The use of suture button 'tight-ropes' versus metal screws for fixation across the syndesmosis has become a highly debated topic. Previous authors have compared subjective, functional, and radiographic outcomes between the two fixation methods with good outcomes reported. The primary aim of this study is to compare clinical outcomes of syndesmotic suture button fixation versus syndesmotic screw fixation for operative management of syndesmotic injuries. A secondary aim is to determine failure rates of both fixation techniques requiring revision syndesmosis surgery. We hypothesize that there will be no difference in subjective outcomes or activity scores when comparing screw versus suture button. This study is to improve patient care and outcomes.

Methods:

In this multi-center, retrospective cohort study, we identified patients with syndesmotic injuries who underwent surgical treatment at two separate academic referral centers from 2010 through 2017. All patients were diagnosed by attending orthopaedic surgeons at the participating study sites, and where their syndesmotic injuries were treated with either suture-button fixation or metal screw fixation based on surgeon preference. Patients were matched by age, gender, and OTA fracture classification. The primary subjective outcome measure was the Tegner activity level, and the secondary subjective outcomes measures were the Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) subscale, FAAM sport subscale, and patient satisfaction score. The primary objective outcomes included failure and reoperation rate.

Results:

41 patients treated with a suture button (71% male, mean age 39.7 years) and 21 patients treated with metal screws (67% male, mean age 43.7 years) were included in the study. Patient demographics were similar between groups. There was no significant difference in FAAM ADL scores between patients based on surgical procedure for the treatment of a syndesmosis injury (suture button versus metal screw fixation), t (50) = 1.373 (p =0.176). There was a significant difference in Tegner activity scale scores, with patients who underwent suture button fixation reporting significantly higher Tegner activity level scores on average than those who underwent syndesmosis repair with screw fixation (U = 141, p =0.002) (Figure 1).

Conclusion:

In this multi-center study, we report higher mean Tegner activity scale scores in patients treated with suture button fixation when compared to patients treated with metal screws for unstable syndesmotic injuries. Patients in both treatment cohorts reported similar FAAM ADL scores. The authors believe that both syndesmotic fixation techniques are acceptable in the treatment of syndesmosis of injuries, but recommend consideration given to suture button fixation in patients with higher activity levels.

Accessibility and Thickness of Medial and Lateral Talar Body Cartilage for Treatment of Ankle and Foot Osteochondral Lesions

BACKGROUND

The purposes of this study were to determine (1) if cartilage thicknesses on the talar dome and medial/lateral surfaces of the talus were similar, (2) whether there was sufficient donor cartilage surface area on the medial and lateral talar surfaces to repair talar dome cartilage injuries of the talus, and (3) whether the cartilage surface could be increased following anterior talofibular ligament (ATFL) and sectioning of the tibionavicular and tibiospring portion of the anterior deltoid.

METHODS

Medial and lateral approaches were utilized in 8 cadaveric ankles to identify the accessible medial, lateral, and talar dome cartilage surfaces in 3 conditions: (1) intact, (2) ATFL release, and (3) superficial anterior deltoid ligament release. The talus was explanted, and the cartilage areas were digitized with a coordinate measuring machine. Cartilage thickness was quantified using a laser scanner.

RESULTS

The mean cartilage thickness was 1.0 ± 0.1 mm in all areas tested. In intact ankles, the medial side of the talus showed a larger total area of available cartilage than the lateral side (152 mm² vs 133 mm²). ATFL release increased the available cartilage area on the medial and lateral sides to 167 mm² and 194 mm², respectively. However, only the lateral talar surface had sufficient circular graft donor cartilage available for autologous osteochondral transplantation (AOT) procedures of the talus. After ATFL and deltoid sectioning, there was an increase in available graft donor cartilage available for AOT procedures.

CONCLUSION

The thickness of the medial and lateral talar cartilage surfaces is very similar to that of the talar dome cartilage surface, which provides evidence that the medial and lateral surfaces may serve as acceptable AOT donor cartilage. The surface area available for AOT donor site grafting was sufficient in the intact state; however, sectioning the ATFL and superficial anterior deltoid ligament increased the overall lateral talar surface area available for circular grafting for an AOT procedure that requires a larger graft. These results support the idea that lateral surfaces of the talus may be used as donor cartilage for an AOT procedure since donor and recipient sites are similar in cartilage thickness, and there is sufficient cartilage surface area available for common lesion sizes in the foot and ankle.

CLINICAL RELEVANCE

This anatomical study investigates the feasibility of talar osteochondral autografts from the medial or lateral talar surfaces exposed with standard approaches. It confirms the similar cartilage thickness of the talar dome and the ability to access up to an 8- to 10-mm donor graft from the lateral side of the talus after ligament release. This knowledge may allow better operative planning for use of these surfaces for osteochondral lesions within the foot and ankle, particularly in certain circumstances of a revision microfracture.

Relationship Between Tibiotalar Joint Space and Ankle Function Following Ankle Surgery

BACKGROUND

Joint-preserving procedures of the ankle may postpone the need for ankle arthrodesis (AA) or total ankle replacement (TAR). The challenge for the surgeon is to determine which patients may benefit from these joint-preserving procedures. We hypothesized that patents with less than 2 mm of ankle joint space on preoperative radiographs would report inferior outcomes following joint-preserving surgery compared with those with 2 mm or greater joint space.

METHODS

Patients 18 years of age or older treated with joint-preserving ankle surgery with a minimum of 2 years of follow-up were considered for study inclusion. The ankle joint space was measured on standardized weightbearing preoperative radiographs. At follow-up, patients completed questionnaires including the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales, the Short Form-12 (SF-12) Physical Component Summary and Mental Component Summary, the Tegner Activity Scale, and satisfaction with outcome.

RESULTS

A total of 251 patients were included in the study. Forty-three patients had an ankle joint space of less than 2 mm. Compared with the 208 patients with an ankle joint space of 2 mm or greater, they had inferior FAAM ADL, FAAM Sports, and SF-12 Physical Component Summary scores (P = .001, P = .001, and P = .006, respectively). Additionally, a statistically significant positive correlation between joint space distance and the FAAM ADL (P = .012, r = 0.158), FAAM Sports (P < .001, r = 0.301), and SF-12 Physical Component Summary (P < .010, r = 0.163) scores was found.

CONCLUSION

Patients with a preoperatively narrowed ankle joint space of less than 2 mm had significantly lower outcome scores following joint-preserving ankle surgery compared with patients with preserved ankle joint space. These results may assist clinicians in selecting patients who may benefit from ankle joint-preserving procedures, as well as counseling patients with a narrowed ankle joint space regarding expected outcome after joint-preserving ankle surgery.

LEVEL OF EVIDENCE

Level II, prognostic comparative study.

