Suture Tape Augmentation Improves the Biomechanical Performance of Bone-Patellar Tendon-Bone Grafts Used for Anterior Cruciate Ligament Reconstruction.

PURPOSE: The purpose of this study was to investigate the time-zero biomechanical properties (stiffness, displacement, and load at failure) of bone-patellar tendon-bone (BTB) grafts used for anterior cruciate ligament (ACL) reconstruction with and without suture tape augmentation as a means to determine the potential clinical benefit of this technique. METHODS: Eight juvenile porcine knees underwent ACL reconstruction with a human cadaveric BTB graft (control). These were compared to 8 juvenile porcine knees that underwent ACL reconstruction with a BTB graft augmented with suture tape. All knees underwent biomechanical testing utilizing a dynamic tensile testing machine. Cyclic loading between 50-250N was performed for 500 cycles at 1 Hz to simulate in vivo ACL loads during the early rehabilitation phase. The grafts were displaced during load-at-failure tensile testing at 20 mm/min. Differences in graft displacement, stiffness, and load at failure for the control and suture tape augmented groups were compared with the Student t-test with a significance level of P < .05. RESULTS: There was no difference in graft displacement between the 2 groups. A 104% higher postcyclic stiffness was noted in the augmented group compared to the controls (augmentation: 261 ± 76 N/mm versus control 128 ± 28 N/mm, P = .002). The mean ultimate load at failure was 57% higher in the augmented group compared to controls (744 ± 219 N vs postcyclic 473 ± 169 N, respectively [P = .015]). There was no difference in mode of failure between the control knees and those augmented with suture tape, with approximately half failing from pull off of the tendon from the bone plug and half with pull out of the bone plug from the tunnel. CONCLUSION: Independent suture tape augmentation of a BTB ACL reconstruction grafts was associated with a 104% increase in graft stiffness and a 57% increase in load at failure compared to nonaugmented BTB grafts. CLINICAL RELEVANCE: In vivo suture tape augmentation of a BTB ACL reconstruction increases graft construct strength and stiffness, which may reduce graft failure in the clinical setting.

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Pilot Economic Decision Analysis.

BACKGROUND: The operative treatment of Achilles tendon ruptures has been associated with lower rerupture rates and better function but also a risk of surgery-related complications compared with nonoperative treatment, which may provide improved outcomes with accelerated rehabilitation protocols. However, economic decision analyses integrating the updated costs of both treatment options are limited in the literature. PURPOSE: To compare the cost-effectiveness of operative and nonoperative treatment of acute Achilles tendon tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: An economic decision model was built to assess the cost-utility ratio (CUR) of open primary repair versus nonoperative treatment for acute Achilles tendon ruptures, based on direct costs from the practices of sports medicine and foot and ankle surgeons at a single tertiary academic center, with published outcome probabilities and patient utility data. Multiway sensitivity analyses were performed to reflect the range of data. RESULTS: Nonoperative treatment was more cost-effective in the average scenario (nonoperative CUR, US$520; operative CUR, US$1995), but crossover occurred during the sensitivity analysis (nonoperative CUR range, US$224-US$2079; operative CUR range, US$789-US$8380). Operative treatment cost an extra average marginal CUR of US$1475 compared with nonoperative treatment, assuming uneventful healing in both treatment arms. The sensitivity analysis demonstrated a decreased marginal CUR of operative treatment when the outcome utility was maximized, and rerupture rates were minimized compared with nonoperative treatment. CONCLUSION: Nonoperative treatment was more cost-effective in average scenarios. Crossover indicated that open primary repair would be favorable for maximized outcome utility, such as that for young athletes or heavy laborers. The treatment decision for acute Achilles tendon ruptures should be individualized. These pilot results provide inferences for further longitudinal analyses incorporating future clinical evidence.

Medial Tibial Slope Determined by Plain Radiography Is Not Associated with Primary or Recurrent Anterior Cruciate Ligament Tears.

