Meniscal and Articular Cartilage Predictors of Outcome After Revision ACL Reconstruction: A 6-Year Follow-up Cohort Study

BACKGROUND

Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction.

PURPOSE

To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patient's outcome at 6-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction.

RESULTS

An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P≤ .04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P = .04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation (P < .05). Articular cartilage pathology significantly impaired all KOOS subscale scores (P < .05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years.

CONCLUSION

Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery.

Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting

BACKGROUND

Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described.

PURPOSE

To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics.

RESULTS

A total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group.

CONCLUSION

Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Returning to Activity After Anterior Cruciate Ligament Revision Surgery: An Analysis of the Multicenter Anterior Cruciate Ligament Revision Study (MARS) Cohort at 2 Years Postoperative

BACKGROUND

Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes).

HYPOTHESES

Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level.

RESULTS

At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels.

CONCLUSION

Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Prospective 1-Year Outcomes Are Maintained at Short-Term Final Follow-Up After Superior Capsular Reconstruction Augmentation of Complete Rotator Cuff Repair

PURPOSE

To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) augmentation of complete, massive rotator cuff repair (RCR).

METHODS

A retrospective study of dermal allograft SCR-augmented RCRs performed by a single surgeon from June 2016 through December 2017 was performed with the following inclusion criteria: massive rotator cuff tear amenable to complete repair but with poor-quality native rotator cuff tissue. Radiographic follow-up was performed at 1 year, and clinical follow-up was performed at both 1 year and a minimum 2 years after surgery. Clinical follow-up included the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, Subjective Shoulder Value score, active forward elevation, and external rotation. Radiographs and magnetic resonance imaging (MRI) scans were assessed for muscle quality using the Goutallier classification, and graft and cuff integrity was assessed according to the Sugaya classification.

RESULTS

The inclusion criteria were met by 24 patients at 1 year and by 18 (75%) at a minimum of 2 years postoperatively. Patient-reported outcomes were improved compared with preoperative data and were maintained at minimum 2-year follow-up, with median American Shoulder and Elbow Surgeons scores of 42.5 (interquartile range [IQR], 30.8-58.7) versus 93.9 (IQR, 82.4-100) (P < .001); median Subjective Shoulder Value scores of 30 (IQR, 20-50) versus 90 (IQR, 86.2-97.2) (P < .001); and median visual analog scale pain scores of 5.5 (IQR, 1-9) versus 0 (IQR, 0-0.8) (P = .001). Evaluation of graft and tendon healing on postoperative MRI revealed poor interobserver agreement and showed 10 completely healed grafts (42%), 9 partially healed grafts (38%), and 5 completely disrupted grafts (21%), with 42% of supraspinatus tendons and 54% of infraspinatus tendons healed.

CONCLUSIONS

SCR with dermal allograft augmentation of complete RCR with poor-quality tissue shows very good clinical outcomes at minimum 2-year follow-up. Poor interobserver agreement regarding postoperative graft and rotator cuff integrity by MRI was found. The healing rate for the SCR grafts was 79%. The rates of healing of the native supraspinatus and infraspinatus tendons were 42% and 54%, respectively.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Current Reviews in Musculoskeletal Medicine: Current Controversies for Treatment of Meniscus Root Tears

PURPOSE OF REVIEW

The role of the meniscus in preserving the biomechanical function of the knee joint has been clearly defined. The hypothesis that meniscus root integrity is a prerequisite for meniscus function is supported by the development of progressive knee osteoarthritis (OA) following meniscus root tears (MRTs) treated either non-operatively or with meniscectomy. Consequently, there has been a resurgence of interest in the diagnosis and treatment of MRTs. This review examines the contemporary literature surrounding the natural history, clinical presentation, evaluation, preferred surgical repair technique and outcomes.

RECENT FINDINGS

Surgeons must have a high index of suspicion in order to diagnose a MRT because of the nonspecific clinical presentation and difficult visualization on imaging. Compared with medial MRTs that commonly occur in middle age/older patients, lateral meniscus root injuries tend to occur in younger males with lower BMIs, less cartilage degeneration, and with concomitant ligament injury. Subchondral insufficiency fractures of the knee have been found to be associated with both MRTs and following arthroscopic procedures. Meniscus root repair has demonstrated good outcomes, and acute injuries with intact cartilage should be repaired. Cartilage degeneration, BMI, and malalignment are important considerations when choosing surgical candidates. Meniscus centralization has emerged as a viable adjunct strategy aimed at correcting meniscus extrusion. Meniscus root repair results in a decreased rate of OA and arthroplasty and is economically advantageous when compared with nonoperative treatment and partial meniscectomy. The transtibial pull-through technique with the addition of centralization for the medial meniscus is associated with encouraging early results.

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort

BACKGROUND

Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.

HYPOTHESIS

In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.

RESULTS

A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).

CONCLUSION

BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Rate of infection following revision anterior cruciate ligament reconstruction and associated patient- and surgeon-dependent risk factors: Retrospective results from MOON and MARS data collected from 2002 to 2011

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR.

Meniscal Repair in the Setting of Revision Anterior Cruciate Ligament Reconstruction: Results From the MARS Cohort

BACKGROUND

Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented.

PURPOSE

To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment.

RESULTS

In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction.

CONCLUSION

Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both <10% and consistent with success rates of primary ACL reconstruction meniscal repair. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears.

Likelihood of Return to Duty Is Low After Meniscal Allograft Transplantation in an Active-duty Military Population

BACKGROUND

Meniscal allograft transplantation (MAT) is considered a viable surgical treatment option in the symptomatic, postmeniscectomy knee and as a concomitant procedure with ACL revision and articular cartilage repair. Although promising outcomes have recently been reported in active and athletic populations, MAT has not been well-studied in the high-demand military population.

QUESTIONS/PURPOSES

(1) What proportion of active-duty military patients who underwent MAT returned to full, unrestricted duty? (2) What demographic and surgical variables, if any, correlated with return to full, unrestricted duty?

METHODS

Between 2005 and 2015, three fellowship-trained sports surgeons (TMD, SJS, BDO) performed 110 MAT procedures in active-duty military patients, of which 95% (104 patients) were available for follow-up at a minimum 2 years (mean 2.8 ± SD 1.1 year). During the study period, indications for MAT generally included unicompartmental pain and swelling in a postmeniscectomized knee and as a concomitant procedure when a meniscal-deficient compartment was associated with either an ACL revision reconstruction or cartilage repair. Demographic and surgical variables were collected and analyzed. The primary endpoints were the decision for permanent profile activity restrictions and military duty termination by a medical board. The term "medical board" implies termination of military service because of medical reasons. We elected to set statistical significance at p < 0.001 to reduce the potential for spurious statistical findings in the setting of a relatively small sample size.