Use of Anatomical Landmarks in Ankle Arthroscopy to Determine Accuracy of Syndesmotic Reduction: A Cadaveric Study

Background. The aim of this study was to determine the accuracy of ankle arthroscopy as a means for diagnosing syndesmotic reduction or malreduction and to determine anatomical landmarks for diagnosis. Methods. Six matched-pair cadavers (n = 12) with through-knee amputations were studied. Component parts of the syndesmosis and distal 10 cm of the interosseous membrane (IOM) were sectioned in each. The 12 specimens were divided into 2 groups: 6 specimens in the in-situ group fixed with suture button technique and 6 specimens in the malreduced group rigidly held with a 3.5-mm screw. Specimens were randomized to undergo diagnostic arthroscopy by 3 fellowship-trained foot and ankle orthopaedic surgeons in a blinded fashion. Surgeons were asked to determine if the syndesmosis was reduced or malreduced and provide arthroscopic measurements of their findings. Results. Of 36 arthroscopic evaluations, 34 (94%) were correctly diagnosed. Arthroscopic measurement of 3.5 mm diastasis or greater at the anterior aspect of the distal tibiofibular syndesmosis correlated with a posteriorly malreduced fibula. Arthroscopic evaluation of the Anterior inferior tibiofibular ligament (AITFL), IOM, Posterior inferior tibiofibular ligament (PITFL), lateral fibular gutter, and the tibia/fibula relationship were found to be reliable landmarks in determining syndesmotic reduction. An intraclass correlation coefficient (ICC) for interrater reliability of 1.00 was determined for each of these landmarks between 2 surgeons (P < .001). The ICCs between 2 surgeons' measurements and the computed tomography measurements were found to be 0.896 (P value < .001). Conclusions. Ankle arthroscopy is a reliable method to assess syndesmotic relationship when reduced in situ or posteriorly malreduced 10 mm. Levels of Evidence: Level V: Cadaveric.

Rasch Analysis of Reliability and Validity of Scores From the Foot and Ankle Ability Measure (FAAM)

BACKGROUND

The purpose of this study was to determine the reliability and validity of scores from the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports scales in patients who have a variety of ankle injuries.

METHODS

All patients who underwent surgical treatment for an ankle injury and completed the FAAM ADL and Sport scales were included in this study (n = 456; 192 females, 264 males). The average age was 47.6 years (range, 18-79 years). The average time to follow-up was 3.8 years (range, 2.0-7.7 years). All data were collected prospectively and reviewed retrospectively. A reliability and validity analysis, utilizing the Rasch measurement model, a special case of item response theory (IRT), was conducted.

RESULTS

Reliability was very good. For FAAM ADL, person reliability was 0.87 and item reliability was 0.99. For FAAM Sport, person reliability was 0.89 and item reliability was 1.0. Infit mean square (MNSQ) values, which assess internal scale validity, were examined. For FAAM ADL, items 11 (coming up on your toes) and 10 (squatting) were high (2.27 and 2.08, respectively). All other infit values were within the acceptable range of 0.5 to 1.7. For FAAM Sport, all infit values were within the acceptable range. Outfit MNSQ values, which assess the FAAM ADL and Sport rating scale function, were examined. Three items from FAAM ADL were beyond the acceptable range. Items 10 and 11 from FAAM ADL had high outfit MNSQ values (2.15 and 1.98, respectively). Item 19 (light to moderate work) item had a marginally low outfit MNSQ of 0.48. For FAAM Sport, all outfit values were within the acceptable range.

CONCLUSION

There was very good evidence of the reliability and validity of FAAM ADL and FAAM Sport scores. Two FAAM ADL items may indicate the need for further scale development for use in a diverse surgical ankle population.

LEVEL OF EVIDENCE

Level III, comparative series.

Primary Versus Revision Anterior Cruciate Ligament Reconstruction: Patient Demographics, Radiographic Findings, and Associated Lesions

PURPOSE

The purpose of this study was to evaluate the differences in intra-articular pathology, demographic characteristics, and radiographic characteristics of the knee associated with primary anterior cruciate ligament reconstruction (ACLR) versus revision ACLR at the time of initial presentation with either a native anterior cruciate ligament tear or an anterior cruciate ligament graft tear. Secondarily, we aimed to investigate risk factors for concomitant medial and lateral meniscal tears and cartilage injuries at the time of ACLR.

METHODS

This was a retrospective review of patients who underwent primary or revision ACLR by a single surgeon. The exclusion criteria were as follows: skeletally immature patients; patients with an intra-articular fracture; patients with an ipsilateral knee infection; or patients who underwent an osteotomy, cartilage restoration procedure, or meniscal transplantation either previously or concomitantly with the ACLR. Detailed patient demographic data, radiographic long-standing alignment, tibial slope, and intraoperative findings including articular cartilage injury grade and meniscus integrity were documented at surgery.

RESULTS

There were 487 patients included in this study (363 with primary ACLR and 124 with revision ACLR). There were no significant differences in age (P = .119), sex (P = .917), body mass index (P = .468), allograft versus autograft reconstruction (P = .916), or prevalence of meniscal tears (P = .142) between the primary and revision groups. Patients who underwent revision ACLR had a significantly increased medial tibial slope (P = .048) and a higher prevalence of chondral defects on both the medial (P < .001) and lateral (P = .003) femoral condyles when compared with primary ACLR patients. Logistic regression showed that a decreased tibial slope was correlated with femoral medial-sided chondral injuries and that varus or valgus coronal-plane malalignment was correlated with lateral meniscal tears in both groups.

CONCLUSIONS

The findings of this study show that patients undergoing a revision ACLR have significantly more chondral lesions, as well as higher-grade chondral lesions, at the time of presentation. Furthermore, coronal malalignment and a decreased tibial slope may contribute to injury patterns of the lateral meniscus and medial compartment cartilage, respectively. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Posteromedially placed plates with anterior staple reinforcement are not successful in decreasing tibial slope in opening-wedge proximal tibial osteotomy

PURPOSE

To document the effectiveness of a novel technique to decrease tibial slope in patients who underwent a proximal opening-wedge osteotomy with an anteriorly sloped plate placed in a posteromedial position. The hypothesis was that posteromedial placement of an anteriorly sloped osteotomy plate with an adjunctive anterior bone staple on the tibia would decrease, and maintain, the tibial slope correction at a minimum of 6 months following the osteotomy.

METHODS

All patients who underwent biplanar medial opening-wedge proximal tibial osteotomy with anterior staple augmentation to decrease sagittal plane tibial slope were included, and data were collected prospectively and reviewed retrospectively. Indications for decreasing tibial slope included medial compartment osteoarthritis with at least one of the following: ACL deficiency, posterior meniscus deficiency, or flexion contracture. Preoperative, immediate postoperative, and 6-month postoperative radiographs were reviewed.

RESULTS

Twenty-one patients (14 males and 7 females) were included in the study with a mean age of 36.5 years. Intrarater and interrater reliability of slope measurements were excellent at all time points (ICC ≥ 0.94, ICC ≥ 0.85). The osteotomy resulted in an average tibial slope decrease of 0.8 from preoperative (n.s.). At 6-month postoperative, average slope was not significantly different from time-zero postoperative slope (mean = +0.2°).

CONCLUSIONS

The most important finding of this study was that posteromedial placement of an anteriorly angled osteotomy plate augmented with an anterior staple during a biplanar medial opening-wedge proximal tibial osteotomy did not decrease sagittal plane tibial slope. Whether a staple was effective in maintaining tibial slope from time zero to 6 months postoperatively was unable to be assessed due to no significant change in tibial slope from the preoperative postoperative states. The results of this study note that current osteotomy plate designs and surgical techniques are not effective in decreasing sagittal plane tibial slope.

LEVEL OF EVIDENCE

IV.

Outcomes After 1-Stage Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction

BACKGROUND

Revision anterior cruciate ligament reconstruction (ACLR) is becoming increasingly common as the number of primary ACLR cases continues to rise. Despite this, there are limited data on the outcomes of revision ACLR and even less information specifically addressing the differences in 1-stage revision reconstruction versus those performed in a 2-stage fashion after primary reconstruction.