Increased tibial slope may be associated with anterior cruciate ligament (ACL) injuries, although potential confounding effects from various patient characteristics and radiographic quantification methods have not been rigorously studied. The association of the slope of the lateral plateau with recurrent ACL injury after primary ACL reconstruction has recently been reported, but the role of medial slope is less well defined. The purpose of this study was to (1) assess medial tibial slope measurement reliability among examiners, (2) compare medial tibial slope values between patients undergoing primary ACL reconstruction, reinjured patients undergoing revision ACL reconstruction, and a control cohort with an intact ACL, (3) analyze if the medial tibial slope is an independent risk factor for noncontact ACL injury, and (4) assess how different anatomical references affect medial tibial slope values. A total of 206 patients were enrolled into one of three groups: (1) ACL-intact controls (CONTROL, n = 83), (2) first-time ACL-injured patients (PRIMARY, n = 77), and (3) patients undergoing revision ACL reconstruction (REVISION, n = 46). Three fellowship-trained sports medicine surgeons performed repeated measurements of plain lateral radiographs. The medial tibial slope was determined by three anatomical references: anterior tibial cortex (anterior tibial slope [ATS]), posterior tibial cortex (posterior tibial slope [PTS]), and the anatomical long axis of the tibia (composite tibial slope [CTS]). Substantial intra- and interobserver reliabilities were established by the intraclass correlation coefficient of 0.73 to 0.89. There was no difference in CTS, ATS, or PTS comparing the CONTROL, PRIMARY, and REVISION groups upon univariate analyses. Multivariable logistic regression model showed that none of the slope values was independently associated with ACL injury. The mean ATS for all 206 subjects was 4 and 8 degrees greater than the mean CTS and PTS, respectively. ATS correlated only moderately to PTS. We concluded that medial tibial slope measured on radiographs is not associated with primary or recurrent ACL injury, and has substantial variation and suboptimal correlation when using different anatomical references despite good inter- and intraobserver reliabilities.

The Perioperative Continuation of Aspirin in Patients Undergoing Arthroscopic Surgery of the Knee.

BACKGROUND: The perioperative withdrawal of aspirin increases the risk of cardiac, neurologic, and vascular thromboembolic events. The safety of continuing aspirin in patients undergoing knee arthroscopy is unknown. HYPOTHESIS: Perioperative continuation of aspirin does not increase surgical complications or worsen outcomes in patients 50 years of age and older undergoing knee arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This is a single-center, institutional review board-approved, prospective matched dual-cohort study comparing the surgical complication rates and postoperative outcomes of patients taking daily aspirin with those of unmedicated controls. Ninety patients who were 50 years of age or older and taking 81 mg or 325 mg daily aspirin were matched to 90 controls. Patients were matched on age, surgery type, and the use of a tourniquet. A complication was defined as bleeding, wound dehiscence, or wound infection requiring reoperation. Postoperative outcome measures including hematoma formation, extent of ecchymosis (mm), visual analog scale (VAS) scores for pain and swelling, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were collected preoperatively and postoperatively (10-14 days and 4-6 weeks). RESULTS: There were no complications (0%) in either cohort. There was no difference in hematoma formation (aspirin, 1.8%; controls, 2.4%; P = .79), incidence of ecchymosis (aspirin, 17%; controls, 21%; P = .70), or the average extent of ecchymosis (aspirin, 124.6 mm; controls, 80.3 mm; P = .36) between patients taking aspirin and controls. There was no significant difference in pre- or postoperative knee range of motion between controls and patients taking aspirin. The KOOS subscores and VAS pain scores were similar between patients taking aspirin and controls at baseline and at follow-up. CONCLUSION: The perioperative continuation of daily aspirin in patients 50 years of age and older undergoing arthroscopic procedures of the knee is safe and does not result in an increased rate of bleeding or wound complications requiring reoperation. Continued aspirin use in patients 50 years of age and older had no significant effect on postoperative physical examination measures or patient-rated outcome scores.

In Vitro Analysis of Micronized Cartilage Stability in the Knee: Effect of Fibrin Level, Defect Size, and Defect Location.