RESULTS

Forty-six percent (48 of 104) of eligible patients had permanent profile activity restrictions and 50% (52 of 104) eventually had their military duty terminated by a military board. Only 20% (21 of 104) had neither permanent profile activity restrictions nor medical-board termination and were subsequently able to return to full duty, and only 13% (13 of 104) continued unrestricted military service beyond 2 years after surgery. Age, gender, tobacco use, and BMI did not correlate with return to full duty. Combat arms soldiers were less likely to have permanent profile activity restrictions (odds ratio 4.76 [95% confidence interval 1.93 to 11.8]; p = 0.001) and were more likely to return to full duty than soldiers in support roles (OR 0.24 [95% CI 0.09 to 0.65]; p = 0.005), although these findings did not reach statistical significance. Officers were more likely to return to full duty than enlisted soldiers at more than 2 years after surgery (OR 17.44 [95% CI 4.56 to 66.65]; p < 0.001). No surgical variables correlated with return-to-duty endpoints.

CONCLUSIONS

Surgeons should be aware of the low likelihood of return to military duty at more than 2 years after MAT and counsel patients accordingly. Based on this study, MAT does not appear to be compatible with continued unrestricted military duty for most patients.

LEVEL OF EVIDENCE

IV, therapeutic study.

Is Intraoperative Fluoroscopy Necessary to Confirm Device Position for Femoral-Sided Cortical Suspensory Fixation during Anterior Cruciate Ligament Reconstruction?

Increased laxity within the graft construct system can lead to graft failure after anterior cruciate ligament (ACL) reconstruction. Suboptimal cortical device positioning could lead to increased laxity within the system, which could influence the mechanics and function of the graft reconstruction. This study evaluates the benefit of intraoperative fluoroscopy to confirm device position on the femur during ACL reconstruction using cortical suspensory fixation. One hundred consecutive patients who underwent soft tissue ACL reconstruction using a suspensory cortical device for femoral fixation were retrospectively evaluated. Patients were split into two groups: Group A utilized anteromedial portal visualization and had intraoperative fluoroscopic imaging performed at the time of ACL graft fixation to confirm femoral device placement on the lateral femoral metaphyseal cortex. Group B utilized anteromedial portal visualization alone. Both groups had radiographic X-rays performed at the first postoperative visit to evaluate device location and all images were independently evaluated by three fellowship trained orthopaedic surgeons. Device position was classified as optimal if there was complete apposition of the entire device against the femoral cortex and suboptimal if it was > 2 mm off the cortex. Fisher's exact test, analysis of variance, and 95% confidence intervals were calculated to compare the groups for statistical significance. The results showed 0/60 (0%) patients in group A had suboptimal device position at postoperative follow-up, while 4/40 (10%) patients in group B had suboptimal device position (p = 0.013). There were no graft failures in group A and one graft failure in group B. There was a significant difference in cortical device position in patients who had intraoperative fluoroscopic imaging versus patients who had no intraoperative imaging. The use of confirmatory intraoperative imaging may be beneficial to confirm appropriate device location when using a femoral cortical suspensory fixation technique for ACL reconstruction.

Predictors of Patient-Reported Outcomes at 2 Years After Revision Anterior Cruciate Ligament Reconstruction

BACKGROUND

Patient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients.

PURPOSE/HYPOTHESIS

The purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery.

RESULTS

A total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery.

CONCLUSION

PROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures

BACKGROUND

Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery.

HYPOTHESES

Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates.

RESULTS

Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS-Sports and Recreation (P = .04), and KOOS-Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates.

CONCLUSION

Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group

BACKGROUND

The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR.

RESULTS

Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03).

CONCLUSION

This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Risk Factors and Predictors of Significant Chondral Surface Change From Primary to Revision Anterior Cruciate Ligament Reconstruction: A MOON and MARS Cohort Study

BACKGROUND

Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage.

HYPOTHESIS

Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery.

RESULTS

A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had <33% of the medial meniscus excised at the time of the primary reconstruction had 4.8-times greater odds of progression of articular cartilage injury than those with an intact medial meniscus ( P = .02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age ( P ≤ .02). For the patellofemoral compartment, the use of allograft in primary reconstruction was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft ( P < .001). Each 1-unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage ( P = .046) in the patellofemoral compartment.

CONCLUSION

Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

Surgical Predictors of Clinical Outcomes After Revision Anterior Cruciate Ligament Reconstruction

BACKGROUND

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction.

HYPOTHESIS

Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction.

RESULTS

A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort.

CONCLUSION

There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

The Effect of Subcritical Bone Loss and Exposure on Recurrent Instability After Arthroscopic Bankart Repair in Intercollegiate American Football

BACKGROUND

There is no consensus on the optimal method of stabilization (arthroscopic or open) in collision athletes with anterior shoulder instability.

PURPOSE

To examine the effect of "subcritical" bone loss and football-specific exposure on the rate of recurrent shoulder instability after arthroscopic stabilization in an intercollegiate American football population.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Fifty intercollegiate football players underwent primary arthroscopic stabilization for anterior shoulder instability and returned to football for at least a single season. Preoperatively, 32 patients experienced recurrent subluxations, and 18 patients experienced a single or recurrent dislocation. Shoulders with glenoid bone loss >20%, an engaging Hill-Sachs lesion, an off-track lesion, and concomitant rotator cuff repair were excluded from the study. The primary outcome of interest was the ability to return to football without subsequent instability. Patients were followed for time to a subsequent instability event after return to play using days of exposure to football and total follow-up time after arthroscopic stabilization.

