Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger.

BACKGROUND: The current body of literature surrounding anterior cruciate ligament (ACL) survival and the variables contributing to further ACL injuries after primary ACL reconstruction in children and adolescents is limited, with no long-term evidence examining the incidence and contributing factors of further ACL injuries in this younger patient population. PURPOSE: To determine the long-term survival of the ACL graft and the contralateral ACL (CACL) after primary reconstruction in patients aged ≤18 years and to identify the factors that increase the odds of subsequent ACL injuries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients having undergone primary ACL reconstruction at age ≤18 years between 1993 and 1998 who were included in a prospective database by a single surgeon were considered for this study. Single-incision endoscopic ACL reconstruction was performed with either an autologous bone-patellar tendon-bone graft or a hamstring tendon graft. At a minimum of 15 years after ACL reconstruction, patients completed a subjective survey involving the International Knee Documentation Committee (IKDC) questionnaire in addition to questions regarding current symptoms, further ACL injuries, family history of ACL injury, and current level of activity. RESULTS: A total of 288 adolescents (age range, 13-18 years) met the inclusion criteria, of whom 242 (84%) were reviewed at a mean of 16 years and 6 months after ACL reconstruction. Of these patients, 75 (31%) sustained a further ACL injury: 27 (11.2%) suffered an ACL graft rupture, 33 suffered a CACL injury (13.6%), and 15 sustained both an ACL graft rupture and a CACL injury (6.2%) over 15 years. Survival of the ACL graft was 95%, 92%, 88%, 85%, and 83% at 1, 2, 5, 10, and 15 years, respectively, and survival of the CACL was 99%, 98%, 90%, 83%, and 81%, respectively. Survival of the ACL graft was less favorable in those with a family history of ACL injury than in those without a family history (69% vs 90%, respectively; hazard ratio [HR], 3.6; P = .001). Survival of the CACL was less favorable in male patients than in female patients (75% vs 88%, respectively; HR, 2.1; P = .03) and in those who returned to competitive team ball sports than in those who did not (78% vs 89%, respectively; HR, 2.3; P = .05). CONCLUSION: After ACL reconstruction in patients aged ≤18 years, a further ACL injury occurred in 1 in 3 patients over 15 years. The 15-year survival rate of the ACL graft was 83%, and the 15-year survival rate of the CACL was 81%. The ACL graft and CACL were most vulnerable within the first 5 years after index surgery. A family history of ACL rupture significantly increased the risk for ACL graft ruptures, and a CACL injury was more common in male patients and those who returned to team ball sports. High IKDC scores and continued participation in sports were maintained over the long term after ACL reconstruction in the adolescent population.

Arthroscopic Treatment of Labral Tears in Patients Aged 60 Years or Older.

PURPOSE: The purpose of this study was to (1) evaluate the clinical outcomes of a series of patients aged 60 years or older who underwent hip arthroscopy for labral tears with minimum 2-year follow-up and (2) identify risk factors for conversion to total hip arthroplasty (THA). METHODS: Outcome data were prospectively collected and retrospectively reviewed in patients aged 60 years or older who underwent hip arthroscopy between April 2008 and May 2012. Four patient-reported outcome (PRO) scores, pain scores, and satisfaction ratings were collected. Conversion to THA and revision surgery rates were recorded. A subgroup analysis compared survivors with patients requiring THA. RESULTS: Minimum 2-year follow-up was available for 30 patients with a mean age of 63.9 years. The 2-year survivorship rate was 70%, with 9 patients undergoing conversion to THA at a mean of 1.1 years after hip arthroscopy. Two patients required additional surgery during the study period, for a reoperation rate of 37% (11 of 30 patients). The remaining cohort showed mean improvements in all PRO scores. All scores, except the sports-related PRO (P = .12), improved significantly from the preoperative baseline scores. Visual analog scale scores for pain decreased from a mean of 5.0 preoperatively to 2.7 postoperatively (P = .003). Patients who required conversion to THA had lower preoperative modified Harris Hip Scores (P = .015), lower preoperative Hip Outcome Score-Activity of Daily Living values (P = .01), higher pain scores (P = .05), greater acetabular inclination (P = .023), and more severe chondral damage (P = .033). CONCLUSIONS: Arthroscopic treatment of labral tears in patients aged 60 years or older should be approached with caution. Patients in this age group had an overall 2-year survivorship rate of 70% and should be counseled before surgery on the possibility of subsequent conversion to THA. Patients aged 60 years or older with poor preoperative PRO scores, high pain scores, radiographic evidence of borderline dysplasia, and severe chondral damage may be poor candidates for hip arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The role of arthroscopy in the management of glenohumeral osteoarthritis: a Markov decision model.

