Faculty Bibliography

BACKGROUND:Meniscal tears are common in the young, active population. In this group of patients, repair is advised when possible. While inside-out repair remains the standard technique, recent advances in all-inside repair devices have led to a growth in their popularity. Previous reviews on the topic have focused on outdated implants of limited clinical relevance. PURPOSE:To determine the difference in failure rates, functional outcomes, and complications between inside-out and modern all-inside repairs. STUDY DESIGN:Systematic review. METHODS:A systematic review was registered with PROSPERO and performed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using the MEDLINE, EMBASE, and Cochrane databases. Inclusion criteria were (1) clinical study reporting on all-inside or inside-out repair, (2) evidence levels 1 to 4, and (3) use of modern all-inside implants for all-inside repairs. Exclusion criteria were (1) use of meniscal arrows or screws and (2) concomitant surgical procedures. Study characteristics, subjects, surgical technique, clinical outcomes, and complications were collected and analyzed. RESULTS:A total of 481 studies were screened and assessed for eligibility, which identified 27 studies for review. Studies defined clinical failure as persistent mechanical symptoms, effusion, or joint line tenderness, while anatomic failure was incomplete or no healing on MRI or second-look arthroscopy. There were no significant differences in clinical or anatomic failure rates between inside-out and all-inside repairs (clinical failure: 11% vs 10%, respectively, P = .58; anatomic failure: 13% vs 16%, respectively, P = .63). Mean ± SD Lysholm and Tegner scores for inside-out repair were 88.0 ± 3.5 and 5.3 ± 1.2, while the respective scores for all-inside repair were 90.4 ± 3.7 and 6.3 ± 1.3. Complications occurred at a rate of 5.1% for inside-out repairs and 4.6% for all-inside repairs. CONCLUSION:The quality of the evidence comparing inside-out and all-inside meniscal repair remains low, with a majority of the literature being evidence level 4 studies. In this review comparing modern all-inside devices with inside-out repair, no differences were seen in failure rates, functional outcome scores, or complication rates.

Coracoid transfer procedures are highly effective at improving glenohumeral stability in patients with recurrent shoulder instability; complication rates from this procedure are generally low. We present the first case in the literature of a Propionibacterium acnes (P. acnes) infection following a coracoid transfer. The case stresses the importance of proper antibiotic prophylaxis for patients undergoing Latarjet procedures, as well as the workup for a painful postoperative shoulder, and the need to maintain cultures from the shoulder for up to 21 days to isolate P. acnes.

Knee pain is one of the most frequent complaints evaluated by orthopedic surgeons. It encompasses a broad range of pathology and can present in a variety of ways. Most of this pain can be attributed to essential structures of the knee, including the menisci, cruciate or collateral ligaments, and articular cartilage. However, there are underrecognized structures in and around the knee that can frequently be a cause of knee pathology and pain. Knee pain stemming from these structures may be missed or incorrectly diagnosed, and these patients often present for second and third opinions because of failure to diagnose and treat the underlying pathology. The synovial plica, suprapatellar pouch, lateral retinaculum, infrapatellar fat pad, and infrapatellar branch of the saphenous nerve are less common but still significant causes of knee pain. Although initial treatment involves various nonoperative modalities, operative treatment is often warranted. Operative and nonoperative management of these soft tissue structures may occur in isolation or with concomitant procedures, including knee ligament reconstruction, total knee arthroplasty, tibial tuberosity osteotomy, or lysis of adhesions. With proper recognition of the role of these structures in knee pain, the orthopedic surgeon can offer a valuable primary or adjunctive treatment option for patients with knee pain, especially those without localizing signs of meniscal, ligamentous, or cartilage damage.

PURPOSE/OBJECTIVE:We report a rare case of primary uveal lymphoma and characterize it using histopathology and multimodal imaging. PATIENT AND METHODS/METHODS:A 41-year-old male presented with a 2-year history of increasingly blurry vision in his right eye and no systemic symptoms. Examination revealed a retinal detachment and mass lesion in the right eye. Radiologic and histologic testing was performed. RESULTS:Multimodal imaging localized the lesion to the choroid, and fine needle aspiration biopsy diagnosed the lesion as a low-grade B-cell lymphoma. The patient was treated with external beam radiation, resulting in regression of the mass and resolution of the retinal detachment. CONCLUSIONS:Primary uveal lymphoma is a rare, usually indolent tumor that carries a good prognosis. In this case, we show that primary uveal lymphoma has distinct findings via histopathology and multimodal imaging, and that imaging after radiation treatment documents disease regression.

The number of primary anterior cruciate ligament (ACL) tears is rapidly increasing. In patients who wish to return to their preoperative level of function, specifically as it pertains to participation in sports, the gold standard of treatment following an ACL tear remains an anterior cruciate ligament (ACL) reconstruction. Despite a majority of good/excellent results following primary ACL reconstruction, there is a growing subset of patients with persistent or recurrent functional instability who require revision ACL reconstruction. Preoperative planning for revision ACL reconstruction requires a careful understanding of the root cause of ACL failure, including possible technical causes of primary ACL failure and the presence of combined knee pathology that was not addressed at the index ACL reconstruction. The decision to perform 2-stage revision ACL reconstruction is multifactorial and is reached by technical considerations that may make a 1-stage revision less optimal, including tunnel widening, arthrofibrosis, active infection, and others. Concomitant knee pathology such as meniscal deficiency, malalignment (including an increase in posterior tibial slope), chondral lesions, and other ligamentous laxity may also require a staged approach to treatment. This evidence-based review covers the indications for 2-stage revision ACL reconstruction, surgical techniques, evidence for and technique of bone grafting prior ACL tunnels, and outcomes of 2-stage revision stratified by initial cause of ACL reconstruction failure. With proper preoperative planning and an understanding of the cause of failure following the primary ACL reconstruction, revision ACL reconstruction can offer excellent outcomes in the motivated patient. [Orthopedics. 2016; 39(3):e456-e464.].

