Four-Year Outcomes Following Arthroscopic Microfracture of the Hip in Patients with Advanced Chondral Lesions.

PURPOSE: This report examines 4-year patient reported outcomes and procedural survivorship in patients who underwent microfracture during hip arthroscopy compared to a matched group of non-microfracture patients as well as the risk factors for procedural failure following microfracture of articular lesions in the hip. METHODS: Data for 38 consecutive patients undergoing arthroscopic microfracture was retrospectively analyzed. Propensity score matching identified a matched group of hip arthroscopy patients who had Outerbridge grade 3 or grade 4 chondral lesions but did not undergo microfracture. Preoperative modified Harris Hip Scores (mHHS) and NonArthritic Hip Scores (NAHS) were compared to those at 2- and 4-year follow-up. Postoperative rates of ipsilateral revision arthroscopic surgery or hip arthroplasty were assessed. RESULTS: Thirty-three (86.8%) of the 38 microfracture patients were available for 4-year follow-up. Forty-six patients were matched with the microfracture group. Scores including mHHS and NAHS increased postoperatively for both groups (p < 0.05), though there were no significant differences between groups (p > 0.05). Overall reoperations rates were 24.2% and 21.7% (p = 0.873) for the microfracture and non-microfracture groups, respectively. Hip arthroplasty rates were higher among microfracture patients (18.2% vs. 2.2%, p = 0.038), wherein Tonnis grade ≥ 2, cartilage lesions ≥ 400 mm2 , and femoral-sided lesions were associated with failure. CONCLUSIONS: Patients who underwent microfracture treatment of chondral lesions fared no better than a matched group of patients who did not receive microfracture treatment. Risk of reoperation is high for both groups and microfracture patients are more likely to require conversion to total hip arthroplasty or hip resurfacing.

Young age, female gender, Caucasian race, and workers' compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction.

PURPOSE: Given the increasing incidence of arthroscopic anterior cruciate ligament reconstruction (ACLR), mid- to long-term rates of reoperations were investigated on the ipsilateral knee following ACLR. METHODS: New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2003 to 2012 to identify patients with a primary ICD-9 diagnosis for ACL tear and concomitant CPT code for ACLR. Patients were longitudinally followed for at least 2 years to determine incidence and nature of subsequent ipsilateral knee procedures. RESULTS: The inclusion criteria were met by 45,231 patients who had undergone ACLR between 2003 and 2012. Mean age was found to be 29.7 years (SD 11.6). Subsequent ipsilateral outpatient knee surgery after a mean of 25.7 ± 24.5 months was performed in 10.7% of patients. Revision ACLR was performed for nearly one-third of reoperations. Meniscal pathology was addressed in 58% of subsequent procedures. Age 19 or younger, female gender, worker's compensation (WC) insurance, and Caucasian race were identified as independent risk factors for any ipsilateral reoperation. An initial isolated ACLR and initial ACLR performed by a high-volume surgeon were found to be independently associated with lower reoperation rates. Tobacco use was not significant. Survival rates of 93.4%, 89.8% and 86.7% at 2-, 5- and 10 years, respectively, were found for any ipsilateral reoperation. CONCLUSION: A 10.7% ipsilateral reoperation rate at an average of 25.9 (SD 24.5) months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated by the analysis. Meniscal pathology was addressed in the majority of subsequent interventions. Age 19 or younger, female gender, Caucasian race, and WC claim were associated with reoperation. Initial isolated ACLR and procedure performed by high-volume surgeon were associated with reduced reoperation. LEVEL OF EVIDENCE: Level III.

Ulnar Collateral Ligament Repair With Collagen-Dipped FiberTape Augmentation in Overhead-Throwing Athletes.