PURPOSE

To compare the outcomes, patient satisfaction, and failure rates of 1-stage versus 2-stage revision ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients who underwent revision ACLR between 2010 and 2014 by a single surgeon were collected, and skeletally mature patients over the age of 17 years were included. Patients were excluded if they were skeletally immature; had a previous intra-articular infection in the ipsilateral knee; underwent a prior alignment correction procedure, cartilage repair or transplant procedure, or meniscal allograft transplantation; or had an intra-articular fracture. An ipsilateral or contralateral bone-patellar tendon-bone (BPTB) autograft was the graft of choice. A BPTB allograft was considered for patients aged ≥50 years, for any patient with an insufficient ipsilateral or contralateral patellar tendon, or for those who chose not to have the contralateral patellar tendon graft harvested. Patients completed a subjective questionnaire preoperatively and at a minimum of 2 years postoperatively. Magnetic resonance imaging and computed tomography of all knees were performed preoperatively to assess for associated injuries and to evaluate the ACLR tunnel size and location. Patients with malpositioned tunnels that would critically overlap with an anatomically placed tunnel or those with tunnels ≥14 mm in size underwent bone grafting.

RESULTS

A total of 88 patients met the inclusion criteria for this study. There were 39 patients in the 1-stage revision surgery group (19 male, 20 female) and 49 patients in the 2-stage revision surgery group who underwent tunnel bone grafting first (27 male, 22 female). In both groups, the 12-item Short Form Health Survey (SF-12) Physical Component Summary, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner activity scale scores significantly improved from preoperatively to postoperatively. There was no significant difference in the SF-12 Mental Component Summary score before and after surgery in either group. Furthermore, there was no significant difference in failure rates or other demographic data between the groups. We observed 4 failures in the 1-stage reconstruction group (10.3%) and 3 failures in the 2-stage reconstruction group (6.1%).

CONCLUSION

In this study, objective outcomes and subjective patient scores and satisfaction were not significantly different between 1-stage and 2-stage revision ACLRs. Both groups had significantly improved objective outcomes and patient subjective outcomes without notable differences in failure rates. Further longitudinal studies comparing 1-stage and 2-stage revision ACLRs over a longer time frame are recommended.

Outcomes of Inside-out Meniscal Repair in the Setting of Multiligament Reconstruction in the Knee

BACKGROUND

Limited evidence exists for meniscal repair outcomes in a multiligament reconstruction setting. Purpose/Hypothesis: The purpose of this study was to assess outcomes and failure rates of meniscal repair in patients who underwent multiligament reconstruction compared with patients who underwent multiligament reconstruction but lacked meniscal tears. The authors hypothesized that the outcomes of meniscal repair associated with concomitant multiligament reconstruction would significantly improve from preoperatively to postoperatively at a minimum of 2 years after the index surgery. Secondarily, they hypothesized that this cohort would demonstrate similar outcomes and failure rates compared with the cohort that did not have meniscal lesions at the time of multiligament reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Inclusion criteria for the study included radiographically confirmed skeletally mature patients of at least 16 years of age who underwent multiligamentous reconstruction of the knee without previous ipsilateral osteotomy, intra-articular infections, or intra-articular fractures. Patients were included in the experimental group if they underwent inside-out meniscal suture repair with concurrent multiligament reconstruction. Those included in the control group (multiligament reconstruction without a meniscal tear) underwent multiligament reconstruction but did not undergo any type of meniscal surgery. Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-12 physical component summary and mental component summary, Tegner activity scale, and patient satisfaction scores were recorded preoperatively and postoperatively. The failure of meniscal repair was defined as a retear of the meniscus that was confirmed arthroscopically.

RESULTS

There were 43 patients (16 female, 27 male) in the meniscal repair group and 62 patients (25 female, 37 male) in the control group. Follow-up was obtained in 93% of patients with a mean of 3.0 years (range, 2.0-4.7 years). There was a significant improvement between all preoperative and postoperative outcome scores ( P < .05) for both groups. The meniscal repair group had significantly lower preoperative Lysholm and Tegner scores ( P = .009 and P = .02, respectively). There were no significant differences between any other outcome scores preoperatively. The failure rate of the meniscal repair group was 2.7%, consisting of 1 symptomatic meniscal retear. There was no significant difference in any postoperative outcome score at a minimum 2-year follow-up between the 2 groups.

CONCLUSION

Good to excellent patient-reported outcomes were reported for both groups with no significant differences in outcomes between the cohorts. Additionally, the failure rate for inside-out meniscal repair with concomitant multiligament reconstruction was low, regardless of meniscus laterality and tear characteristics. The use of multiple vertical mattress sutures and the biological augmentation resulting from intra-articular cruciate ligament reconstruction tunnel reaming may be partially responsible for the stability of the meniscal repair construct and thereby contribute to the overall improved outcomes and the low failure rate of meniscal repair, despite lower preoperative Lysholm and Tegner scores in the meniscal repair group.

Outcomes After Biologically Augmented Isolated Meniscal Repair With Marrow Venting Are Comparable With Those After Meniscal Repair With Concomitant Anterior Cruciate Ligament Reconstruction

BACKGROUND

Meniscal repair in the setting of anterior cruciate ligament (ACL) reconstruction has demonstrated superior outcomes compared with isolated meniscal repair. Limited evidence exists for the effects of biological augmentation in isolated meniscal repair, particularly as compared with meniscal repair with concomitant ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to compare the outcomes and survivorship of meniscal repair in 2 cohorts of patients: meniscal repair with biological augmentation using a marrow venting procedure (MVP) of the intercondylar notch, and meniscal repair with concomitant ACL reconstruction. We hypothesized that the clinical outcomes and survivorship of meniscal repair with concomitant ACL reconstruction would be improved compared with meniscal repair with biological augmentation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Inclusion criteria were skeletally mature patients aged ≥16 years who underwent inside-out meniscal repair and either a concomitant MVP of the intercondylar notch or ACL reconstruction. Patients were excluded from this study if they were skeletally immature, underwent meniscus root or radial tear repair, or underwent meniscal repair with concurrent ligamentous reconstruction not limited to the ACL. At the preoperative evaluation and a minimum 2 years after the index meniscal repair procedure, patients were administered a subjective questionnaire. Differences in outcome scores, survivorship, and failure rates between the cohorts were assessed. Failure was defined as reoperation with meniscectomy or revision meniscal repair.

RESULTS

There were 109 patients (52 female, 57 male) who met the inclusion criteria for this study. There were 37 knees in cohort 1 (isolated meniscal repair plus MVP) and 72 knees in cohort 2 (meniscal repair plus ACL reconstruction). The failure status was known in 95 patients, and patient-reported outcome scores were obtained in 89 (82%) patients. Both cohorts demonstrated a significant improvement in all outcome scores, and there was no significant difference in any of the preoperative or postoperative outcome measures. The overall failure rate was 9.5% (9/95). There were 4 (12.9%) failures in cohort 1 and 5 failures (7.8%) in cohort 2, with no significant difference in failures between the cohorts ( P = .429). There was a significant association between failure and female sex ( P = .001).

CONCLUSION

The most important finding in this study was that there was no difference in outcomes in meniscal repair performed with biological augmentation using an MVP versus that performed concomitantly with ACL reconstruction. The similar outcomes reported for meniscal repair with an MVP and meniscal repair with ACL reconstruction may be partly attributed to biological augmentation.