PURPOSE: The purpose of the study is to assess the stability of a dehydrated cartilage allograft combined with platelet-rich plasma sealed with fibrin glue within trochlear and medial femoral condyle (MFC) chondral defects in a cadaver knee model. METHODS: Defects were made in the trochlea (20, 25, and 30 mm) and MFC (15, 20, and 25 mm) of 6 cadaver specimens. Allograft was applied utilizing 2 different techniques: (1) proud in which the fibrin level extends beyond surrounding cartilage and (2) recessed in which the fibrin level is even with or below the surrounding cartilage. The knees were cycled by using a continuous passive motion machine through a range of motion. Defects were assessed for superficial delamination and displacement of the allograft. This was quantified as the percentage of surface delamination and/or exposed bone. Comparisons were made with regard to defect size, location, and fill. RESULTS: In both the MFC and trochlea, proud application resulted in an increased rate of fibrin delamination. In the trochlea, an average of 38% delamination was detected in the recessed 20-mm defect compared with 70% in the proud 30-mm defect (P < .05). This effect was increased with increasing defect size. In the MFC, mean delamination of 43% and 28% exposed bone was noticed in the proud 15-mm defect compared with 95% delamination and 71% exposed bone at 25 mm. In 82% of specimens, displacement and/or delamination occurred within the first 15 minutes of testing. CONCLUSIONS: Increased defect size in both the trochlea and femoral condyle, as well as a proud construct application, were associated with significant delamination and displacement of the allograft/fibrin construct. CLINICAL RELEVANCE: Proud application of allograft increases the likelihood of fibrin delamination and graft displacement in both trochlear and MFC defects. This effect is increased with increasing defect size. These data may support limiting range of motion immediately after an allograft procedure.

Revision Anterior Cruciate Ligament Reconstruction Outcomes at a Minimum of 5-Year Follow-Up: A Systematic Review.

Revision anterior cruciate ligament (ACL) reconstruction typically has worse outcomes than primary reconstructions. Minimal long-term data exist regarding 5-year results. We chose to perform a systematic review to evaluate midterm (5-year) revision ACL reconstruction outcomes (patient-reported outcomes, reoperation, stability, arthritis) in comparison to primary ACL reconstructions at similar time points. Embase, Cochrane, and PubMed databases were queried, and four studies met the inclusion criteria. Two authors reviewed and performed data extraction. All were level 4 studies. Review of the studies demonstrated that results at 5 years are consistently worse than those noted in primary reconstructions for objective and patient-reported outcomes. Revision ACL reconstruction outcomes remain worse than primary reconstructions at midterm 5-year follow-up. The level of evidence is 4.

Opioid Consumption After Knee Arthroscopy.

BACKGROUND: The opioid epidemic in the United States has placed increased pressure on physicians to engage in responsible opioid prescribing practices. However, surgeons currently have little information to guide their postoperative prescription decision-making. The purpose of this study was to assess opioid consumption after knee arthroscopy and identify preoperative factors that may predict higher opioid usage. METHODS: A prospective observational study of 221 patients was conducted in patients undergoing outpatient knee arthroscopy for meniscal repair, partial meniscectomy, debridement, chondroplasty, or loose body removal. Participants recorded their daily opioid consumption in a postoperative pain diary. Total opioid consumption was calculated from counts of remaining pills at the 2-week and 6-week postoperative office visits. Variables, including age, sex, body mass index, smoking status, alcohol consumption, preoperative pain severity and duration, preoperative opioid usage, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and the Connor-Davidson Resilience Scale, were evaluated for an association with opioid consumption. RESULTS: Total opioid consumption ranged from 0 to 188 pills, with a median of 7 pills (hydrocodone 5-mg equivalents). Forty-six percent of patients took ≤5 pills, 59% took ≤10 pills, and 81% took ≤20 pills. Fifty-six percent of patients had discontinued opioid usage by the third postoperative day. Eighty-eight percent of patients had surplus opioid medication at the time of the final follow-up. Patients undergoing meniscal repair, smokers, and those taking preoperative opioids were significantly more likely to take ≥20 pills (p < 0.05). CONCLUSIONS: The median number of pills taken after knee arthroscopy is 7, with the majority of patients consuming ≤20 pills. Meniscal repair, smoking, and preoperative opioid usage were associated with higher postoperative opioid consumption. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient Reported Outcomes Measurement Information System Scores Are Responsive to Early Changes in Patient Outcomes Following Arthroscopic Partial Meniscectomy.

