Search

Background: Meniscal allograft transplantation improves functional and patient-reported outcomes in patients with meniscal deficiency without significant osteoarthritis. In addition, it is known that valgus malalignment of the knee can lead to meniscal and chondral damage, and surgery is often indicated to restore the mechanical axis and slow progression of osteoarthritis. Indications: Indications for this procedure include patients with symptomatic lateral meniscal deficiency with associated valgus deformity of the knee. Patient’s age must be less than 50 years, body mass index less than 35 kg/m2, meniscal deficiency, and ipsilateral pain with or without swelling. Ligament tears, focal cartilage loss, and malalignment are not contraindications if also corrected. Technique Description: We begin by removing the remaining lateral meniscus, taking care to leave a small peripheral rim of meniscus. A transpatellar tendon arthrotomy is performed, and the meniscal allograft is passed through the arthrotomy and into the knee. An inside-out repair is performed using vertical mattress sutures. The sutures are tightened and tied with the knee at 30° to 40° of flexion. The distal femoral osteotomy is then performed. An approach is made to the lateral femur, where initial guidewires are placed using fluoroscopic guidance. The initial saw cut is made about 75% of the way across the femur, and an osteotome is used to complete the osteotomy. Care is taken to preserve the far medial cortex. An adjustable wedge osteotome is placed to open the lateral cortex in accordance with the preoperative template. The cortical wedge is fashioned using the tibial allograft from the meniscal transplant and is placed into the osteotomy. The osteotomy is secured using a locking plate with locking screws, and this is confirmed in safe position using fluoroscopy prior to the conclusion of the case. Results: Patients will have effective deformity correction and alleviation of pain. Many patients can return to sport without restrictions following appropriate rehabhilitation. Conclusion: Lateral meniscal allograft transplantation with distal femoral opening wedge osteotomy is an effective treatment for symptomatic lateral meniscal insufficiency with associated valgus deformity of the knee in patients without osteoarthritis. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Objective Precise graft-host interference fit is a potentially import factor for the successful incorporation of osteochondral allograft (OCA) transplants for the treatment of symptomatic focal cartilage defects. It was hypothesized that selection of OCA plug instrumentation set has a significant effect on graft integration and morphology after OCA transplantation Methods Thirty-one patients who underwent OCA transplantation between July 2013 and July 2016 were identified for this comparative magnetic resonance imaging (MRI) analysis. Patients were stratified into two groups based on the treatment with the Arthrex Allograft OATS Instrument Set or the JRF Ortho Osteochondral Allograft Plug Instrumentation. MRI was obtained at 12 months postoperatively. All grafts were assessed for integration using the Osteochondral Allograft MRI Scoring System (OCAMRISS), host marrow edema size, graft-host interface distance, graft cartilage integrity, cyst size, graft contour and presence of effusion. Results At a mean follow-up of 11.39 ± 1.98 months, 95.5% of all grafts showed osseous integration into the recipient bone with 68.2% presenting without cystic changes of the graft or host-graft junction. No differences were seen in any OCAMRISS subscale besides cartilage signal, which demonstrated minimal differences ( P = 0.046). Conclusion OCAs show excellent osseous integration at the graft-host junction at 12 months postoperatively. The comparative MRI analysis of two instrumentation sets yielded no significant differences in terms of graft integration, bone marrow edema, or cystic formation. Hence, this study cannot recommend one instrumentation set over the other. Consequently, the individual preference should guide the surgeon’s selection of instrumentation for OCA transplantation.

Objectives: Anterior cruciate ligament reconstruction (ACLR) graft failure continues to be a problem with failure rates reported up to 11%. Following revision ACLR, 3.3 – 4.3% of these patients suffer re-tear of the revision ACL graft. The purpose of this study was to evaluate the influence of posterior tibial slope (PTS) on ACL graft re-tear after revision ACLR. It was hypothesized that increased posterior tibial slope (PTS) is associated with an increased risk of ACL graft re-tear following revision ACLR. Methods: Retrospective chart review identified patients who underwent revision ACLR between 2005 and 2016 at a single institution. Patients who suffered an ACL re-tear following revision surgery were matched by age, sex, and graft type to controls who had intact revision ACLR grafts at a minimum of 2 years follow-up. Medial posterior tibial slope (MPTS) and lateral posterior tibial slope (LPTS) were measured on lateral radiographs and sagittal magnetic resonance imaging (MRI). Tibial slope was then compared between groups using independent sample t-tests. Results: Twenty-nine patients with a graft failure after revision ACLR were included and compared to 29 matched controls with a mean follow-up of 5.8 years (range: 2 to 11.3 years). Each group included 16 males and 13 females. Average age was 26 +/- 8.3 years at time of revision ACLR. Both x-ray and MRI demonstrated increased LPTS in the failure group versus controls (12.7 ± 3.2 degrees vs. 10.6 ± 3.6 degrees, p = 0.02 and 8.1 ± 3.4 degrees vs. 5.0 ± 3.5 degrees, p = 0.001, respectively). There was no significant difference in MPTS between the failure and control groups on x-ray (11.9 ± 2.9 degrees vs. 11.1 ± 3.6 degrees, p = 0.3772) nor MRI (4.3 ± 3.5 degrees vs. 3.3 ± 3.0 degrees, p = 0.2486). Conclusions: Matching for age, sex, and graft type, increased LPTS measured on both x-ray and MRI is associated with increased risk of a subsequent ACL injury following revision ACLR. Identification of at-risk patients may guide pre-operative discussions regarding revision ACL graft failure risk.