Posterior Meniscal Root Repairs: Outcomes of an Anatomic Transtibial Pull-Out Technique

BACKGROUND

Outcomes after transtibial pull-out repair for posterior meniscal root tears remain underreported, and factors that may affect outcomes are unknown. Purpose/Hypothesis: The purpose of this study was to compare patient-centered outcomes after transtibial pull-out repair for posterior root tears in patients <50 and ≥50 years of age. We hypothesized that improvement in function and activity level at minimum 2-year follow-up would be similar among patients <50 years of age compared with patients ≥50 years and among patients undergoing medial versus lateral root repairs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Inclusion criteria were patients aged 18 years or older who underwent anatomic transtibial pull-out repair of the medial or lateral posterior meniscus root by a single surgeon. All patients were identified from a data registry consisting of prospectively collected data in a consecutive series. Cohorts were analyzed by age (<50 years [n = 35] vs ≥50 years [n = 15]) and laterality (lateral [n = 15] vs medial [n = 35]). Patients completed a subjective questionnaire preoperatively and at minimum of 2 years postoperatively (Lysholm, Tegner, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], 12-Item Short Form Health Survey [SF-12], and patient satisfaction with outcome). Failure was defined as revision meniscal root repair or partial meniscectomy.

RESULTS

The analysis included 50 knees in 49 patients (16 females, 33 males; mean age, 38.3 years; mean body mass index, 26.6). Of the 50 knees, 45 were available for analysis. Three of 45 (6.7%) required revision surgery. All failures were in patients <50 years old, and all failures underwent medial root repair. No significant difference in failure was found based on age ( P=.541) or laterality ( P = .544). For age cohorts, Lysholm and WOMAC scores demonstrated significant postoperative improvement. For laterality cohorts, all functional scores significantly improved postoperatively. No significant difference was noted in postoperative Lysholm, WOMAC, SF-12, Tegner, or patient satisfaction scores for the age cohort or the laterality cohort.

CONCLUSION

Outcomes after posterior meniscal root repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. Transtibial double-tunnel pull-out meniscal root repair provided improvement in function, pain, and activity level, which may aid in delayed progression of knee osteoarthritis.

A prospective observational study assessing the feasibility of measuring blood lead levels in New Zealand hunters eating meat harvested with lead projectiles

There is no safe level of lead exposure. Correlations suggest that hunters harvesting wild game with lead bullets may be at risk of lead exposure through eating minute lead particles from shrapnel in their wild game. This feasibility study will determine if it is possible to conduct an interventional controlled, blinded study to evaluate if there is a causal relationship between meat harvested with lead bullets and elevated blood lead levels in those who consume the meat. This is an observational case crossover study and the primary outcome is blood lead levels. Individuals will have blood lead levels measured 2-4 days after eating one serving of meat harvested with lead bullets. At three potential washout periods these same individuals will have a subsequent blood lead level analysis. This observational study will provide the data necessary to determine the washout period and sample size for a prospective interventional study to evaluate if meat harvested with lead bullets raises blood-lead levels in those who consume the meat. This study has been approved by the Health and Disabilities Ethics Committees of New Zealand.

Trial registration

NCT02775890.

Bone marrow aspirate concentrate for the treatment of osteochondral lesions of the talus: a systematic review of outcomes

Background

The goal of this perform a systematic review on the outcomes of bone marrow aspirate concentrate (BMAC) for the treatment of chondral defects and osteoarthritis (OA) of the talus.

Results

The systematic search performed identified 47 studies after duplicates were removed. After inclusion criteria were applied four studies were considered for insightful analysis for the treatment of focal chondral defects in the foot and ankle with the use of BMAC. Three studies were retrospective and one study was prospective in nature. One study was a comparative cohort study and three studies were case series.

Conclusions

This review denotes that there exists an overwhelming paucity of long-term data and high-level evidence supporting BMAC for the treatment of chondral defects. Nonetheless, the evidence available showed varying degrees of beneficial results of BMAC for the treatment of ankle cartilage defects. The limited literature presented in this review demonstrates the need for more advanced, comparative studies to further investigate the efficacy, safety and techniques for BMAC in the treatment of OLTs. The authors recommend that BMAC therapy should be performed with careful consideration until the application and target population for this treatment are established.

Patient-Centered Outcomes Following Total Ankle Arthroplasty vs Ankle Arthrodesis

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthritis is a debilitating disorder, which has been shown to significantly limit activities of daily living and lead to reduced quality of life. Total ankle arthroplasty (TAA) and ankle arthrodesis are common treatments for ankle arthritis; however, patient indications may differ based on individual patient needs. Few studies compare patient-centered outcomes following these two procedures, which may be useful in determining the appropriate procedure.

Methods:

This study was approved by an IRB. All patients between January 2009 and November 2013 who underwent TAA with a third generation implant or ankle arthrodesis by a single surgeon for treatment of ankle arthritis were included. Patients completed a subjective questionnaire at minimum two years following index surgery. Outcomes measures included Foot and Ankle Disability Index (FADI), Foot and Ankle Ability Measure (FAAM), Lysholm score, WOMAC, SF-12 physical component summary (PCS) and mental component summary (MCS), Tegner activity scale and patient satisfaction with outcome. Detailed operative data and intraoperative findings were documented at time of surgery. All data were collected prospectively.

Results:

There were 77 patients (46 males, 31 females) (mean age = 60.2 years (range 30.2-78.4), (mean BMI=27.7 (range 17.0- 39.1)) included in this study. There was 85% follow-up at an average of 3.5 years (range 2.0-6.6). The arthrodesis cohort was significantly younger than the TAA cohort (54.1 vs. 62.7) (P=.002). Five (7.8%) patients required revision surgery. There was no significant difference in failure rate between cohorts, with 3 patients in the TAA cohort and 2 patients in the arthrodesis cohort (P=.593). There was no significant difference in any outcome measures including FADI and subscales, FAAM and subscales, Lysholm, WOMAC and subscales, SF-12 PCS and MCS or patient satisfaction with outcome, except Tegner (Table 1).

Conclusion:

Patients who underwent TAA or arthrodesis as treatment for end-stage ankle arthritis had low failure rates and similar postoperative function at final follow-up. Activity level was significantly lower in the TAA cohort; however, patients were highly satisfied with their outcome regardless of cohort. Since good outcomes may be achieved with both TAA and arthrodesis, operative procedure should be matched based on patient expectations of activity and function.

Activity Level and Function After Lateral Ankle Ligament Repair Versus Reconstruction

BACKGROUND

Few studies have compared outcomes of Broström-Gould repair and allograft reconstruction.

HYPOTHESIS/PURPOSE

The purpose of this study was to compare outcomes and revision rates after Broström-Gould lateral ankle ligament repair versus anatomic allograft reconstruction in patients with lateral ankle instability. The hypothesis was that patients who underwent lateral ankle ligament repair would have outcomes and revision rates similar to those of patients who underwent anatomic allograft reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients who underwent surgical repair or reconstruction of the anterior talofibular ligament and/or the calcaneofibular ligament by a single surgeon between September 2009 and February 2013 were included in this study. Patients completed a subjective questionnaire at minimum 2 years after ankle surgery. Outcomes measures included the Foot and Ankle Disability Index (FADI), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Lysholm score, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Short Form-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, Tegner activity scale, and patient satisfaction with outcome. Detailed surgical data and intraoperative findings were documented at the time of surgery. All data were collected prospectively and reviewed retrospectively.