BACKGROUND: There has been a renewed interest in ulnar collateral ligament (UCL) repair in overhead athletes because of a greater understanding of UCL injuries, an improvement in fixation technology, and the extensive rehabilitation time to return to play. PURPOSE/HYPOTHESIS: To evaluate the clinical outcomes of a novel technique of UCL repair with internal brace augmentation in overhead throwers. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients undergoing a novel technique of UCL repair with internal brace augmentation were prospectively followed for a minimum of 1 year. Potential candidates for repair were selected after the failure of nonoperative treatment when imaging suggested a complete or partial avulsion of the UCL from either the sublime tubercle or medial epicondyle, without evidence of poor tissue quality of the ligament. The final decision on UCL repair or traditional reconstruction was determined intraoperatively. Demographic and operative data were collected at the time of surgery. Return to play, and Kerlan-Jobe Orthopaedic Clinic (KJOC) scores were collected at 1 year and then again at 2 years postoperatively. RESULTS: Of the 111 overhead athletes eligible for the study, 92% (102/111) of those who desired to return to the same or higher level of competition were able to do so at a mean time of 6.7 months. These patients had a mean KJOC score of 88.2 at final follow-up. CONCLUSION: UCL repair with internal brace augmentation is a viable option for amateur overhead throwers with selected UCL injuries who wish to return to sport in a shorter time frame than allowed by traditional UCL reconstruction.

The Anterolateral Ligament (ALL) The New Ligament?

BACKGROUND: Despite advances in technology, graft rupture rates reported in the literature following anterior cruciate ligament (ACL) surgery range from 1.8% to 18%. Recent anatomical studies have identified a lateral structure, the anterolateral ligament (ALL), as a potential source of residual pivoting following ACL reconstruction. The purpose of this report is to review the history surrounding the ALL and recent anatomic studies, identify its biomechanical and clinical implications, and develop a practical approach to utilizing it during ACL reconstruction. METHODS: An extensive review of the historical and current literature surrounding the identification of the ALL, its biomechanical function, reconstruction, and outcomes of ALL reconstruction was performed. DISCUSSION: After the storm of media coverage surrounding the "new ligament" known as the ALL, much attention was focused on cadaveric dissection, biomechanical analysis, and reconstruction of this structure. Several techniques have been described, and currently studies are being performed both retrospectively and prospectively to evaluate the added benefit of ALL reconstruction to the rotational stability of the knee and outcomes after ACL reconstruction. CONCLUSION: The ALL is a lateral-based structure that provides rotational stability to the knee in the presence of ACL deficiency. Reconstruction of this ligament may provide added benefit to stability and outcomes following ACL reconstruction in certain patient populations. Further randomized controlled trials are needed to elucidate the true benefit of ALL reconstruction and those patients who should undergo this added procedure.

Independent Risk Factors for Revision Surgery or Conversion to Total Hip Arthroplasty After Hip Arthroscopy: A Review of a Large Statewide Database From 2011 to 2012.

PURPOSE: To use a large heterogeneous population to identify independent risk factors for revision surgery or conversion to total hip arthroplasty (THA) after hip arthroscopy. METHODS: The New York Statewide Planning and Research Cooperative System database was queried from 2011 through 2012 to identify patients undergoing hip arthroscopy. All patients aged 18 years or older who underwent hip arthroscopy according to Current Procedural Terminology coding were included. We chose to divide surgical volume into tertiles for the purposes of statistical analysis. Longitudinal analysis for a minimum of 2 years was performed to determine risk factors for revision surgery or conversion to THA. RESULTS: We identified 3,957 patients. The mean age was 35.8 years (standard deviation, 13.1 years). After a minimum follow-up period of 2 years, the overall failure rate was 9.6%: 3.7% of patients underwent revision hip arthroscopy at an average of 15.8 months, whereas 5.9% underwent conversion to THA at 14.7 months. Index surgery performed by surgeons in the third tertile of surgical volume (<40 cases per annum) was an independent risk factor for revision (odds ratio [OR], 1.71; P = .001), as well as conversion to THA (OR, 1.90; P < .001). Female patients (OR, 1.8; P < .001), older patients (OR, 3.4; P < .001), and patients with a history of obesity (OR, 5.6; P < .001) underwent conversion to THA at significantly higher rates than other patients. Young patients (OR, 4.4; P < .001) and female patients (OR, 1.6; P < .001) were more likely to undergo revision hip arthroscopy. CONCLUSIONS: Our analysis of 3,957 patients found that female sex, age under 40 years, absence of a labral repair, and index procedure performed by a low-volume surgeon were independent risk factors for revision hip arthroscopy. Age over 60 years, index procedure performed by a low-volume surgeon, female sex, obesity, and the presence of pre-existing arthritis were risk factors for THA conversion. LEVEL OF EVIDENCE: Level III, case-control study.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management.