RESULTS

Fifty consecutive patients returned to American football for a mean 1.5 seasons (range, 1-3) after arthroscopic stabilization. Three of 50 (6%; 95% CI, 1.3%-16.5%) patients experienced recurrent instability. There were no subsequent instability events after a mean 3.2 years of military service. All shoulders with glenoid bone loss >13.5% (n = 3) that underwent arthroscopic stabilization experienced recurrent instability upon returning to sport, while none of the shoulders with <13.5% glenoid bone loss (n = 47) sustained a recurrent instability event during football ( X² = 15.80, P < .001). Shoulders with >13.5% glenoid bone loss had an incidence rate of 5.31 cases of recurrent instability per 1000 athlete-exposures of football. In 72,000 athlete-exposures to football with <13.5% glenoid bone loss, there was no recurrent instability. Significantly more anchors were used during the primary arthroscopic stabilization procedure in patients who experienced multiple preoperative instability events ( P = .005), and lesions spanned significantly more extensive portions along the circumference of the glenoid ( P = .001) compared with shoulders having a single preoperative instability event before surgical stabilization.

CONCLUSION

Arthroscopic stabilization of anterior shoulder instability in American football players with <13.5% glenoid bone loss provides reliable outcomes and low recurrence rates.

Subsequent Surgery After Revision Anterior Cruciate Ligament Reconstruction: Rates and Risk Factors From a Multicenter Cohort

BACKGROUND

While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR.

PURPOSE

To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation.

RESULTS

Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged <20 years had twice the odds of patients aged 20 to 29 years to undergo a reoperation. The use of an allograft at the time of revision ACLR (odds ratio [OR], 1.79; P = .007) was a significant predictor for reoperations at 2 years, while staged revision (bone grafting of tunnels before revision ACLR) (OR, 1.93; P = .052) did not reach significance. Patients with grade 4 cartilage damage seen during revision ACLR were 78% less likely to undergo subsequent operations within 2 years. Sex, body mass index, smoking history, Marx activity score, technique for femoral tunnel placement, and meniscal tearing or meniscal treatment at the time of revision ACLR showed no significant effect on the reoperation rate.

CONCLUSION

There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age <20 years and the use of allograft tissue at the time of revision ACLR.

Editorial Commentary: Not All Cortical Suspensory Fixation Devices Are Created Equal

Fixed-loop and adjustable-loop cortical suspensory fixation devices are both available as graft fixation options for surgeons. Fixed devices require facilities to manage various available sizes in the inventory, whereas adjustable devices are a true one-size-fits-all device requiring one inventory item for all cases. Adjustable-loop devices are also the only device that allows for postfixation tightening that may be advantageous for the surgeon who desires to tighten and retighten the graft construct once again before the case is completed.

Magnetic Resonance Imaging Characterization and Clinical Outcomes After NeoCart Surgical Therapy as a Primary Reparative Treatment for Knee Cartilage Injuries

BACKGROUND

Autologous cartilage tissue implants, including the NeoCart implant, are intended to repair focal articular cartilage lesions. Short-term results from United States Food and Drug Administration (FDA) phase I and phase II clinical trials indicated that the NeoCart implant was safe when surgically applied as a cell-based therapy and efficacious compared with microfracture.

HYPOTHESIS

Quantitative magnetic resonance imaging (MRI) analysis would reveal NeoCart tissue maturation through to 60-month follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with symptomatic full-thickness cartilage lesions of the distal femoral condyle were treated with NeoCart in FDA clinical trials. Safety and efficacy were evaluated prospectively by MRI and clinical patient-reported outcomes (PROs) through to 60-month follow-up. Qualitative MRI metrics were quantified according to modified MOCART (magnetic resonance observation of cartilage repair tissue) criteria, with an independent evaluation of repair tissue signal intensity. Subjective PROs and objective range of motion (ROM) were obtained at baseline and through to 60 months.

RESULTS

Twenty-nine patients treated with NeoCart were observed over a mean of 52.0 ± 15.5 months (median, 60 months). MOCART analyses indicated significant improvement ( P < .001) in cartilage quality from 3 to 24 months, with stabilization from 24 to 60 months. Signal intensity of the repair tissue evolved from hyperintense at early follow-up to isointense after 6 months and to hypointense after 24 months. The temporal progression toward hypointense T2 signals at later time points observed here indicated a further reorganization of the repair tissue toward a dense tissue that was less similar to the surrounding native tissue. However, 80% of patients showed evidence of subchondral bone changes on MRI at all time points; 4 patients (14%) showed no improvement of MRI criteria. Compared with baseline values, significant improvement ( P < .001) was seen in PROs (mean [±SD] baseline to mean [±SD] final follow-up), including the International Knee Documentation Committee score (47.9 ± 17.4 to 75.5 ± 22.1), physical component summary of the Short Form-36 (40.5 ± 7.2 to 51.4 ± 8.1), and all 5 domains of the Knee injury and Osteoarthritis Outcome Score (Pain: 64.8 ± 12.1 to 86.1 ± 17.3; Activities of Daily Living: 75.5 ± 14.8 to 91.6 ± 13.8; Quality of Life: 28.6 ± 15.5 to 69.4 ± 28.0; Symptoms: 65.8 ± 13.8 to 86.6 ± 13.4; Sports and Recreation: 41.4 ± 24.3 to 72.4 ± 28.8). Significant ( P < .0001) decreases from baseline scores for the visual analog scale for pain (34.6 ± 22.5) were seen by 6 months and sustained at final follow-up (14.3 ± 18.4). ROM significantly ( P < .0001) improved from baseline (131.5° ± 7.9°) to final follow-up (140.7° ± 6.3°).

CONCLUSION

Longitudinal MRI analysis demonstrated that NeoCart-based repair tissue is durable and evolves over time. For a majority of patients, this progression trended from an initial hyperintense signal to a hypointense signal at later follow-ups. Changes in radiographic measures over time corresponded with improvement in clinical measures, with maximum benefits experienced at 24-month follow-up. Similarly, clinical efficacy for the total cohort, determined by clinical outcome scores, reached a maximum at 24 months without decline to 60 months. Results from safety and exploratory clinical trials indicate that NeoCart is a safe and effective treatment for articular cartilage lesions through to 5-year follow-up. Registration: NCT00548119 ( ClinicalTrials.gov identifier).

Applying Military Strategy to Complex Knee Reconstruction: Tips for Planning and Executing Advanced Surgery

Complex knee restoration for injured soldiers follows a similar paradigm as for high-end civilian athletes. The military healthcare paradigm often involves the added logistics of transporting the service member to the correct military treatment facility at the correct time and ensuring the patient's work-up is complete before he or she arrives for the complex knee restoration. Such cases require significant rehabilitation and time away from family and work, so anything that reduces the morbidity of the surgical undertaking and the overall "morbidity footprint" of time away and that helps the patient return to normal function are value-added and worthy of our attention and diligence in developing an efficient system for managing complex cases. The globally integrated military healthcare system that is in place has matured over the past decades to allow for the significant majority of the necessary preoperative work-up to be performed at a soldier's current duty station, wherever in the world that may be, under the guidance of local healthcare providers with specific inputs from the knee restoration surgeon who eventually receives the patient for the planned surgical intervention. Efficient preoperative workup and cutting edge knee restoration procedures that are often combined to limit overall morbidity along with managed physical therapy are the keys to success.