RESULTS

A total of 86 patients were included in this study: 45 men and 41 women (mean age, 38 years; range, 19-68 years) with a mean body mass index of 26.5 (range, 17.5-47.1). There were 61 (71%) patients in the repair cohort and 25 (29%) in the reconstruction cohort. There was no significant difference in age or sex between cohorts. Seventy-six (88%) patients had minimum 2-year follow-up (mean follow-up, 3.0 years; range, 2.0-5.3 years). There was no significant difference in FADI (87 vs 91; P = .553), AOFAS (77 vs 82; P = .372), Lysholm score (83 vs 87; P = .110), Tegner activity scale (6 vs 4; P = .271), patient satisfaction (9 vs 10; P = .058), WOMAC (8 vs 5; P = .264), or Short Form-12 PCS (51.3 vs 54.6; P = .169) or MCS (54.8 vs 51.5; P = .239) score between the repair cohort and the reconstruction cohort, respectively. No patient in either cohort underwent revision lateral ligament surgery.

CONCLUSION

When compared with lateral ankle repair, anatomic allograft reconstruction produced similarly favorable outcomes, including high patient satisfaction, high function and activity levels, and no revision surgeries in either cohort.

Patient-Centered Outcomes and Revision Rate in Patients Undergoing ACL Reconstruction Using Bone-Patellar Tendon-Bone Autograft Compared With Bone-Patellar Tendon-Bone Allograft: A Matched Case-Control Study

PURPOSE

To determine whether outcomes after ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft are similar to those of BPTB allograft, while controlling for graft, surgical technique, and surgeon.

METHODS

This study was approved by the institutional review board at The Vail Valley Medical Center in Vail, Colorado. Patients 18 to 70 years old who underwent primary ACL reconstruction were included. Patients in each group were matched by age and gender. Patient demographic data, surgical data, and subjective data were collected prospectively. Subjective questionnaires were administered at a minimum of 2 years after ACL reconstruction.

RESULTS

This study included 192 knees (191 patients; 143 male, 48 female; mean age, 33 years; range, 18 to 57 years), with 96 knees in each group. No autografts required ACL revision. The revision rate for allograft group was 14% (n = 11; mean age, 23 years; range, 18 to 40 years). Of 11 revisions, 9 (82%) were ≤25 years old. In allograft group, patients ≤25 years old were 23 times (95% confidence interval, 4.4 to 123.0) more likely to require revision ACL reconstruction than patients >25 years (P < .001). Follow-up was available for 87% of patients (n = 156/180). Mean follow-up time in the allograft group was 4.7 years (range, 2.0 to 9.8 years), and in the autograft group, 8.6 years (range, 2.0 to 16.2 years; P < .001). There was no significant difference between allografts and autografts for mean Lysholm (85.6 v 83.4; P = .43), mean Tegner (6.0 v 5.4; P = .09), or mean patient satisfaction (9.0 v 8.8; P = .57). Lysholm score correlated to Tegner (rho = 0.404; P < .001) and patient satisfaction with outcome (rho = 0.443; P ≤ .001). Tegner was correlated with age at surgery (rho = -0.274; P < .001).

CONCLUSIONS

There was no significant difference in patient-centered outcomes based on graft type; however, the allograft group required more revisions. Patient satisfaction was high for both groups. ACL reconstruction using BPTB autograft or allograft produces similar outcomes; however, revision rates were higher for allografts.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Meniscus suture repair: minimum 10-year outcomes in patients younger than 40 years compared with patients 40 and older

BACKGROUND

Few studies have compared outcomes after meniscus suture repair in patients younger than 40 years versus patients 40 years and older.

PURPOSE

To document failure rates and long-term outcomes after meniscus suture repair by a single surgeon, using the inside-out technique, at a minimum 10-year follow-up in patients younger than 40 years versus those 40 years and older.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included all patients 18 years or older who underwent meniscus suture repair with the inside-out technique by a single surgeon between January 1992 and December 2003. Patients were divided into 2 cohorts according to age: <40 years (cohort 1) and ≥40 years (cohort 2). If patients underwent subsequent knee surgery, all subsequent reports, whether performed by the original treating surgeon or by a different surgeon elsewhere, were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surgery treated the same area of the meniscus as repaired in the index surgery. Patients completed a subjective questionnaire at minimum of 10 years after arthroscopy. Outcomes measures included Lysholm, Tegner, and patient satisfaction with outcome. All data were collected prospectively.

RESULTS

The surgeon performed 339 meniscus repairs between 1992 and 2003. The study included 181 knees in 178 patients, who had a mean age of 33 years (range, 18-70 years). Cohort 1 contained 136 knees; 16 patients (12%) were lost to follow-up and 47 (35%) underwent a subsequent knee arthroscopy. Cohort 2 contained 45 knees; 2 patients (4.4%) were lost to follow-up, 3 patients had a total knee arthroplasty, and 12 patients (28%) underwent a subsequent knee arthroscopy. In cohort 1, the meniscus repair failure rate was 5.5% (6/110), and in cohort 2 it was 5.3% (2/38) (P = .927). There was no significant difference in failure rate based on which meniscus was repaired (P = .257), concomitant anterior cruciate ligament (ACL) reconstruction (P = .092), or microfracture (P = .674). Average follow-up time for cohort 1 was 16.1 years (range, 10.0-21.9 years), with 82% follow-up (n = 73/89); average follow-up time for cohort 2 was 16.2 years (range, 10.1-21.0 years), with 93% follow-up (n = 28/30). There were no significant differences in outcomes scores after meniscus suture repair based on age cohort or meniscus side, presence of an ACL tear, or concomitant microfracture procedure.

CONCLUSION

Meniscus repair failure rate was not different in patients who were younger than 40 years versus those who were 40 years or older at time of meniscus index surgery. Patients who underwent meniscus suture repair had high function and high patient satisfaction at an average of 16 years after meniscus suture repair, and no differences were seen based on age.

Outcomes following microfracture of full-thickness articular cartilage lesions of the knee in adolescent patients

The purpose of this study was to document outcomes following microfracture for full-thickness cartilage defects of the knee in adolescents. Our hypothesis was that patients aged 18 years or less would have excellent outcomes and function following microfracture of full-thickness knee articular cartilage defects. This study was approved by the Institutional Review Board. Patients < 19 years old with full-thickness knee articular cartilage defects treated with microfracture between January 1992 and June 2008 were identified. Surgical, demographic data, Lysholm score, Tegner activity scale, and patient satisfaction were collected prospectively. A total of 26 patients (14 females, 12 males) met inclusion criteria. Average age was 16.6 years (range: 12-18.9 years). Ninety-six percent of lesions were patellar (37%) or femoral condyle defects (medial 26%, lateral 33%). Minimum 2-year follow-up was obtained in 22/26 patients (85%) with average follow-up of 5.8 years (range: 2.0-13.3 years). Average postoperative Lysholm score was 90 (range: 50-100). Median Tegner scale was 6 (range: 2-10). Median patient satisfaction with outcome was 10 (range: 1-10). Lysholm correlated with Tegner scale (rho = 0.586; p = 0.011) and patient satisfaction (rho = 0.70; p = 0.001). Average postoperative Lysholm score in males was 93 and 86 in females (p = 0.22). One patient underwent revision microfracture. This study showed that adolescent patients who underwent microfracture for treatment of full-thickness knee chondral defects demonstrated increased activity levels and excellent function following surgery.