Background: Recurrent patellar instability is frequently treated surgically with reconstruction of the medial patellofemoral ligament (MPFL). Patients with significant patella alta, trochlear dysplasia, and/or an elevated tibial tubercle–trochlear groove (TT-TG) distance may benefit from a concurrent bony procedure such as tibial tubercle osteotomy or trochleoplasty. The indications to perform such procedures are traditionally based on imaging criteria but remain controversial. Patellar apprehension is common in patients with patellar instability but typically resolves in higher degrees of knee flexion. Hypothesis: The persistence of patellar apprehension at greater than 60° of knee flexion is associated with patella alta, an increased TT-TG distance, and trochlear dysplasia. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 76 patients with recurrent patellar instability were prospectively identified in a sports medicine clinic. Patellar apprehension was evaluated in each patient. Apprehension was defined as the patient reporting that the patella felt unstable to lateral patellar translation. Apprehension was first assessed at full knee extension and repeatedly assessed as the knee was flexed in 10° intervals, as measured using a goniometer. The degree of flexion at which patellar apprehension disappeared was recorded. Plain radiographs and magnetic resonance imaging (MRI) scans were obtained for all patients. Patellar height was assessed with the Caton-Deschamps (CD) index, and trochlear morphology was assessed through measurements of the sulcus angle and depth on MRI and classified using the Dejour classification system. Imaging measurements of patients in whom apprehension resolved by 60° of knee flexion were compared with measurements for those with apprehension that persisted deeper into flexion. Results: Apprehension resolved by 60° of flexion in 56 patients and persisted into deeper flexion in 20 patients. The patients with a delayed resolution of apprehension demonstrated a higher CD index; elevated TT-TG distance; increased sulcus angle; decreased sulcus depth; and higher incidence of Dejour type B, C, or D dysplasia (all P < .05). Of the 20 patients with a delayed resolution of apprehension, 18 had either Dejour type B, C, or D dysplasia or a CD index of at least 1.30. A delayed resolution of apprehension was present in 11 of the 16 patients with Dejour type B, C, or D dysplasia. Conclusion: Overall, 90% of patients with significant patella alta and the majority of patients with high-grade trochlear dysplasia demonstrated patellar apprehension that persisted beyond 60° of knee flexion. Additionally, 90% of patients with persistent apprehension had significant patella alta and/or trochlear dysplasia. Further work is needed to evaluate the utility of these findings to inform surgical decision-making in this population.

Background: Patient-reported outcome (PRO) measures are progressively utilized as evaluation tools in preoperative and postoperative assessments in orthopaedic practice. Identifying the potential utility of psychosocial factors to predict patient-reported pain and functional outcomes is of increasing interest to determine which patients will derive the greatest benefit from surgical treatment. Purpose/Hypothesis: The purpose of this study was to determine potential predictive associations between the preoperative 12-Item Short Form Health Survey Mental Component Summary (SF-12 MCS) score, patient characteristics or osteochondral allograft (OCA) morphology, and PROs in patients who underwent OCA transplantation. We hypothesized that poor preoperative mental health is associated with diminished PROs at final follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 67 patients with a mean follow-up of 2.7 ± 1.0 years (range, 2-6 years) with complete preoperative and at least 24-month postoperative SF-12 MCS, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scores were included in this study. Pearson correlation coefficients and linear regression models were used to distinguish associations between age, sex, smoking status, body mass index, workers’ compensation, previous surgery, concomitant surgery, number of grafts, defect location, total graft size, SF-12 MCS score, and postoperative PRO scores as well as their improvement from baseline (delta). Results: The SF-12 MCS showed significant correlation with the KOOS Activities of Daily Living subscale ( P = .015), KOOS Sport/Recreation subscale ( P = .024), and IKDC ( P = .039). In the multivariable linear regression models, the SF-12 MCS had no predictive association with any PRO measure. Patient sex contributed significantly to the final regression models of the KOOS Sport/Recreation ( P = .042), Tegner score ( P = .024), and Lysholm score ( P = .031). The SF-12 MCS showed no bivariate correlation with changes in any PRO score (delta) ( P > .05). Conclusion: Preoperative mental health status did not predict perceived functional outcomes as assessed by PRO measures at final follow-up. Female sex was negatively correlated with KOOS Sport/Recreation, Tegner, and Lysholm scores.