PURPOSE: The purpose of this study was to test the hypothesis that Patient Reported Outcomes Measurement Information System (PROMIS) computer-adaptive testing (CAT) physical function and pain interference scores can detect early variations in postoperative outcomes following arthroscopic partial meniscectomy and to determine whether age, sex, body mass index, mechanical symptoms, duration of symptoms, and the severity of chondrosis affect these scores. METHODS: Seventy-five patients who had undergone a partial meniscectomy between September 2015 and March 2016 and had both preoperative and postoperative PROMIS-CAT data for physical function, pain interference, and depression were included. Demographic, clinical, and surgical data including the presence of intraoperative chondral lesions were collected for statistical analysis to assess for factors that led to differences in PROMIS-CAT outcomes. RESULTS: Preoperatively, patients had decreased physical function and increased pain interference in excess of 1 standard deviation from the general population with mean PROMIS scores of 38.5 and 63.5, respectively. At the 6-week postoperative visit, patients had significant improvements in both physical function and pain interference with mean scores of 43.4 (P < .001, SE = 0.75) and 55.5 (P < .001, SE = 0.83). Female patients had less improvement in PROMIS physical function (P = .03) and depression (P = .02) scores postoperatively compared with male patients. Patients with high-grade articular cartilage lesions had less improvement in physical function (P = .014) and pain interference (P = .010) at 6 weeks postoperative compared with patients with low grade or no chondral lesion. CONCLUSIONS: PROMIS-CAT provides responsive outcome measures to early postoperative changes in physical function and pain following arthroscopic partial meniscectomy and has prognostic value in patient outcomes 6 weeks after procedure. LEVEL OF EVIDENCE: Level IV case series.

Diagnosis, Evaluation, and Endoscopic Repair of Partial Articular Gluteus Tendon Avulsion.

In addition to trochanteric bursitis, gluteus medius and minimus tears (GMMTs) can be a common source of insidious lateral hip pain and dysfunction. Partial-thickness GMMTs are much more common than full-thickness GMMTs but are frequently overlooked by both radiologists and orthopaedic surgeons. GMMTs are commonly identified on magnetic resonance imaging ordered for lateral hip pain unresponsive to conservative management. Imaging can show that high-grade partial articular gluteus tendon avulsion (PAGTA) can occur as either an isolated gluteus medius tear, an isolated gluteus minimus tear, or a combined GMMT. We describe how to identify PAGTA injuries with intraoperative assessment and identification of the interval between the gluteus medius and minimus tendons to allow access to the PAGTA without violating the bursal side of the tendon. PAGTAs can be repaired arthroscopically by single- or double-row suture anchor fixation depending on the size of the tear. The purpose of this article is to guide orthopaedic surgeons in the recognition of PAGTA with magnetic resonance imaging and dynamic examination to allow for accurate repair of GMMTs.

Biomechanical Evaluation of Posterior Cruciate Ligament Reconstruction With Quadriceps Versus Achilles Tendon Bone Block Allograft.

BACKGROUND: Long-term studies of posterior cruciate ligament (PCL) reconstruction suggest that normal stability is not restored in the majority of patients. The Achilles tendon allograft is frequently utilized, although recently, the quadriceps tendon has been introduced as an alternative option due to its size and high patellar bone density. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the biomechanical strength of PCL reconstructions using a quadriceps versus an Achilles allograft. The hypothesis was that quadriceps bone block allograft has comparable mechanical properties to those of Achilles bone block allograft. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-nine fresh-frozen cadaveric knees were assigned to 1 of 3 groups: (1) intact PCL, (2) PCL reconstruction with Achilles tendon allograft, or (3) PCL reconstruction with quadriceps tendon allograft. After reconstruction, all supporting capsular and ligamentous tissues were removed. Posterior tibial translation was measured at neutral and 20° external rotation. Each specimen underwent a preload, 2 cyclic loading protocols of 500 cycles, then load to failure. RESULTS: Construct creep deformation was significantly lower in the intact group compared with both Achilles and quadriceps allograft (P = .008). The intact specimens reached the greatest ultimate load compared with both reconstructions (1974 ± 752 N, P = .0001). The difference in ultimate load for quadriceps versus Achilles allograft was significant (P = .048), with the quadriceps group having greater maximum force during failure testing. No significant differences were noted between quadriceps versus Achilles allograft for differences in crosshead excursion during cyclic testing (peak-valley [P-V] extension stretch), creep deformation, or stiffness. Construct stiffness measured during the failure test was greatest in the intact group (117 ± 9 N/mm, P = .0001) compared with the Achilles (43 ± 11 N/mm) and quadriceps (43 ± 7 N/mm) groups. CONCLUSION: While the quadriceps trended to be a stronger construct with a greater maximum load and stiffness required during load to failure, only maximum force in comparison with the Achilles reached statistical significance. Quadriceps and Achilles tendon allografts had similar other biomechanical characteristics when used for a PCL reconstruction, but both were inferior to the native PCL. CLINICAL RELEVANCE: The quadriceps tendon is a viable graft option in PCL reconstruction as it exhibits a greater maximum force and is otherwise comparable to the Achilles allograft. These findings expand allograft availability in PCL reconstruction.