Diagnostic accuracy of 3.0 Tesla magnetic resonance imaging for the detection of articular cartilage lesions of the talus

BACKGROUND

Talar chondral defects can be a source of persistent ankle pain and disability. If untreated, there is an increased risk of osteoarthritis. The purpose of our study was to determine diagnostic accuracy of 3T MRI in detecting Outerbridge grades 3 and 4 articular cartilage lesions of the talus in a clinical setting, utilizing a standardized clinical MRI protocol.

METHODS

Patients who had a 3T ankle MRI and subsequent ankle surgery, by a single surgeon, were included in this study. MRI exams were performed 180 days or less before surgery. Seventy-nine ankles in 78 patients (mean age of 42.3 years) were included in this study. Mean body mass index was 26.3. A standard clinical MRI exam was performed on a 3T MRI scanner. Mean days from MRI to surgery was 39 days. All MRI exams were read and findings recorded by a musculoskeletal radiologist. Arthroscopic examination was performed by a single orthopaedic surgeon. Detailed arthroscopic findings and demographic data were collected prospectively and stored in a data registry. Of the 78 patients, 31 (39.2%) reported previous ankle surgery. Pain was the primary reason for seeking medical attention as reported by 95% of patients, followed by instability in 44% and loss of function with 42%.

RESULTS

Prevalence of Outerbridge grade 3 and 4 talar articular cartilage defects identified at arthroscopy was 17.7%. The 3T MRI demonstrated a sensitivity of 0.714, specificity of 0.738, positive predictive value of 0.370, and negative predictive value of 0.923.

CONCLUSION

Sensitivity and specificity levels were acceptable for detection of grades 3 and 4 articular cartilage defects of the talar dome using 3T MRI. The high negative predictive value may be beneficial in preoperative planning. While these values are acceptable, a high index of suspicion should be maintained in the appropriate clinical setting.

Diagnostic accuracy of 3.0 T magnetic resonance imaging for the detection of meniscus posterior root pathology

PURPOSE

The purpose of this study was to determine the diagnostic accuracy of 3 T MRI, including sensitivity, specificity, negative and positive predictive values, for detection of posterior medial and lateral meniscus root tears and avulsions.

METHODS

All patients who had a 3 T MRI of the knee, followed by arthroscopic surgery, were included in this study. Arthroscopy was considered the gold standard. Meniscus root tears diagnosed at arthroscopy and on MRI were defined as a complete meniscus root detachment within 9 mm of the root. All surgical data were collected prospectively and stored in a data registry. MRI exams were reported prospectively by a musculoskeletal radiologist and reviewed retrospectively.

RESULTS

There were 287 consecutive patients (156 males, 131 females; mean age 41.7 years) in this study. Prevalence of meniscus posterior root tears identified at arthroscopy was 9.1, 5.9% for medial and 3.5% for lateral root tears (one patient had both). Sensitivity was 0.770 (95% CI 0.570, 0.901), specificity was 0.729 (95% CI 0.708, 0.741), positive predictive value was 0.220 (95% CI 0.163, 0.257) and negative predictive value was 0.970 (95% CI 0.943, 0.987). For medial root tears, sensitivity was 0.824 (95% CI 0.569, 0.953), specificity was 0.800 (95% CI 0.784, 0.808), positive predictive value was 0.206 (95% CI 0.142, 0.238) and negative predictive value was 0.986 (95% CI 0.967, 0.996). For lateral meniscus posterior root tears, sensitivity was 0.600 (95% CI 0.281, 0.860), specificity was 0.903 (95% CI 0.891, 0.912), positive predictive value was 0.181 (95% CI 0.085, 0.261) and negative predictive value was 0.984 (95% CI 0.972, 0.994).

CONCLUSIONS

This study demonstrated moderate sensitivity and specificity of 3 T MRI to detect posterior meniscus root tears. The negative predictive value of 3 T MRI to detect posterior meniscus root tears was high; however, the positive predictive value was low. Sensitivity was higher for medial root tears, indicating a higher risk of missing lateral root tears on MRI. Imaging has an important role in identifying meniscus posterior horn root tears; however, some root tears may not be identified until arthroscopy.

LEVEL OF EVIDENCE

Prognostic study (diagnostic), Level II.

Outcomes after knee microfracture of chondral defects in alpine ski racers

Articular cartilage defects of the knee have been shown to cause pain, swelling, decreased function, and suboptimal athletic performance. Treatment of elite-level athletes presenting with full-thickness chondral defects of the knee continues to be a challenge for orthopedic surgeons. The purpose of this study was to document outcomes in elite professional alpine ski racers after microfracture surgery. This study was approved by an institutional review board. All patients who competed in professional ski races recognized by International Ski Federation and had a full-thickness knee articular cartilage defect, treated with microfracture, by a single surgeon, were included in the study. All data were collected prospectively. At minimum 2 years following microfracture, all patients completed a questionnaire, including Lysholm score, Tegner activity scale, and patient satisfaction with outcome. Minimum 2-year follow-up was available for 18 of 20 skiers (90%) at an average follow-up of 77 months (range, 24-255 months). Size of knee articular cartilage defect was larger in males (195 mm(2)) compared with females (155 mm(2)); however, this difference was not statistically significant (p > 0.05). Median postoperative Tegner activity scale was 10 (range, 4-10). Mean postoperative Lysholm score was 86 (range, 41-100). Median postoperative patient satisfaction score was 10 (range, 9-10). Out of the 20 skiers, 19 (95%) returned to competitive skiing. The age of the skier who did not return was 28 years. The average time from surgery to return to competition was 13.4 months (range, 0.5-25.3 months). Average end-of-season overall World Cup ranking was calculated for the nine skiers before and after surgery. Of these nine skiers, six had an improved average overall World Cup ranking after microfracture. In this study, patient satisfaction with outcome and function were high following microfracture of full-thickness chondral lesions of the knee. Nearly all skiers returned to full competition. Microfracture is an acceptable treatment option for elite skiers who have full thickness articular cartilage lesions of the knee.

Outcomes Following Microfracture in Grade 3 and 4 Articular Cartilage Lesions of the Ankle

BACKGROUND

The purpose of this study was to document outcomes following microfracture of articular cartilage lesions of the ankle. Our hypothesis was that patients who underwent ankle microfracture would have good to excellent outcomes.

METHODS

This study was institutional review board approved. Patients older than 18 years who underwent ankle microfracture surgery for Outerbridge grade 3 or 4 articular cartilage lesions, by a single surgeon, were included. Detailed intraoperative findings were documented at surgery. Patients completed a questionnaire with Foot and Ankle Disability Index (FADI), Lysholm, Tegner, and patient satisfaction with outcome. All data were collected prospectively and stored in a data registry and retrospectively reviewed. Forty patients (21 males, 19 females, mean age = 42 years [range, 19-65 years]) were included in this study. Thirteen (33%) had previous ankle surgery. Follow-up was obtained for 94% of patients (n = 34). Mean follow-up time was 26 months (range, 12-48 months).

RESULTS

Mean talar defect size was 70 mm² (range, 4-300 mm²). Mean tibia defect size was 31 mm² (range, 8-54 mm²). Four patients (10.5%) required subsequent surgery following microfracture surgery. Mean time to second surgery was 17 months (range, 4-32 months). Mean Lysholm score was 74 (range, 31-96). Mean FADI Activities of Daily Living (ADL) was 81 (range, 33-99), FADI Sport was 62 (range, 13-100), and FADI total score was 77 (range, 28-98). Median Tegner was 4 (range, 0-10). Median patient satisfaction was 8 (range, 3-10). Patients who had previous ankle surgery had significantly lower outcome scores versus patients who did not have previous ankle surgery for FADI ADL (70 vs 81, P = .029) and FADI Total (51 vs 77, P = .028). Days from injury to surgery were correlated with age at surgery (r = .323, P = .042) and negatively correlated with FADI ADL (r = -.431, P = .014), FADI Sport (r = -.490, P = .004), FADI Total (r = -.429, P = .014), and Tegner (r = -.402, P = .023).