Background: Pathology of the long head of the biceps tendon is a well-known cause of shoulder pain that is commonly managed with arthroscopic suprapectoral biceps tenodesis when conservative treatment fails. Purpose: To present an arthroscopic knotless suprapectoral biceps tenodesis technique known as “Loop ’n’ Tack” tenodesis and to report the clinical outcomes of patients with a minimum 2 years of follow-up. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of all patients who had undergone Loop ’n’ Tack tenodesis between January 2009 and May 2014 was completed. Charts were reviewed, and patients were contacted for demographic data, time from surgery, concomitant procedures, and workers’ compensation status, as well as visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and University of California, Los Angeles (UCLA) scores. Results: Complete follow-up evaluations were performed for 59 of 68 patients (87%). Mean follow-up was 43 months. A majority (88%) of patients had at least 1 additional procedure performed at the time of biceps tenodesis. The mean ASES shoulder score improved from 42.6 preoperatively to 91.0 postoperatively ( P < .001), and 54 of 59 patients (91.5%) had a good/excellent outcome, with a UCLA shoulder score >27 and ASES shoulder score >70. Three patients (5%) reported biceps cramping pain with overuse, and 2 (3.3%) reported intermittent anterior shoulder pain. No patients had developed a “Popeye” deformity at final clinical examination, and 97% reported that they were overall satisfied with the procedure. Conclusion: The Loop ’n’ Tack tenodesis technique results in a high rate of patient satisfaction, significant improvement in shoulder outcome scores, and a low incidence of postoperative pain, with no reoperations for biceps-related pathology.

Objectives: Pathology of the long of head of the biceps tendon (LHB) is a well-known cause of shoulder pain that is commonly managed with arthroscopic suprapectoral biceps tenodesis when conservative treatment fails. The purpose of this study is to present an arthroscopic, knotless, suprapectoral biceps tenodesis technique known as the Loop ‘N’ Tack and report the clinical outcomes in patients with a minimum of 2 years follow-up. Methods: The technique grasps the LHB proximally at the superior labrum and fixes it to the most distally visualized portion of the intra-articular bicipital groove. A retrospective review of all patients who had undergone the Loop ‘N’ Tack biceps tenodesis by the senior author between January 2009 and May 2014 was completed. Patients were excluded if any portion of the surgery was performed open, or if they had less than 2 years of follow-up. Charts were reviewed and patients were contacted for demographic data, time from surgery, concomitant procedures, worker’s compensation (WC) status, visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and University of California, Los Angeles (UCLA) scores. Statistical analysis was performed using Mann-Whitney U test for comparing non-parametric data sets. Results: follow-up evaluations were performed in 59 of 68 patients (87%). Average follow-up was 43 months. 88% of patients had at least 1 additional procedure performed at the time of biceps tenodesis. The mean ASES scores improved from 42.5 preoperatively to 90.1 postoperatively (p < 0.001). Fifty-four of fifty-nine patients (91.5%) had a good/excellent outcome with UCLA score > 27 and ASES > 70. Three patients (5%) reported biceps cramping pain with overuse. Two patients (3.3%) reported intermittent anterior shoulder pain similar to preoperative symptoms. No patients had developed a “Popeye” deformity at final clinical examination. 97% of patients reported that they were satisfied overall with the procedure. Comparing patients who had a rotator cuff repair or labrum repair at the time of biceps tenodesis with patients who did not have either, there were no significant differences in preoperative VAS or ASES, or postoperative outcomes scores. There were 10 WC patients who had worse postoperative VAS (p = 0.02), ASES (p = 0.03), SANE (p = 0.03), and UCLA scores (p = 0.02) compared to non-WC patients. Conclusion: The Loop ‘N’ Tack biceps tenodesis technique provides a high rate of patient satisfaction and high outcomes scores with a low rate of postoperative pain and no reported incidence of ‘Popeye’ deformity. We believe these good clinical results are due to the secure fixation of the LHB while relieving tension and minimizing motion of the tendon within the bicipital groove. [Figure: see text]