Tibial Fixation Properties of a Continuous-Loop ACL Hamstring Graft Construct with Suspensory Fixation in Porcine Bone

The aim of this article is to compare tibial fixation strength of suspensory fixation for a quadrupled semitendinosus continuous loop all-inside anterior cruciate ligament (ACL) construct versus a doubled semitendinosus and gracilis graft fixated with an interference screw. Biomechanical testing was conducted using human hamstring allografts and porcine tibias. Constructs were cycled from 50 to 250 N for 500 cycles followed by a pull to failure. The average load to failure of tibial suspensory fixation of the all-inside continuous loop construct (1,012 N) was statistically different compared with the tibial interference screw group (612 N) (p < 0.001). The cyclic displacement of the continuous loop construct (2.5 mm) was not statistically different from the interference screw construct (1.9 mm). For both the groups, approximately half the overall cyclic displacement occurred with the first cycle. Tibial side suspensory fixation of a novel all-inside continuous loop hamstring graft provided suitable strength for tibial fixation for ACL reconstruction. The continuous loop construct had a significantly higher load to failure compared with the use of an interference screw, and cyclic loading was comparable. Use of hamstring soft tissue grafts is very common for ACL reconstruction. An all-inside ACL reconstruction is based on a continuous loop construct utilizing a single semitendinosus graft that is quadrupled employing suspensory fixation on both the femoral and tibial side. Suspensory fixation on the femoral side been previously reported, but this is the first report of strength of this method of suspensory fixation on the tibia.

Multirater agreement of the causes of anterior cruciate ligament reconstruction failure: a radiographic and video analysis of the MARS cohort

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement.

HYPOTHESIS

Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon's training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK).

RESULTS

The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17).

CONCLUSION

This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction.

Arthroscopic Versus Open Stabilization for Anterior Shoulder Subluxations

Background:

Most of the literature on shoulder instability focuses on patients experiencing anterior glenohumeral dislocation, with little known about the treatment of anterior subluxation events.

Purpose:

To determine the outcomes of surgical stabilization of patients with anterior glenohumeral subluxations and to compare open and arthroscopic approaches.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

We prospectively enrolled patients with anterior glenohumeral subluxations undergoing surgical stabilization. Patients were offered randomization between open and arthroscopic stabilization. Inclusion criteria included patients with anterior glenohumeral subluxations undergoing Bankart repair, while exclusions included the presence of glenoid or humeral bone loss, multidirectional instability, capsular tear/humeral avulsion of the glenohumeral ligament lesion, and rotator cuff tear requiring repair. Patients were randomized to an open Bankart repair through a subscapularis takedown or an arthroscopic Bankart repair, both using the same bioabsorbable suture anchors, and they were followed for a minimum of 2 years. Outcomes were evaluated with the Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), Rowe, and Tegner activity scores.

Results:

A total of 26 patients were enrolled, with 7 being lost to follow-up. Complete follow-up data were available on 19 subjects (74%): 10 in the open group and 9 in the arthroscopic group. There were no significant differences noted between the randomized groups, with a 2-year WOSI score of 320 in the open subjects and 330 in the arthroscopic subjects, and similar findings in the other scoring scales. There were no cases of dislocation following surgery. There were 3 patients with recurrent instability (subluxations only) in each group at a mean of 17 months, for an overall recurrent subluxation rate of 31%. These subjects with recurrence had lower outcome scores (WOSI, 532; SANE, 88.4). The outcomes of the 9 subjects with ≤3 subluxation events were superior to those of the 10 subjects with >3 events prior to stabilization. The patients with ≤3 events had a WOSI score of 143, compared with 470 (P = .042), and an ASES mean score of 98.8, compared with 87.1 (P = .048). Four of the 6 patients with recurrent subluxations had sustained >3 subluxations prior to stabilization.

Conclusion:

Overall, patients with Bankart lesions resulting from an anterior glenohumeral subluxation event had excellent outcomes with surgical stabilization. The overall recurrence in the 19 subjects with at least 2-year follow-up was 6 cases (31%), with no instances of dislocation in this young, active cohort. There was no significant benefit to open or arthroscopic stabilization, and we did find that stabilization of subluxation patients with ≤3 events resulted in superior outcomes compared with chronic recurrent subluxation patients with >3 events. We recommend early surgical stabilization of young athletes with Bankart lesions that result from anterior subluxation events.

Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort

BACKGROUND

Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts.

HYPOTHESES

Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery.

RESULTS

A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up (P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment (P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores (P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC (P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale (P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale (P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores (P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft (P = .047; 95% CI, 1.01-7.69).

CONCLUSION

Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone-patellar tendon-bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

History of shoulder instability and subsequent injury during four years of follow-up: a survival analysis

BACKGROUND

Little is known about the risk factors for glenohumeral joint instability. We hypothesized that a prior history of instability would be a significant risk factor for subsequent injury.

METHODS

We conducted a prospective cohort study over a four-year period within a high-risk group of young athletes to address the research hypothesis. Subjects were freshmen entering the U.S. Military Academy in June of 2006. Part of the baseline assessment included documenting a prior history of glenohumeral instability on entry into the study. All subjects were followed for subsequent glenohumeral joint instability events until graduation in May of 2010. The primary outcome of interest in this study was time to glenohumeral instability event during the follow-up period. We examined injury outcomes, looking for any instability, anterior instability, and posterior instability events. Cox proportional-hazards regression models were used to analyze the data.

RESULTS

Among the 714 subjects, eight shoulders were excluded from the analyses due to prior surgical stabilization, leaving 1420 shoulders, of which 126 had a self-reported prior history of instability. There were forty-six (thirty-nine anterior and seven posterior) acute instability events documented in the cohort during the follow-up period. Subjects with a prior history of instability were over five times (p < 0.001) more likely to sustain an acute (anterior or posterior) instability event during the follow-up period. Subjects with a history of instability were also 5.6 times (p < 0.001) more likely to experience a subsequent anterior instability event and 4.6 times (p = 0.068) more likely to experience a posterior instability event during follow-up. Similar results were observed in multivariable models after controlling for the influence of demographic and baseline physical examination findings.