PURPOSE: The purposes of this study were (1) to construct a theoretical Markov decision model to compare the total remaining quality-adjusted life-years following either arthroscopic management (AM) or total shoulder arthroplasty (TSA) for the treatment of glenohumeral osteoarthritis and (2) to determine the possible effects of age on the preferred treatment strategy. METHODS: A Markov decision model was constructed to compare AM and TSA in patients with glenohumeral osteoarthritis. The rates of surgical complications, revision surgery, and death were derived from the literature and analyzed. The principal outcome measure was the mean total remaining quality-adjusted life-years after each treatment strategy. Sensitivity analyses were performed for age at the initial procedure, utilities, and transition probabilities. RESULTS: This theoretical decision model showed that AM was the preferred strategy for patients younger than 47 years, TSA was the preferred strategy for patients older than 66 years, and both treatment strategies were reasonable for patients aged between 47 and 66 years. The model was highly sensitive to age at the index surgery, utilities of wellness states, survivorship, and the probability of failure after either AM or TSA. CONCLUSIONS: According to this theoretical decision model, AM was the preferred treatment strategy for patients younger than 47 years, primary TSA was the preferred treatment strategy for patients older than 66 years, and both treatment options were reasonable for patients aged between 47 and 66 years. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases.

BACKGROUND: Few studies have reported incidence of or risk factors for morbidity and mortality after elective shoulder arthroscopy. METHODS: We used Current Procedural Terminology (CPT) billing codes to query the National Surgical Quality Improvement Program database and identified 9410 cases of elective shoulder arthroscopy. Univariate and multivariate analyses were used to identify risk factors for complication. RESULTS: Among 9410 patients, 109 complications occurred in 93 (0.99%). Major morbidity was 0.54% (51 patients), which included 4 patients (0.04%) with a mortality, and minor morbidity was 0.44% (42 patients). The most common complication was a return to the operating room (29 cases, 0.31%). Superficial surgical site infections occurred in 15 cases (0.16%), deep infections in 1 (0.01%), deep venous thrombosis or thrombophlebitis in 8 (0.09%), peripheral nerve injury in 1 (0.01%), and pulmonary embolism in 6 (0.06%). The multivariate analysis showed smoking history (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.12-3.27), history of chronic obstructive pulmonary disease (OR, 3.25; 94% CI, 1.38-7.66), operative time of longer than 1.5 hours (OR, 2.1; 95% CI, 1.32-3.36), and American Society of Anesthesia class of 3 or 4 compared with 1 or 2 (OR, 1.82; 95% CI, 1.03-3.21) as risk factors for complication. CONCLUSIONS: Morbidity and mortality are rare events after elective shoulder arthroscopy, and the procedure should generally be considered safe. Surgeons should offer smoking cessation to active users of tobacco and should be efficient with operative time whenever possible. LEVEL OF EVIDENCE: Level II, prospective cohort design, treatment study.

Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database.

BACKGROUND: Knee arthroscopy is among the most common orthopaedic surgical procedures. However, the incidence and risk factors for postsurgical morbidity and mortality remain poorly defined. METHODS: The American College of Surgeons National Surgical Quality Improvement Program prospectively collects thirty-day morbidity and mortality data from more than 258 hospitals around the United States. We used Current Procedural Terminology codes to retrospectively query the database and identified 12,271 cases of elective knee arthroscopy performed from January 1, 2005, to December 31, 2010. Postoperative complications were divided into categories of minor morbidity, major morbidity or mortality, or any complication. The potential risk factors for complications were analyzed with use of univariate and multivariate analyses. RESULTS: The overall incidence of any complication was 1.6% (199 patients). The major morbidity was 0.76% (ninety-three patients), which included one patient death (0.008%), and the minor morbidity was 0.86% (106 patients). The most frequent major complication was a return to the operating room. The most common minor complication was deep venous thrombosis or thrombophlebitis. The risk factors identified in the univariate analysis for any complication included black race, prior operation within thirty days, American Society of Anesthesiologists class, and operative time of >1.5 hours as compared with ≤1.5 hours (p < 0.05 for each). The independent risk factors identified in the multivariate analysis for any complication included black race (odds ratio, 1.81 [95% confidence interval, 1.13 to 2.89]), prior operation within thirty days (odds ratio, 6.33 [95% confidence interval, 1.45 to 27.66]), operative time of >1.5 hours (odds ratio, 1.84 [95% confidence interval, 1.21 to 2.78]), and age of forty to sixty-five years (odds ratio, 1.46 [95% confidence interval, 1.01 to 2.11]). CONCLUSIONS: The incidence of complication following elective knee arthroscopy is low. The data presented here should be useful for providing prognostic information to patients during informed consent. Surgeons should be encouraged to minimize operative time whenever possible, and may wish to delay elective arthroscopy in patients who have had other recent surgical procedures.