CONCLUSION

Patients who underwent microfracture for grade 3 or 4 ankle articular cartilage lesions had high patient satisfaction. Patients who had previous ankle surgery had lower postoperative ankle function; however, patient satisfaction remained high. This study supports microfracture for treatment of grade 3 and 4 ankle articular cartilage lesions.

LEVEL OF EVIDENCE

Level IV, case series.

Magnetic resonance imaging findings of snowboarding osteochondral injuries to the middle talocalcaneal articulation

This report presents 2 cases of subtle injuries to the subtalar joint, specifically, osteochondral defects of the middle facet of the talus and concomitant involvement of the middle talocalcaneal articulation sustained while snowboarding. The 3T magnetic resonance image revealed fracture of the lateral talar process with osteochondral lesions of the middle talocalcaneal articulation. This injury can lead to severe and chronic disability if undetected and could ultimately end athletic participation prematurely.

Complications after tendon transfers in the foot and ankle using bioabsorbable screws

BACKGROUND

Tendon transfers are commonly used for correction of pathology or deformity of the foot and ankle. Bioabsorbable implants have been developed as an alternative to metal interference screws. The purpose of this study was to document complications following tendon transfers of the foot and ankle using bioabsorbable poly-L-lactide interference screws.

METHODS

A retrospective chart review was used to identify patients in whom either of the 2 senior authors had performed a tendon transfer of the foot and ankle using a bioabsorbable interference screw between 1999 and 2005. A minimum of 6 months of follow-up was required for inclusion in the study. In all, 31 patients were identified who met the inclusion criteria with an average follow-up of 75 weeks. All screws were made of poly-L-lactide (PLLA).

RESULTS

Complications were identified in 12 (39%) of patients. All of the complications reported were known complications of the tendon transfer procedure itself, and were not directly related to the bioabsorbable screw.

CONCLUSIONS

Based on these early results, PLLA implants appear safe and effective for tendon transfers of the foot and ankle. However, until long-term outcomes are available, judicious use of these implants is recommended.

Quantitative analysis of torsional stiffness in supplemental one-third tubular plate fixation in the management of isolated syndesmosis injuries: a biomechanical study

BACKGROUND

Disruption of the distal tibia and fibula articulation or syndesmosis can occur without fracture, and isolated syndesmotic disruption is often treated operatively. Following syndesmotic screw removal, a period of protected weight-bearing usually follows to allow the screw holes to heal. Our hypothesis was that supplementing transsyndesmotic fixation with a one-third tubular plate would potentially increase the torsional stiffness about the ankle, thus reducing the risk of fracture after screw removal and potentially allowing a faster return to weight-bearing and sport.

METHODS

Ten pairs of fresh frozen cadaveric specimens were divided into 2 groups. In group 1 (7 pairs), each left extremity underwent the placement, and subsequent removal, of a 4.5-mm transsyndesmotic screw in a tricortical fashion. The matching right extremity underwent the same procedure but with the addition of a one-third tubular plate, which remained in situ after screw removal. In group 2 (3 pairs), the left specimens had a screw placed and removed while the right limbs remained intact. All specimens were tested under an axial preload and a torsional load until failure.

RESULTS

In group 1, the results demonstrated an increase in torsional stiffness in 5 of 7 specimens with supplemental fixation of a one-third tubular plate. In group 2, the presence of the screw hole alone reduced the torsional stiffness in all specimens tested when compared with intact specimens. However, neither of these differences were statistically significant.

CONCLUSION

From this study, we can conclude that the use of supplementary one-third tubular plate fixation demonstrated a trend toward increasing the torsional stiffness following transsyndesmotic screw removal.

CLINICAL RELEVANCE

We believe the trend toward improved stiffness justifies the continued use of our technique, although further studies are necessary to confirm it.

Outcomes and revision rate after bone-patellar tendon-bone allograft versus autograft anterior cruciate ligament reconstruction in patients aged 18 years or younger with closed physes

PURPOSE

The purpose of this study was to compare revision rates and outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autografts versus BPTB allografts in patients aged 18 years or younger with closed physes.

METHODS

Institutional review board approval was obtained for this study. This study included 90 consecutive patients aged 18 years or younger with closed physes who underwent primary ACL reconstruction by a single surgeon between 1998 and 2009, with either BPTB autograft (n = 70) or BPTB allograft (n = 20). Patients who had concomitant ligament injuries were excluded. Outcome measures included the Lysholm score, Tegner activity scale, and patient satisfaction (0, very unsatisfied; 10, very satisfied). Failures were defined as cases requiring ACL revision surgery.

RESULTS

Of the 90 patients, 79 (88%) were contacted (20 of 20 with allografts and 59 of 70 with autografts). Of these 79 patients, 9 (11%) required revision ACL reconstruction. In the autograft group, 3% (2 of 59) required revision ACL reconstruction at a mean of 15.4 months (range, 13.0 to 17.7 months) after the index procedure. In the allograft group, 35% (7 of 20) required revision ACL reconstruction at a mean of 9.1 months (range, 5.3 to 12.0 months) after the index procedure. The allograft group was 15 (95% confidence interval [CI], 2 to 123) times more likely to require revision reconstruction than the autograft group (P = .001). The mean Lysholm score at follow-up was 85 (95% CI, 80.4 to 90.3) for the autograft group and 91 (95% CI, 88.1 to 97.3) for the allograft group (P = .46). The median Tegner activity scale was 7.0 (95% CI, 6.9 to 8.0) for autograft group and 6.5 (95% CI, 4.9 to 8.4) for the allograft group (P = .27). Median patient satisfaction score was 10 of 10 in both cohorts. No failures were seen in either group at 2 years postoperatively. Five of seven allograft failures occurred because of a premature return to sports.

CONCLUSIONS

No significant differences in function, activity, or satisfaction were found between allograft and autograft reconstructions in this patient population. The allograft group had a failure rate 15 times greater than that in the autograft group, with all failures occurring within the first year after reconstruction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Improvement in quality of life with use of an unloader knee brace in active patients with OA: a prospective cohort study

The purpose of this study was to determine if short form (SF)-12 physical component would increase with unloader brace use. Patient expectations and predictors of significant improvement were determined. Our hypothesis was that patients with unloader braces will have increases in general physical health (SF-12) and function (Western Ontario and McMaster Universities Arthritis Index [WOMAC]). Patients were enrolled in institutional review board-approved prospective cohort study. They completed a self-administered questionnaire (SF-12; WOMAC, Tegner activity scale, expectations) at enrollment, 3 weeks, 6 weeks, and 6 months. In this study, 39 patients, 23 males and 16 females (average age = 61 years [range 44 to 87]), were prescribed an unloader brace. Patients had significant improvement in quality of life (SF-12) (p < 0.05). There was significant improvement in pain, stiffness, and function (WOMAC) (p < 0.05). Patients who reported Tegner of 3 or greater at final follow-up had significantly higher SF-12 physical component (48 vs. 37; p = 0.023). Return to recreational sports was very important in 83% and somewhat important in 17%. Improving ability to walk was very important in 89%. Pain relief was very important in 69%, somewhat important in 17%. Of these, 39% expected most pain to be relieved and 57% expected all pain to be relieved. The most important expectations were to have confidence in knee (97% very important), avoid future knee degeneration (90% very important), and improve ability to maintain general health (93% very important). Patients demonstrated a significant decrease in pain and disability. Patients saw improvement in SF-12 physical component. Braces specifically designed to unload the degenerative compartment of the knee can be an effective treatment to decrease pain and maintain activity level to increase overall physical health.