CONCLUSIONS

Despite meeting the rigorous physical induction standards for military service, subjects with a prior history of glenohumeral joint instability were approximately five times more likely to experience a subsequent instability event, regardless of direction, within this high-risk athletic population.

Evaluation of blunt abdominal trauma

Sports medicine physicians should be aware of the many injuries that are associated with blunt abdominal trauma. From benign diaphragmatic spasms and rectus abdominis hematomas to the more concerning liver, splenic, renal, and pancreatic injuries, the sideline physician needs to be able to triage athletic-related injuries. Furthermore, many athletes will ask their physician about return-to-play recommendations and continuing care following blunt abdominal trauma. The sports medicine physician should have a working knowledge of the pathophysiology of various abdominal injuries to best advise and treat his or her team members.

NeoCart, an autologous cartilage tissue implant, compared with microfracture for treatment of distal femoral cartilage lesions: an FDA phase-II prospective, randomized clinical trial after two years

BACKGROUND

Despite introduction of autologous chondrocyte therapy for repair of hyaline articular cartilage injury in 1994, microfracture remains a primary standard of care. NeoCart, an autologous cartilage tissue implant, was compared with microfracture in a multisite prospective, randomized trial of a tissue-engineered bioimplant for treating articular cartilage injuries in the knee.

METHODS

Thirty patients were randomized at a ratio of two to one (two were treated with an autologous cartilage tissue implant [NeoCart] for each patient treated with microfracture) at the time of arthroscopic confirmation of an International Cartilage Repair Society (ICRS) grade-III lesion(s). Microfracture or cartilage biopsy was performed. NeoCart, produced by seeding a type-I collagen matrix scaffold with autogenous chondrocytes and bioreactor treatment, was implanted six weeks following arthroscopic cartilage biopsy. Standard evaluations were performed with validated clinical outcomes measures.

RESULTS

Three, six, twelve, and twenty-four-month data are reported. The mean duration of follow-up (and standard deviation) was 26 ± 2 months. There were twenty-one patients in the NeoCart group and nine in the microfracture group. The mean age (40 ± 9 years), body mass index (BMI) (28 ± 4 kg/m2), duration between the first symptoms and treatment (3 ± 5 years), and lesion size (287 ± 138 mm2 in the NeoCart group and 252 ± 135 mm2 in the microfracture group) were similar between the groups. Adverse event rates per procedure did not differ between the treatment arms. The scores on the Short Form-36 (SF-36), Knee Injury and Osteoarthritis Outcome Score (KOOS) activities of daily living (ADL) scale, and International Knee Documentation Committee (IKDC) form improved from baseline (p < 0.05) to two years postoperatively in both treatment groups. In the NeoCart group, improvement, compared with baseline, was significant (p < 0.05) for all measures at six, twelve, and twenty-four months. Improvement in the NeoCart group was significantly greater (p < 0.05) than that in the microfracture group for the KOOS pain score at six, twelve, and twenty-four months; the KOOS symptom score at six months; the IKDC, KOOS sports, and visual analog scale (VAS) pain scores at twelve and twenty-four months; and the KOOS quality of life (QOL) score at twenty-four months. Analysis of covariance (ANCOVA) at one year indicated that the change in the KOOS pain (p = 0.016) and IKDC (p = 0.028) scores from pretreatment levels favored the NeoCart group. Significantly more NeoCart-treated patients (p = 0.0125) had responded to therapy (were therapeutic responders) at six months (43% versus 25% in the microfracture group) and twelve months (76% versus 22% in the microfracture group). This trend continued, as the proportion of NeoCart-treated patients (fifteen of nineteen) who were therapeutic responders at twenty-four months was greater than the proportion of microfracture-treated participants (four of nine) who were therapeutic responders at that time.

CONCLUSIONS

This randomized study suggests that the safety of autologous cartilage tissue implantation, with use of the NeoCart technique, is similar to that of microfracture surgery and is associated with greater clinical efficacy at two years after treatment.

Association of generalized joint hypermobility with a history of glenohumeral joint instability

CONTEXT

Little is known about the relationship among sex, generalized joint hypermobility, and glenohumeral joint instability.

OBJECTIVE

To examine the relationship among sex, generalized joint hypermobility scores, and a history of glenohumeral joint instability within a young, physically active cohort and to describe the incidence of generalized joint hypermobility within this population.

DESIGN

Cross-sectional cohort study.

SETTING

United States Military Academy at West Point, New York.

PATIENTS OR OTHER PARTICIPANTS

Of the 1311 members of the entering freshman class of 2010, 1050 (80%) agreed to participate.

MAIN OUTCOME MEASURE(S)

Generalized joint hypermobility was assessed using the Beighton Scale. A history of glenohumeral joint instability was identified via a baseline questionnaire.

RESULTS

Most participants (78%) had no signs of generalized joint hypermobility. Only 11 volunteers (1.5%) had Beighton Scale scores of 4 or greater. Logistic regression analysis revealed a relationship between generalized joint hypermobility and a history of glenohumeral joint instability (P = .023). When sex and race were controlled, those with a total Beighton Scale score of >or=2 were nearly 2.5 times as likely (odds ratio = 2.48, 95% confidence interval = 1.19, 5.20, P = .016) to have reported a history of glenohumeral joint instability. A relationship was observed between sex and nearly all individual Beighton Scale items. Although women had higher total Beighton Scale scores than men, sex (P = .658) and race (P = .410) were not related to a history of glenohumeral joint instability when other variables in the model were controlled.

CONCLUSIONS

In these participants, generalized joint hypermobility and a history of glenohumeral joint instability were associated.

Incidence of ankle sprains among active-duty members of the United States Armed Services from 1998 through 2006

CONTEXT

Ankle sprains have been reported as one of the most common injuries sustained by members of the US Armed Services. However, little is known about the incidence rate and injury patterns associated with ankle sprains in this population.

OBJECTIVE

To examine the incidence of ankle sprains among active-duty members of the US Armed Services from 1998 through 2006. A secondary objective was to describe the sex, age, and service-specific injury patterns in this young, physically active population.

DESIGN

Cohort study.

PATIENTS OR OTHER PARTICIPANTS

All active-duty service members from the day they enter military service until the day they leave military service and US Army Reserve and National Guard service members during periods of active duty and mobilization.