All-Endoscopic Single-Row Repair of Full-Thickness Gluteus Medius Tears.

Abductor tendon tears typically develop insidiously in middle-aged women and can lead to debilitating lateral hip pain and a Trendelenburg limp. The gluteus medius tendon is most commonly torn and may show fatty degeneration over time, similar to the rotator cuff muscles of the shoulder. Endoscopic repair offers a therapeutic alternative to traditional open techniques. This article describes the workup, examination, and endoscopic repair of a full-thickness gluteus medius tear presenting as lateral hip pain and weakness. The surgical repair for this case used a single-row suture anchor technique. In addition, the indications and technique for a double-row repair will be discussed.

The Impact of Uninterrupted Warfarin on Hand and Wrist Surgery.

PURPOSE: To determine the impact of uninterrupted use of warfarin on hand and wrist surgery. METHODS: This single-center, prospective cohort trial enrolled adult patients undergoing hand and wrist surgery. Between May 2009 and August 2014, 47 surgical patients receiving uninterrupted warfarin (50 procedures) were enrolled and matched as a group by age and procedure type to 48 surgical patients (50 procedures) who were not prescribed warfarin. Complications, defined as bleeding, infection, or wound dehiscence requiring reoperation, were recorded for each group. Surgical outcome measures were composed of objective findings affected by surgical site bleeding (ie, ecchymosis extent, hematoma presence, 2-point discrimination) and standardized patient-rated assessments (Quick-Disabilities of the Arm, Shoulder, and Hand, and visual analog scales: pain and swelling). We collected data preoperatively and at 2 and 4 weeks postoperatively. Statistical analyses contrasted complications and outcomes data between patient groups. RESULTS: One procedure (2%; 95% confidence interval, 0% to 11%) in a patient taking warfarin was complicated by hematoma requiring reoperation resulting from an elevated postoperative international normalized ratio of 5.4. There were no complications among controls (0%; 95% confidence interval, 0% to 7%). At 2 weeks postoperatively, patients receiving warfarin more frequently had hematomas (28% vs 10%) and demonstrated a greater extent of ecchymosis from the surgical incision (50 vs 19 mm). At 4 weeks, no differences existed in hematoma presence or extent of ecchymosis between groups. The incidence of transiently elevated 2-point discrimination was not different between groups (10% warfarin; 6% controls). Visual analog scores for pain and swelling were not significantly different between groups at any time. Differences in Quick-Disabilities of the Arm, Shoulder, and Hand scores between groups did not exceed a minimal clinically important difference. CONCLUSIONS: Uninterrupted use of warfarin in patients undergoing surgery of the hand and wrist was associated with an infrequent risk of bleeding complication requiring reoperation. Increased rates of hematoma and ecchymosis in patients taking warfarin normalized by 4 weeks postoperatively. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Application of the Goutallier/Fuchs Rotator Cuff Classification to the Evaluation of Hip Abductor Tendon Tears and the Clinical Correlation With Outcome After Repair.