Incidence of symptomatic venous thromboembolism after elective knee arthroscopy.

BACKGROUND: Knee arthroscopy is the most commonly performed orthopaedic procedure in the United States and is usually considered to be a low-risk procedure. The purposes of this study were to describe the incidence of symptomatic deep venous thrombosis, symptomatic pulmonary embolism, and mortality after elective knee arthroscopy performed without thromboembolic prophylaxis, as well as to investigate the association of age, sex, procedure type, and oral contraceptive use with the odds of developing a venous thromboembolism. METHODS: A retrospective cohort study of elective arthroscopic knee procedures during a twenty-seven-month period (January 1, 2006, through March 31, 2008) was performed with use of the administrative database of a large health maintenance organization. Use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) procedure codes for arthroscopic surgery identified 21,794 arthroscopic knee procedures. The occurrence of a symptomatic deep venous thrombosis or pulmonary embolism within ninety days after surgery was identified by reviewing administrative and electronic medical record data for inpatient, outpatient, urgent care, and emergency encounters. Mortality and the cause of death were captured with use of electronic medical records, Social Security Administration Death Master Files, and county death certificates. Patient charts were reviewed for confirmation of the deep venous thrombosis, pulmonary embolism, or death. Patients who had a history of a venous thromboembolism or who had received anticoagulation therapy within fourteen days prior to the index surgery were excluded. RESULTS: The study cohort comprised 20,770 patients who met the inclusion criteria. Fifty-one patients (0.25%; 95% confidence interval, 0.18% to 0.31%) developed a deep venous thrombosis, and thirty-five (0.17%; 95% confidence interval, 0.11% to 0.22%) developed a pulmonary embolism. The incidence of venous thromboembolism was higher in patients who were fifty years of age or older (0.51% compared with 0.34% in younger patients), and the incidence in female patients was higher if they had been prescribed oral contraceptive medication (0.63% compared with 0.30% in female patients with no such prescription). No differences in the incidence of deep venous thrombosis or pulmonary embolism on the basis of sex or arthroscopic procedure code were noted. Nine patients (0.04%) died within ninety days of surgery, although only one death was confirmed to have resulted from a pulmonary embolism. CONCLUSIONS: The ninety-day incidence of symptomatic venous thromboembolism after elective knee arthroscopy was relatively low, with a 0.25% incidence of deep venous thrombosis and a 0.17% incidence of pulmonary embolism. The overall ninety-day mortality after arthroscopic knee surgery was 0.04%.

Is previous knee arthroscopy related to worse results in primary total knee arthroplasty?

According to literature, knee arthroscopy is a minimal invasive surgery performed for minor surgical trauma, reduced morbidity and shortens the hospitalization period. Therefore, this type of surgery before total knee arthroplasty (TKA) could be considered a minor procedure with minimum postoperative complication. A retrospective and cohort series of 1,474 primary TKA was performed with re-assessment after a minimum follow-up period of 2 years: 1,119 primary TKA had no previous surgery (group A) and 60 primary TKA had arthroscopic debridement (group B). All the patients underwent a clinical and radiological evaluation as well as IKS scores. Statistical analysis of postoperative complications revealed that group B had a higher postoperative complication rate (P < 0.01). In this group, 30% of local complications were re-operated and 8.3% of these cases underwent revision TKA (P < 0.01). The mean interval between arthroscopy and primary TKA was 53 months. However, statistical analysis did not reveal a direct correlation between arthroscopy/primary TKA interval and postoperative complications/failures (P = 0.55). The Kaplan-Meier survival curves showed a survival rate of 98.1 and 86.8% at 10 years follow-up for groups A and B, respectively. Our data allow us to conclude that previous knee arthroscopy should be considered a factor related to postoperative primary TKA outcomes as demonstrated by the higher rate of postoperative complications and failures (P < 0.001) as well as a worse survival curve than group A.

Plicatura del ligamento peroneoastragalino anterior del tobillo: una nueva técnica artroscópica / Plasty of talofibular ligament of the ankle: a new arthroscopic technique

Se presenta un método de plicatura artroscópica de tobillo en la lesión del ligamento fibulotalar anterior (LFTA) haciendo énfasis en la necesidad de revisar las patologías intrarticulares que se asocian a dichas lesiones. El etudio incluye 16 casos; de éstos, se detectaron tres (18 por ciento) con patología intraarticular. Se llevó un seguimiento con una media de 23.8 meses (de 6 meses a 4 años) y solamente se encontró una recaída en un solo de ellos (6.25 por ciento) lo que representa un 93.75 por ciento de éxitos, lo cual se compara con la cirugía abierta que presenta una eficacia de 80 por ciento pero con mayor morbilidad y lesionando mayor tejido sano, siendo el intervalo de confianza de 0.83 a 1, con una p < a 0.05