BACKGROUND: Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized. METHODS: We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy. RESULTS: We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary. CONCLUSION: Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Arthroscopic Repair of Hip Labrum With Suture Anchors.

The acetabular labrum and the transverse acetabular ligament form a continuous ring of tissue on the periphery of the acetabulum that provides a seal for the hip joint and increases the surface area to spread load distribution during weight-bearing. When a labral tear is suspected, the treatment algorithm always begins with conservative management, including physical therapy and nonsteroidal anti-inflammatory drugs. When conservative management fails, patients become candidates for arthroscopic labral repair. In the last 2 decades, the rate of hip arthroscopy has increased nearly 4-fold. However, as hip arthroscopy is performed more frequently, there is a need for a proper technique to minimize morbidity, because hip arthroscopy has been known to have a steep learning curve. We present a method for arthroscopic hip labral repair using suture anchors without a capsular repair. This Technical Note highlights our technique for labral repair, along with pearls and pitfalls of hip arthroscopy.

Distal patellar tendon avulsion in association with high-energy knee trauma: A case series and review of the literature.

BACKGROUND: Patellar tendon rupture is rare in the general population. Typically, failure occurs proximally or at the mid-substance. Distal avulsion from the tibial tubercle in adults is rare and not well described in the orthopedic literature. METHODS: We present the largest series of patients with distal patellar tendon injury with associated multi-ligamentous disruption of the knee. A series of six patients with distal patellar tendon avulsion were identified at a single institution. The cases were reviewed and are presented. RESULTS: Each case of distal patellar tendon rupture was associated with high-energy trauma to the knee. There was multi-ligamentous disruption in all cases, associated tibial plateau fracture in one case, and a compartment syndrome diagnosed in another. We propose that distal patellar tendon avulsion is a distinct pathology of the extensor mechanism in healthy adults. When present, it should prompt clinicians to assess patients for occult knee dislocation, monitor their neurovascular status, and obtain an MRI to evaluate for associated multi-ligamentous injury. CONCLUSION: We propose a modification to the Schenk classification to include extensor mechanism injury to help guide steps of operative intervention.

Coracoid Fracture Following Latarjet Failure A Case Report.

The Latarjet procedure involves the transfer of the coracoid process with its soft tissue attachments, thereby providing both bony and soft tissue articular reinforcement for glenohumeral stabilization. Most studies show positive outcomes with this procedure and complications at rates as low as 1%, predominately secondary to technical error. We present a case of recurrent anterior instability after two attempts at soft tissue stabilization (arthroscopic labral repair followed by open inferior capsular shift) in which an open Latarjet procedure was performed followed by subsequent revision secondary to coracoid autograft fracture. The case presented specifically highlights the need to appropriately identify the "bony margins" of the coracoid prior to drilling to make certain that drill holes are not eccentrically placed.

Clinical Outcomes of Hip Arthroscopy in Patients 60 or Older: A Minimum of 2-Year Follow-up.

PURPOSE: To examine clinical outcomes and survivorship in patients aged 60 years or older who underwent hip arthroscopy for management of hip pain. METHODS: Prospectively collected data for patients 60 or older undergoing hip arthroscopy were obtained. All patients were indicated for hip arthroscopy based on standard preoperative examination as well as routine and advanced imaging. Demographic data, diagnosis, and details regarding operative procedures were collected. Baseline preoperative modified Harris Hip Scores (mHHS) and Non-arthritic Hip Scores (NAHS) were compared to mHHS and NAHS at the 2-year follow-up. Survivorship was assessed to determine failure rates, with failure defined as any subsequent ipsilateral revision arthroscopic surgery and/or hip arthroplasty. RESULTS: Forty-two patients met inclusion criteria. Mean age (standard deviation) and body mass index were 65.8 years (4.5 years) and 26.1 (4.7), respectively. Baseline mean mHHS and NAHS for all patients improved from 47.8 (±12.5) and 47.3 (±13.6) to 75.6 (±17.6) and 78.3 (±18.6), respectively (P < .001 for both). Five patients (11.9%) met failure criteria and underwent additional surgery at an average of 14.8 (8-30) months. Three underwent conversion to total hip arthroplasty (7.1%), whereas 2 had revision arthroscopy with cam/pincer resection and labral repair for recurrent symptoms (4.7%). One- and 2-year survival rates were 95.2% and 88.9%, respectively. CONCLUSIONS: Our results suggest that in patients 60 or older with Tonnis grade 0 or 1 osteoarthritic changes on initial radiographs-treatment with hip arthroscopy can lead to reliable improvement in early outcomes. As use of hip arthroscopy for treatment of mechanical hip pain increases, additional studies with long-term follow-up are needed. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Postoperative pain control after arthroscopic rotator cuff repair.