PURPOSE: To assess the reliability and reproducibility of the Goutallier/Fuchs classification for the evaluation of abductor tendon tears of the hip, as well as to identify the relation between preoperative tear size, abductor muscle quality, and the success of endoscopic tendon repair. METHODS: This is a retrospective review of 30 consecutive endoscopic abductor tendon repairs performed by a single surgeon over a 2-year period. Preoperative magnetic resonance imaging scans were reviewed, and the muscle was assigned a grade according to the Goutallier/Fuchs classification. Patient-rated outcome scores--visual analog scale score, Hip Outcome Score (HOS), and modified Harris Hip Score (mHHS)--were collected preoperatively and at a minimum of 2 years postoperatively. Intraobserver and interobserver reliability for muscle grading was calculated. Postoperative outcome measures were compared with preoperative tear size, muscle grade, and repair type to assess for correlations. RESULTS: Of the 30 hips included in the study, over 75% were classified as grade 1 (n = 15) or grade 2 (n = 8). The intraobserver reliability and interobserver reliability of the classification system averaged 0.872 and 0.916, respectively. Two patients (grades 3 and 4) had repair failure and underwent muscle transfer. In the remaining 28 hips, improvement was seen in the visual analog scale score (6.0 v 1.7, P < .0001), HOS-Activities of Daily Living subscale score (58.8 v 83.4, P < .0001), HOS-Sport-Specific subscale score (40.0 v 75.0, P < .0001), and mHHS (55.6 points v 81.1 points, P < .0001) postoperatively. Increasing preoperative fatty infiltration and atrophy correlated with increased postoperative pain levels (regression coefficient, 0.93; P < .001) and decreased postoperative HOS-Activities of Daily Living subscale scores (regression coefficient, -3.36; P = .011), HOS-Sport-Specific subscale scores (regression coefficient, -5.63; P = .016), mHHS values (regression coefficient, -3.50; P = .0008), and patient satisfaction (regression coefficient, -1.04; P < .0001). Patient age, tear size, or repair type (double v single row) did not affect postoperative outcomes. CONCLUSIONS: The Goutallier/Fuchs classification system can be reliably and reproducibly applied to the evaluation of abductor tendon tears of the hip and appears to correlate with patient-rated outcomes after repair. Increasing preoperative muscle fatty atrophy correlates with increased patient pain and decreased patient satisfaction and functional outcomes after repair. LEVEL OF EVIDENCE: Level IV, prognostic case series.

A Case of Posterior Sternoclavicular Dislocation in a Professional American Football Player.

Sternoclavicular (SC) dislocation is a rare injury of the upper extremity. Treatment of posterior SC dislocation ranges from conservative (closed reduction) to operative (open reduction with or without surgical reconstruction of the SC joint). To date, we are unaware of any literature that exists pertaining to this injury or its treatment in elite athletes. The purpose of this case report is to describe a posterior SC joint dislocation in a professional American football player and to illustrate the issues associated with its diagnosis and treatment and the athlete's return to sports. To our knowledge, this case is the first reported in a professional athlete. He was treated successfully with closed reduction and returned to play within 5 weeks of injury.

Are there sex-dependent differences in acetabular dysplasia characteristics?