Return to play in athletes following ankle injuries

BACKGROUND

The decision to return to play following an ankle injury is a multifactorial process involving both physical and psychological parameters. The current body of literature lacks evidence-based guidelines to assist in the decision.

OBJECTIVE

THIS ARTICLE REVIEWS THE EVIDENCE TO SUPPORT SUCH TESTING: the dorsiflexion lunge test, star excursion balance test, agility T-test, and sargent/vertical jump test. The importance of psychological factors is also highlighted.

EVIDENCE ACQUISITION

The primary literature search was conducted using PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) with the search terms "ankle AND injury" and the following limits activated: English language. A secondary search was then conducted with the search terms "return to play" and "sport injuries and return to play."

RESULTS

Various functional tests have been used to determine whether a patient is able to return to play following an ankle injury. This study documented four tests that have been used to assess range of motion, balance and proprioception, agility and strength and the reasoning as to why these tests are used.

CONCLUSIONS

Functional testing provides objective measures for gauging an athlete's progression through the rehabilitation process. Testing balance and proprioception, strength, range of motion, and agility coupled with psychological assessment evaluates readiness for return to play.

Can Hylan G-F 20 with corticosteroid meet the expectations of osteoarthritis patients?

The purpose of this study was to document expectations and outcomes of active adults suffering from knee osteoarthritis (OA) who underwent treatment protocol of hyaluronic acid injection series with single injection of corticosteroid at initial injection. Our hypothesis was that patients would have functional improvement and pain relief following treatment, and that this treatment protocol will meet patients' expectations of treatment for knee OA. Forty-seven knees (range, 42-80 years) with a diagnosis of knee OA completed a self-administered questionnaire before and post injection series. Prior to injections, patients completed a validated expectation questionnaire and activity level questions. Following treatment, patients expected pain relief, to walk longer distances, and to increase activity level. Patients showed significant improvement in WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain subscale, comparing pre-injection and 6 months post-injection scores (P = .003) and overall WOMAC score (P = .038). SF-12 physical component significantly improved. Patients in this study expected to return to high levels of activity. Results showed significant improvement in pain relief and function. Our results supported that Hylan G-F 20 and corticosteroid are able to meet expectations of older patients with OA who desire to return to an active lifestyle. This study showed patient expectations do influence patient outcome scores and patient satisfaction.

Outcomes following healing response in older, active patients: a primary anterior cruciate ligament repair technique

The purpose of this study was to document outcomes following the healing response procedure for treatment of complete, proximal anterior cruciate ligament (ACL) tears in a mature, active population. Healing response is an all-arthroscopic procedure that preserves the native ACL and makes use of an arthroscopic awl with a 45-degree angle to make holes in the femoral attachment of the ACL and in the body of the ACL. Patients were included in this IRB-approved study if they were > or =40 years old, had a complete proximal ACL tear, and who had healing response within 6 weeks of initial injury. In this study 48 patients (35 females, 13 males) with an average age of 51 years (range: 41 to 68 years) underwent the healing response procedure. Of these four female patients (8.9%) required subsequent ACL reconstruction. Mean time to ACL reconstruction was 34.5 months (range, 14.3 to 61.2 months). Of the 44, 41 patients (93%) had minimum of 2-year follow-up at an average of 7.6 years (range, 2.2 to 13.4 years). Average preoperative Lysholm score was 54 (range, 10 to 82) and improved to an average of 90 postoperatively (p = 0.001). Median Tegner activity scale at follow-up was 5 (range, 2 to 9). Median patient satisfaction was 10 (range, 4 to 10). Higher patient satisfaction was correlated with increased Lysholm score at follow-up (rho = 0.39, p = 0.02). Tegner activity scale was associated with postoperative Lysholm score (rho = 0.35, p = 0.04). This study demonstrates the effectiveness of the healing response procedure to allow patients to return to high levels of recreational activity and to restore knee function to normal levels. In a select group of mature patients with acute proximal ACL tears, the healing response procedure is an effective treatment technique.

Stingray injury to the webspace of the foot

Stingrays are cartilaginous fish that are related to sharks. They are one of the largest groups of venomous marine animals. Stingrays account for 750 to 2000 injuries annually. They are generally passive, reclusive creatures that only sting in self-defense. Most injuries caused by these animals are nonfatal. A stingray possesses between 1 and 4 venomous stings, which are located along the caudal spine. If a stingray injury is sustained, parts of the spine may be left in the lacerations, which prolongs exposure to venom and increases the risk of subsequent wound infection. Stingray venom is unique in its enzymatic composition and results in distinct soft tissue injury patterns. Typically, a pattern of acute inflammation occurs, with a predominantly lymphoid cellular infiltrate followed by necrosis. The environment in which stingray injuries occur presents unique bacterial flora, and subsequent wound infections require careful antibiotic selection.This article describes a case of a healthy 31-year-old woman who sustained a stingray injury to the webspace of the foot while in Costa Rica. Initial basic first aid measures were applied. However, the wound subsequently became infected, and formal irrigation and debridement were performed. The initial wound cultures grew Staphylococcus viridans. Two months postoperatively, the incision was well healed, and the patient was pain free and returned to work.

Chondral resurfacing and high tibial osteotomy in the varus knee: survivorship analysis

BACKGROUND

Active patients with arthritic malalignment of the knee are difficult to manage. Arthroplasty, unicompartmental or total knee replacement, may not be appropriate in patients who desire to remain highly active. High tibial osteotomy has been recommended for the treatment of varus osteoarthritis to decrease pressure on the damaged medial compartment.

PURPOSE

To determine the length of time patients with varus gonarthrosis can avoid knee arthroplasty with chondral resurfacing (microfracture) and medial opening wedge high tibial osteotomy (HTO).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From 1995 to 2001, the senior authors performed a medial opening wedge HTO/microfracture in 106 knees (mean age, 52 years; range, 30-71 years). Survivorship was defined as not requiring knee arthroplasty after microfracture and HTO.

RESULTS

At 5 years, survivorship was 97%. At 7 years, survivorship was 91%. Twelve patients proceeded to arthroplasty at a mean of 81 months (range, 19-116 months). Follow-up was obtained for 90% of patients. At most recent follow-up, the mean Lysholm score was 71 (range, 5-100). At 3 years, the mean Lysholm score was 73, Tegner score was 2.8, and patient satisfaction was 7.9. At 5 years, the mean Lysholm score was 73, Tegner score was 3.8, and patient satisfaction was 7.5. At 9 years, the mean Lysholm score was 67, Tegner score was 3.1, and patient satisfaction was 7.5. Patients with medial meniscus injury at surgery were 9.2 times more likely to undergo arthroplasty than patients without (95% confidence interval [CI], 1.4-13.5; P = .015).

CONCLUSION

With 91% survivorship at 7 years, microfracture/HTO seems to contribute to a delay of knee replacement in active patients with varus gonarthrosis. Patients who proceeded to knee arthroplasty after combined HTO/microfracture had a mean delay of 81.3 months.