MAIN OUTCOME MEASURE(S)

Injury data were extracted from the Defense Medical Epidemiological Database from 1998 through 2006. All data for ankle sprains, coded according to the International Classification of Diseases (9th revision), were included. Cases were limited to those injuries reported as first occurrences. Incidence rates (IRs) were calculated per 1000 person-years by sex, age, and service. Incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) were used to assess the strength of association between the incidence of ankle sprain and the independent variables of sex, age, and service.

RESULTS

From 1998 through 2006, 423 581 service members sustained ankle sprains and 12 118 863 person-years at risk to injury were documented in this population. The incidence rate was 34.95 (95% CI = 34.85, 35.06) per 1000 person-years at risk. Females were 21% more likely (IRR = 1.21, 95% CI = 1.21, 1.23) to sustain an ankle sprain than males. Sex-specific IR varied by age and service. Differences in the rate of ankle sprains were also noted by age and service.

CONCLUSIONS

The incidence of ankle sprains among US service members was 5 times greater than that previously reported in civilian population studies. Sex, age, and branch of military service are important factors related to the incidence of ankle sprains in this population.

Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort

BACKGROUND

Revision anterior cruciate ligament (ACL) reconstruction has worse outcomes than primary reconstructions. Predictors for these worse outcomes are not known. The Multicenter ACL Revision Study (MARS) Group was developed to perform a multisurgeon, multicenter prospective longitudinal study to obtain sufficient subjects to allow multivariable analysis to determine predictors of clinical outcome.

PURPOSE

To describe the formation of MARS and provide descriptive analysis of patient demographics and clinical features for the initial 460 enrolled patients to date in this prospective cohort.

STUDY DESIGN

Cross-sectional study; Level of evidence, 2.

METHODS

After training and institutional review board approval, surgeons began enrolling patients undergoing revision ACL reconstruction, recording patient demographics, previous ACL reconstruction methods, intra-articular injuries, and current revision techniques. Enrolled subjects completed a questionnaire consisting of validated patient-based outcome measures.

RESULTS

As of April 1, 2009, 87 surgeons have enrolled a total of 460 patients (57% men; median age, 26 years). For 89%, the reconstruction was the first revision. Mode of failure as deemed by the revising surgeon was traumatic (32%), technical (24%), biologic (7%), combination (37%), infection (<1%), and no response (<1%). Previous graft present at the time of injury was 70% autograft, 27% allograft, 2% combination, and 1% unknown. Sixty-two percent were more than 2 years removed from their last reconstruction. Graft choice for revision ACL reconstruction was 45% autograft, 54% allograft, and more than 1% both allograft and autograft. Meniscus and/or chondral damage was found in 90% of patients.

CONCLUSION

The MARS Group has been able to quickly accumulate the largest revision ACL reconstruction cohort reported to date. Traumatic reinjury is deemed by surgeons to be the most common single mode of failure, but a combination of factors represents the most common mode of failure. Allograft graft choice is more common in the revision setting than autograft. Concomitant knee injury is extremely common in this population.

Pathoanatomy of first-time, traumatic, anterior glenohumeral subluxation events

BACKGROUND

Relative to dislocations, glenohumeral subluxation events have received little attention in the literature, despite a high incidence in young athletes. The pathoanatomy of first-time, traumatic, anterior subluxation events has not been defined, to our knowledge.

METHODS

As part of a prospective evaluation of all cases of shoulder instability sustained during one academic year in a closed cohort of military academy cadets, a total of thirty-eight first-time, traumatic, anterior glenohumeral subluxation events were documented. Clinical subluxation events were defined as incomplete instability events that did not require a manual reduction maneuver. Twenty-seven of those events were evaluated with plain radiographs and magnetic resonance imaging within two weeks after the injury and constitute the cohort studied. Magnetic resonance imaging studies were independently evaluated by a musculoskeletal radiologist blinded to the clinical history. Arthroscopic findings were available for the fourteen patients who underwent arthroscopic surgery.

RESULTS

Of the twenty-seven patients who sustained a first-time, traumatic, anterior subluxation, twenty-two were male and five were female, and their mean age was twenty years. Plain radiographs revealed three osseous Bankart lesions and two Hill-Sachs lesions. Magnetic resonance imaging revealed a Bankart lesion in twenty-six of the twenty-seven patients and a Hill-Sachs lesion in twenty-five of the twenty-seven patients. Of the fourteen patients who underwent surgery, thirteen had a Bankart lesion noted during the procedure. Of the thirteen patients who chose nonoperative management, four experienced recurrent instability. Two of the thirteen patients left the academy for nonmedical reasons and were lost to follow-up. The remaining seven patients continued on active-duty service and had not sought care for a recurrent instability event at the time of writing.

CONCLUSIONS

First-time, traumatic, anterior subluxation events result in a high rate of labral and Hill-Sachs lesions. These findings suggest that clinical subluxation events encompass a broad spectrum of incomplete events, including complete separations of the articular surfaces with spontaneous reduction. A high index of suspicion for this injury in young athletes is warranted, and magnetic resonance imaging may reveal a high rate of pathologic changes, suggesting that a complete, transient luxation of the glenohumeral joint has occurred.

Arthroscopic stabilization of acromioclavicular joint dislocation using the AC graftrope system

BACKGROUND

Separation of the acromioclavicular joint (ACJ) is a common orthopaedic injury among athletes involved in contact sports and victims of motor vehicle accidents, particularly motorcycle crashes. High-grade ACJ disruptions (type IV-VI) are managed surgically through a variety of procedures. These range from simple plate and screw fixation to more complex procedures involving ligament repair, transfer, and reconstruction.

METHODS

This paper describes a new technique utilizing a direct subacromial arthroscopic approach to performing a reconstruction of the ruptured coracoclavicular ligaments. The appropriately over-engineered fixation device is made up of a subcoracoid button secured via nonabsorbable sutures to a special clavicular washer and augmented by a centrally placed soft tissue graft.

RESULTS

To date, the senior author has performed 10 cases on both acute and chronic high-grade ACJ separations. All patients greater than 6 months out from surgery have returned to their normal pre-injury level of activity. No complications (infection, hardware, or graft failure) have been documented, and all have maintained the interoperative reduction of the acromioclavicular joint and coracoclavicular space.