Arthroscopic rotator cuff repair (ARCR) can provide excellent clinical results for patients who fail to respond to conservative management of symptomatic rotator cuff tears. ARCR, however, can be associated with severe postoperative pain and discomfort that requires adequate analgesia. As ARCR continues to shift toward being performed as an outpatient procedure, it is incumbent on physicians and ambulatory surgical centers to provide appropriate pain relief with minimal side effects to ensure rapid recovery and safe discharge. Although intravenous and oral opioids are the cornerstone of pain management after orthopedic procedures, they are associated with drowsiness, nausea, vomiting, and increased length of hospital stay. As health care reimbursements continue to become more intimately focused on quality, patient satisfaction, and minimizing of complications, the need for adequate pain control with minimal complications will continue to be a principal focus for providers and institutions alike. We present a review of alternative modalities for pain relief after ARCR, including cryotherapy, intralesional anesthesia, nerve blockade, indwelling continuous nerve block catheters, and multimodal anesthesia. In choosing among these modalities, physicians should consider patient- and system-based factors to allow the efficient delivery of analgesia that optimizes recovery and improves patient satisfaction.

Treatment of Nonunions After Malleolar Fractures.

Ankle fracture nonunion is a rare occurrence following closed or operative intervention. When it does occur, patients can experience debilitating symptoms that limit daily function. Malleolar nonunion can be caused by patient factors, such as smoking, malnutrition, or vascular insufficiency. Surgeon factors, such as insufficient or inappropriate operative fixation, also play a role. Several adjuncts, such as bone grafting, bone morphogenic protein, and bone stimulation, are useful in treating nonunions. Through a multimodal approach, malleolar nonunions are reliably treated with operative fixation leading to good patient outcomes with minimal complications.

Infection rate following total joint arthroplasty in the HIV population.

The purpose of this study is to review a large series of HIV-infected patients who underwent total joint arthroplasty and identify potential risk-factors for infection. Sixty-nine HIV-infected arthroplasty cases were analyzed with 138 matched controls. Deep infection rate following total hip or knee arthroplasty was 4.4% (3 of 69) among HIV cases compared to 0.72% (1 of 138) among controls, yielding a non-significant 6.22 times increased odds of infection (95% CI 0.64-61.0, P=0.11). Kaplan-Meier survival curves for infection free survival and revision free survival revealed non-significantly decreased survival in HIV cases compared to controls (P=0.06 and P=0.09). Our results suggest that the rate of early joint infection following primary total joint arthroplasty in the HIV-infected population is lower than reported in a number of previously published studies.

Unipolar vs bipolar hemostasis in total knee arthroplasty: a prospective randomized trial.

The purpose of this study was to investigate whether unipolar or bipolar hemostasis is more effective in reducing blood loss associated with primary total knee arthroplasty. We randomized 113 consecutive patients undergoing primary total knee arthroplasty into unipolar and bipolar hemostasis treatment groups. The mean postoperative drain output in the unipolar group was 776.5 mL compared with 778.7 mL and was not statistically significant (P = .97). There were no statistically significant differences in postoperative day 1 through 3 hemoglobin level (P = .2-.6) or hematocrit (P = .17-.46) values. The transfusion requirement in the unipolar group was 36% and 40% in the bipolar group (P = .67). Use of bipolar sealer compared with standard unipolar electrocauterization showed no significant difference in postoperative drain output, postoperative hemoglobin level and hematocrit values, or transfusion requirements.