BACKGROUND: Many patients who undergo periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia experience decreased pain and improved function, yet some experience inadequate clinical improvement. The etiologies of treatment failure have not been completely defined, and sex-dependent disease characteristics that may be associated with less pain relief are not understood. QUESTION/PURPOSES: We sought to determine whether there were clinically important sex-specific differences between male and female patients undergoing PAO for acetabular dysplasia in terms of (1) clinical parameters (anthropomorphic traits and hip scores), (2) radiographic findings, and (3) intraoperative findings at the time of PAO, in particular findings potentially associated with femoroacetabular impingement (FAI) such as chondromalacia at the head-neck junction, impingement trough, or reduced head-neck offset. METHODS: Between 2007 and 2012 we treated 245 patients (270 hips) with a PAO for symptomatic acetabular dysplasia. Of those, 16 patients (16 hips; 6%) had insufficient documentation for review in the medical record and another 49 patients (51 hips; 19%) met prespecified exclusion criteria, leaving 180 patients (203 hips; 75%) for analysis in this retrospective study. One hundred thirty-nine patients were females and 41 were males. Clinical data including patient demographics, physical examination, patient self-reported outcome scores, radiographic morphologic features, and intraoperative findings were collected prospectively as part of an institutional registry. Statistical analysis was performed with univariate and multivariate analyses. RESULTS: Mean age was similar among sexes; however, BMI was greater in males compared with females (26 versus 24 kg/m(2); p = 0.002). Males had less hip ROM including internal rotation at 90° flexion (14° ± 13.8° versus 25° ± 16.2°; p = 0.001). Males had higher preoperative UCLA (7 ± 2, versus 6 ± 2; p = 0.02) and Harris hip scores (63 ± 15 versus 58 ± 16; p = 0.04). Radiographically, a crossover sign (88% versus 39%; p < 0.001) and posterior wall sign (92% versus 63%; p < 0.001) were more common in males. Males had greater alpha angles on the frog lateral (63° ± 15.3° versus 58° ± 16°; p = 0.04) and Dunn radiograph views (64° ± 15.5° versus 56° ± 14.8°; p = 0.02). The incidence of femoral head-neck chondromalacia (62% versus 82%; p = 0.03) and an impingement trough observed at surgery was greater in males (35% versus 17%; p = 0.01). Multivariate analysis showed differences between the sexes for reduced internal rotation in flexion, a higher Dunn alpha angle, increased incidence of a crossover sign, and a lower anterior center-edge angle. CONCLUSIONS: There are sex-dependent, disease characteristic differences in patients with symptomatic acetabular dysplasia. Most notably, male patients have a greater prevalence of clinical, radiographic, and intraarticular findings consistent with concurrent FAI and instability and potentially a heightened risk of secondary FAI after PAO, however postoperative and long-term followup are needed to confirm these findings and it remains unclear which patients need surgical correction of the impingement and instability. Preoperative evaluation of acetabular dysplasia in males should at least include careful attention to factors associated with symptomatic FAI; however, further studies are needed to determine when surgical correction is needed.

Treatment of tibial eminence fractures: a systematic review.

Fractures of the tibial eminence are rare, accounting for less than 1% of the injuries involving the anterior cruciate ligament (ACL). Most agree that nondisplaced fractures can be managed nonoperatively, but debate exists over the ideal treatment of displaced fractures. This systematic review evaluates the outcome of nonoperatively and operatively managed displaced tibial eminence fractures. The PubMed, Embase, and Cochrane databases were queried. Inclusion criteria included reported outcomes of displaced tibial eminence fractures, minimum 2-year follow-up, and English language. Outcomes reported were pooled and included the following: clinical instability (Lachman/anterior drawer, pivot shift, and KT 1000), patient-reported pain and/or instability, return to sport, Lysholm, Tegner, and the need for ACL reconstruction. Comparison was made in the outcomes of nonoperatively and operatively treated fractures and between suture and screw fixation techniques. Overall 16 studies met the inclusion criteria. The pooled mean age was 23 years and mean follow-up was 35 months. Clinical instability was seen in 70% of nonoperatively treated patients and 14% of operatively treated patients (p < 0.0001). Patient-reported instability was higher in nonoperatively treated patients (54 vs. 1.2%, p < 0.0001), as was the rate of ACL reconstruction (10 vs. 1.0%, p = 0.036). In comparing suture fixation to screw fixation, patient-reported instability and the rate of ACL reconstruction were equivalent. Patients treated with screw fixation had a higher incidence of clinically measured instability (Lachman and KT arthrometer) and an increased rate of hardware removal (3.9 vs. 64.9%, p < 0.05). Surgically managed patients report less instability, are higher functioning, and require fewer ACL reconstructions when compared with nonoperatively treated patients. Suture fixation was associated with improvements in clinical measures of stability and decreased need for hardware removal; however, patient perception of stability and need for ACL reconstruction was no different between the two treatment methods.

Outcome of All-Inside Second-Generation Meniscal Repair: Minimum Five-Year Follow-up.