CONCLUSION

The arthroscopic reconstruction of the AC separation is a low-morbidity, safe, and reproducible operation that provides adequate fixation and stability combined with the use of a soft tissue graft to promote sound biologic healing.

Incidence of ankle sprains among active-duty members of the United States Armed Services from 1998 through 2006

CONTEXT

Ankle sprains have been reported as one of the most common injuries sustained by members of the US Armed Services. However, little is known about the incidence rate and injury patterns associated with ankle sprains in this population.

OBJECTIVE

To examine the incidence of ankle sprains among active-duty members of the US Armed Services from 1998 through 2006. A secondary objective was to describe the sex, age, and service-specific injury patterns in this young, physically active population.

DESIGN

Cohort study.

PATIENTS OR OTHER PARTICIPANTS

All active-duty service members from the day they enter military service until the day they leave military service and US Army Reserve and National Guard service members during periods of active duty and mobilization.

MAIN OUTCOME MEASURE(S)

Injury data were extracted from the Defense Medical Epidemiological Database from 1998 through 2006. All data for ankle sprains, coded according to the International Classification of Diseases (9th revision), were included. Cases were limited to those injuries reported as first occurrences. Incidence rates (IRs) were calculated per 1000 person-years by sex, age, and service. Incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) were used to assess the strength of association between the incidence of ankle sprain and the independent variables of sex, age, and service.

RESULTS

From 1998 through 2006, 423 581 service members sustained ankle sprains and 12 118 863 person-years at risk to injury were documented in this population. The incidence rate was 34.95 (95% CI = 34.85, 35.06) per 1000 person-years at risk. Females were 21% more likely (IRR = 1.21, 95% CI = 1.21, 1.23) to sustain an ankle sprain than males. Sex-specific IR varied by age and service. Differences in the rate of ankle sprains were also noted by age and service.

CONCLUSIONS

The incidence of ankle sprains among US service members was 5 times greater than that previously reported in civilian population studies. Sex, age, and branch of military service are important factors related to the incidence of ankle sprains in this population.

The relationship between posterior tibial slope and anterior cruciate ligament injuries

BACKGROUND

Two previous studies have examined the association between an increased posterior tibial slope and anterior cruciate ligament (ACL) injuries as measured on plain radiographs. The study results were contradictory, with 1 reporting a statistical difference and the other showing no association.

PURPOSE

To determine if there is a difference in posterior tibial slope angle between patients with a history of noncontact ACL injury and a control group with no history of ACL injury. A secondary objective was to examine differences in tibial slope angle between male and female subjects within each group.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

We identified all noncontact ACL injuries that were treated operatively at the United States Military Academy, West Point, New York, from 2004 to 2007. We digitally measured the posterior tibial slope from plain film radiographs of 140 noncontact ACL injuries, stratified them by sex, and compared them with a control cohort of 179 patients and radiographs.

RESULTS

Subjects in the noncontact ACL group had significantly greater slope angles (9.39 degrees +/- 2.58 degrees) than did control subjects (8.50 degrees +/- 2.67 degrees) (P = .003). The trend toward greater tibial slope angles in the noncontact ACL group was also observed when each sex was examined independently; however, the difference was only statistically significant for the female subjects between the injury and control groups (9.8 degrees +/- 2.6 degrees vs 8.20 degrees +/- 2.4 degrees) (P = .002).

CONCLUSION

Despite the identification of an increased posterior tibial slope as a possible risk factor for women, more research that combines the multifactorial nature of an ACL injury must be performed.

Patellar tendon versus hamstring tendon autografts for anterior cruciate ligament reconstruction: a randomized controlled trial using similar femoral and tibial fixation methods

BACKGROUND

Controversy remains over the most appropriate graft for anterior cruciate ligament reconstruction.

HYPOTHESIS

There is no significant difference in outcomes after 4-strand hamstring and patellar tendon autograft anterior cruciate ligament reconstructions using similar fixation techniques.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Between August 2000 and May 2003, 64 Keller Army Hospital patients with complete anterior cruciate ligament tears were randomized to hamstring (n = 32) or patellar tendon (n = 32) autograft anterior cruciate ligament reconstruction. Operative graft fixation and rehabilitative techniques were the same for both groups. Follow-up assessments included the Single Assessment Numeric Evaluation score, Lysholm score, International Knee Documentation Committee score, and Knee Injury and Osteoarthritis Outcome Score. Postoperative radiographs were analyzed for tunnel location and orientation.

RESULTS

Eleven women and 53 men were randomized. Eighty-three percent of the patients (53 of 64) had follow-up of greater than 2 years, or to the point of graft rupture or removal (average follow-up, 36 months). Four hamstring grafts (12.5%) and three patellar tendon grafts (9.4%) (P = .71) ruptured. One deep infection in a hamstring graft patient necessitated graft removal. Forty-five of the 56 patients with intact grafts had greater than 2-year follow-up. Patients with patellar tendon grafts had greater Tegner activity scores (P = .04). Single Assessment Numeric Evaluation scores were 88.5 (95% confidence interval: 83.1, 93.8) and 90.1 (95% confidence interval: 85.2, 96.1) for the hamstring and patellar tendon groups, respectively (P = .53). Lysholm scores were 90.3 (95% confidence interval: 84.4, 96.1) and 90.4 (95% confidence interval: 84.5, 96.3) for the hamstring and patellar tendon groups, respectively (P = .97). There were no significant differences in knee laxity, kneeling pain, isokinetic peak torque, International Knee Documentation Committee score, or Knee Injury and Osteoarthritis Outcome Scores. Postoperative graft rupture correlated with more horizontal tibial tunnel orientation.

CONCLUSION

Hamstring and patellar tendon autografts provide similar objective, subjective, and functional outcomes when assessed at least 2 years after anterior cruciate ligament reconstruction.

Open scapula resection in beach-chair position for treatment of snapping scapula

We describe a technique of resecting the superomedial border of the scapula for treatment of "snapping scapula." We have performed 5 consecutive open resections with the patient in the beach-chair position, and results have been good. This technique may be of particular benefit in patients who undergo concomitant glenohumeral arthroscopy.

Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes

BACKGROUND

Little is known of the long-term results of acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations.

HYPOTHESIS

Acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations will provide good results at long-term follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors evaluated a cohort of young patients who sustained first-time anterior glenohumeral dislocations and were acutely treated with arthroscopic Bankart repair using bioabsorbable tacks. Subjective outcome measures were obtained at a mean follow-up of 11.7 years (range, 9.1-13.9 years).

RESULTS

Thirty-nine patients (40 shoulders) were available of the original cohort of 49 shoulders (82%). Two of the 9 who were lost to follow-up had revision surgery before being lost and are carried forward in the calculations of recurrent instability and revision surgery but are not included in the calculation of the functional scores. The mean Single Assessment Numeric Evaluation was 91.7, the mean Western Ontario Shoulder Instability score was 371.7, the mean subjective Rowe score was 25.3, the mean Simple Shoulder Test was 11.1, the mean American Shoulder and Elbow Society score was 90.9, the mean Short Form-36 Physical Component score was 94.4, and the mean Tegner score was 6.5. Six patients sustained recurrent dislocations for a redislocation rate of 14.3%. Nine patients (21.4%) reported experiencing subluxation events. Six patients (14.3%) underwent revision stabilization surgery.

CONCLUSION

At long-term follow-up, acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations resulted in excellent subjective function and return to athletics in young, active patients with an acceptable rate of recurrence and reoperation.

Neuromuscular excitability changes in the vastus medialis following anterior cruciate ligament reconstruction

PURPOSE

Quadriceps weakness following anterior cruciate ligament reconstruction (ACLR) is prevalent despite intensive rehabilitation. Diminished neuromuscular excitability is one potential factor that may limit muscular recovery following injury or surgery. The H-reflex provides a measure of alpha motorneuron (neuromuscular) excitability in the sensory-motor pathway of the respective muscle and nerve. To date the vastus medialis (VM) and soleus (SOL) H-reflexes have been examined primarily in control subjects with induced knee joint effusion. This prospective, randomized clinical trial evaluated the affect of ACLR, utilizing hamsting (HS) or bone-patellar tendon-bone (BTB) autograft, on VM and SOL H-reflex latency and amplitude in twenty subjects.

METHODS

Preoperatively bilateral VM and SOL H-reflex tests were conducted. VM and SOL H-reflexes were subsequently conducted on the involved lower extremity at 1 and 3 months post surgery. At each test session subjects completed visual analog scales and knee girth was measured.

RESULTS

The VM H-reflex amplitude increased in the HS group at 3 months compared to 1-month post surgery (p<.05). Significant changes over time were also noted in the visual analog pain and functional scales and the mid-patella girth.

CONCLUSIONS

The increased VM H-reflex amplitude at 3 months following HS autograft ACLR demonstrates an increase in VM neuromuscular excitability. Increased VM neuromuscular excitability was not evident in patients following BTB reconstruction. The increased neuromuscular excitability, observed only in the HS group, warrants consideration when selecting graft type for patients with extensive preoperative quadriceps dysfunction.

A comparison of bioabsorbable and metallic suture anchors in a dynamically loaded, intra-articular caprine model

Little is known about the in vivo behavior of bioabsorbable suture anchors. A goat model was used to biomechanically and histologically test bioabsorbable and metallic suture anchors in an intra-articular environment at 0, 6, and 12 weeks. Significantly greater force was required to break the bioabsorbable construct than the metallic construct at 0 and 6 weeks. Failure of the metallic anchor constructs occurred at the eyelet. Histological analysis of both bone-anchor interfaces demonstrated equally good osteointegration without evidence of osteolysis. The bioabsorbable suture anchor tested is safe for use in clinical practice without concerns for the strength of the construct or bony reaction to the material.

Comparison of the split stacked versus the split achilles allograft for dual femoral tunnel posterior cruciate ligament reconstruction

BACKGROUND

Cadaveric testing has shown that double-bundle reconstruction better replicates the native anatomy of the posterior cruciate ligament. With the current trend toward allograft Achilles posterior cruciate ligament reconstructions, the need to determine a graft configuration with the highest tensile and pull-out strength has become paramount.

HYPOTHESIS

The split stacked Achilles allograft construct provides greater graft material to traverse the notch and provides increased load to failure at the tibial point of fixation compared with a standard monoblock Achilles allograft construct.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight matched pairs of Achilles allograft tendons were secured to 8 matched pairs of fresh-frozen human cadaveric tibiae. Group 1 consisted of single-block grafts (n = 8), and group 2 included the split stacked grafts (n = 8). The cross-sectional area of each graft's 2 collagenous bundles was measured with a micrometer. The graft constructs were pulled to ultimate failure at a rate of 50 mm/min on a materials testing machine.

RESULTS

The mean cross-sectional area of the group 2 split stacked grafts (76.6 +/- 3.1 mm(2)) was significantly greater than that of the group 1 single-block grafts (48.2 +/- 3.0 mm(2); P =.00006). The maximum load to failure of the group 2 construct was significantly greater (1383 +/- 102 N) than that of the group 1 single-block configuration (1020 +/- 136 N; P =.01).

CONCLUSION

These results indicate that the novel split stacked configuration of an Achilles tendon allograft provides a greater cross-sectional area of graft material across the joint as well as a significant increase in the overall load to failure strength compared with a standard monoblock Achilles allograft construct.

CLINICAL RELEVANCE

The split stacked Achilles graft is an efficient method for using the entire allograft. With maintenance and use of all collagen fibers, the split stacked Achilles construct provides essentially 2 grafts in 1 while only using a single tibial tunnel.

Arthroscopic treatment of unresolved Osgood-Schlatter lesions

Osgood-Schlatter disease is a self-limiting condition in most cases. Those with unresolved pain after conservative treatment can obtain relief with surgical debridement of the mobile ossicles and tibial tuberosity. We present an arthroscopic technique for debridement. The location of the inferomedial and lateral parapatella tendon portals can be raised slightly to allow improved instrumentation and visualization in the anterior interval. An anterior interval release is performed with the mechanical shaver and radiofrequency ablation device. Care is taken to visualize the meniscal anterior horns and intermeniscal ligament. By staying anterior to these structures, debridement can be performed aggressively onto the anterior tibial slope. The bony lesions are shelled out from their soft-tissue attachments. Small and loose fragments are removed with a pituitary ronguer, whereas larger lesions are removed with an arthroscopic burr. Working deep along the anterior tibial slope is facilitated by extending the knee and taking tension off the patellar tendon. Postoperatively, patients are allowed full weight bearing and unrestricted range of motion. The advantages of this technique include the avoidance of the patellar tendon longitudinal split required for open procedures and the ability to address concomitant intra-articular pathology.