BACKGROUND: Meniscal repair and preservation are the goal, when possible, of the treatment of meniscal injury. Current research on second-generation all-inside repair systems has been limited to a maximum of three years of follow-up. The purpose of this study was to evaluate the mid-term clinical success (at more than five years) of meniscal repair performed with a second-generation all-inside repair device, both as an isolated procedure and with a concomitant anterior cruciate ligament (ACL) reconstruction. METHODS: This is a retrospective review of patients who underwent meniscal repair with use of the all-inside FAST-FIX Meniscal Repair System (Smith & Nephew Arthroscopy, Andover, Massachusetts) from December 1999 to January 2007. Eighty-three meniscal repairs (in eighty-one patients) were identified, and follow-up data were obtained for seventy-five (90%). Twenty-six (35%) of the meniscal repairs were performed as isolated procedures. Clinical failure was defined as repeat surgical intervention involving resection or revision repair. Clinical outcomes were also assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and the Marx activity score. RESULTS: The minimum duration of follow-up was five years (average, seven years). Twelve patients (16%) had failure of the meniscal repair, at an average of forty-seven months (range, fifteen to ninety-five months). The data did not offer enough statistical evidence, at alpha = 0.05, to establish a difference in average patient age, patient sex, or number of sutures utilized between successful repairs and failures. There was no difference in the failure rate between isolated repairs (12%; 95% confidence interval [CI]: -0.76% to 23.76%) and those performed with concurrent ACL reconstruction (18%; 95% CI: 7.47% to 29.13%), and the average time to failure was similar between these two groups (48.1 months versus 46.6 months, p = 0.939). Postoperative KOOS and IKDC outcome scores were also similar between the groups. CONCLUSIONS: This report of mid-term follow-up results of primary second-generation all-inside meniscal repair demonstrates its effectiveness both as an isolated procedure and when it is performed with concurrent ACL reconstruction. After a minimum of five years of follow-up, 84% of the patients continued to demonstrate successful repair. Treatment success was further supported by favorable results on patient-based outcome measures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Activity Tolerance After Periacetabular Osteotomy.

BACKGROUND: Periacetabular osteotomy is a well-described surgical intervention for symptomatic acetabular deformities in skeletally mature patients. Data regarding return to athletic activity or sport after this procedure are still limited. PURPOSE: To evaluate the ability of patients to return to preoperative levels of activity after periacetabular osteotomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This is a retrospective review of active patients treated with periacetabular osteotomy for acetabular deformity correction. Patients were identified as those with preoperative University of California-Los Angeles activity levels ≥7. Patient demographics, operative data, radiographic measures, and clinical outcomes were documented prospectively. The University of California-Los Angeles activity score, Harris Hip Score, Hip Dysfunction and Osteoarthritis Outcome Score, and Western Ontario and McMaster Universities Osteoarthritis Index were used to measure clinical outcomes, and details regarding activity and satisfaction were analyzed. RESULTS: This study included 36 patients (39 hips; 15 males and 21 females) whose average age was 25 years (range, 15-45 years) and whose average body mass index was 24 ± 3.5 kg/m(2). Mean follow-up was 33 months (range, 18-59 months). Preoperatively, the average lateral center edge angle, anterior center edge angle, and acetabular index were 10°, 14°, and 21°, respectively; 92% of patients had a Tönnis osteoarthritis grade of 0 or 1. One patient failed hip preservation surgery and went on to total hip arthroplasty 27 months after periacetabular osteotomy. Of the remaining patients, 71% reported an increase or no change in activity level postoperatively. The University of California-Los Angeles score was also unchanged (9.2 vs 8.8, P = .157), and the Harris Hip Score (63 vs 87, P < .001), Hip Dysfunction and Osteoarthritis Outcome Score-Quality of Life (38 vs 71, P < .001), and Western Ontario and McMaster Universities Osteoarthritis Index (71 vs 92, P < .001) results improved from preoperative levels. There was a 97% rate of satisfaction with the surgery. Four patients (11%) reported hip pain as the primary factor limiting postoperative activity. CONCLUSION: The majority (71%) of active patients with hip dysplasia return to presurgical or higher activity levels after open hip preservation surgery with the periacetabular osteotomy.

Nonoperative treatment of osteochondritis dissecans of the knee.

Osteochondritis dissecans is a potentially devastating cause of knee pain in adolescents and adults. Prognosis and treatment depends on the stability of the lesion and the age of the patient. Skeletally immature patients with stable lesions are amenable for nonoperative treatment. Nonoperative treatment is less predictable in skeletally mature patients and patients with unstable lesions. Lesion size, location, stability along with symptomatology should all be considered before initiating treatment. Modalities of nonoperative treatment can range from activity modification to complete immobilization. Close follow-up is recommended to monitor healing progression and symptom resolution.