BACKGROUND:Total knee arthroplasty is a successful operation for treatment of arthritis. However, devastating wound complications and infections can compromise the knee joint, particularly in revision situations. METHODS:Soft tissue loss associated with poor wound healing and multiple operations can necessitate the need for reconstruction for wound closure and protection of the prosthesis. RESULTS:Coverage options range from simple closure methods to complex reconstruction, including delayed primary closure, healing by secondary intention, vacuum-assisted closure, skin grafting, local flap coverage, and distant microsurgical tissue transfer. CONCLUSION:Understanding the advantages and pitfalls of each reconstructive option helps to guide treatment and avoid repeated operations and potentially devastating consequences such as knee arthrodesis or amputation.

The goal of this study was to perform a systematic review and meta-analysis of the entire arthroscopic hip preservation literature to answer the question, 'Across the world, are we treating the same patient?' There are significant differences in arthroscopic hip preservation publications, subjects and techniques based on both continent and country published. A systematic review was registered with PROSPERO and performed with PRISMA guidelines using three publicly available databases. Therapeutic clinical outcome investigations reporting arthroscopic hip preservation were eligible for inclusion. All study, subject and surgical technique demographics were analyzed and compared between continents and countries. Statistics were calculated using Student's t-tests, one-way analysis of variance, chi-squared and two-proportion Z-tests. There were 134 studies included in the analysis (10 752 subjects; 11 007 hips; 51% female; mean 37.6 years of age; mean 27.2 months length of follow-up), which had a low Modified Coleman Methodology Score (mean 32.4; poor). North America published the largest number of studies (58%) and the most subjects (55%) and hips (56%). Australia (22%) and Europe (18%) operated on subjects with some amount of osteoarthritis most commonly. North America (2.7%) and Europe (2.0%) operated on subjects with dysplasia or borderline dysplasia most commonly. The Modified Harris Hip Score was the most frequently utilized outcome score (24% of studies). The quantity and quality of arthroscopic hip preservation literature is significantly increasing with time. Several significant differences in study, subject and surgical technique demographics between continents and countries were identified. Deficiencies in use of clinical outcome scores and definitions of treated pathologies preclude complete subject comparisons and serve as an impetus for future study quality improvements.

PURPOSE/OBJECTIVE:To conduct a systematic review of meta-analyses comparing nonoperative and operative treatment of patellar dislocations to elucidate the cause of the variation and to determine which meta-analysis provides the current best available evidence. METHODS:A systematic review of the literature to identify meta-analyses was performed. Data were extracted for patient outcomes and recurrent dislocations. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analysis provided the highest level of evidence. RESULTS:Four meta-analyses met the eligibility criteria: 1 Level I evidence, 2 Level II evidence, and 1 Level III evidence. A total of 1,984 patients were included (997 underwent surgery whereas 987 underwent conservative treatment). Three meta-analyses found a lower subsequent patellar dislocation rate in patients managed operatively compared with nonoperatively, whereas one did not find a difference in recurrent dislocation rates between the operative and nonoperative groups. When the results of all the studies were combined, the overall redislocation rate was 29.4% and the rate of recurrent instability episodes was 32.8%. Patients treated operatively had a 24.0% rate of repeat patellar dislocation and a 32.7% rate of recurrent patellar instability, whereas patients treated nonoperatively had a 34.6% rate of repeat patellar dislocation and a 33.0% rate of recurrent instability. In addition, 1 meta-analysis found a significantly higher rate of patellofemoral osteoarthritis in the operative group. No differences in functional outcomes scores were seen between treatments. Two meta-analyses had low Oxman-Guyatt scores (<4), indicative of major flaws. CONCLUSIONS:According to the best available evidence, operative treatment of acute patellar dislocations may result in a lower rate of recurrent dislocations than nonoperative treatment but does not improve functional outcome scores. LEVEL OF EVIDENCE/METHODS:Level III, systematic review of Level I, II, and II studies.

PURPOSE/OBJECTIVE:To determine indications for, operative findings of, and outcomes of revision hip arthroscopy. METHODS:A systematic review was registered with PROSPERO and performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Therapeutic clinical outcome studies reporting the indications for, operative findings of, and outcomes of revision hip arthroscopy were eligible for inclusion. All study-, patient-, and hip-specific data were extracted and analyzed. The Modified Coleman Methodology Score was used to assess study quality. RESULTS:Five studies were included (348 revision hip arthroscopies; 333 patients; mean age, 31.4 ± 4.2 years; 60% female patients). All 5 studies were either Level III or IV evidence. The surgeon performing revision hip arthroscopy was the same as the primary hip surgeon in only 25% of cases. The mean time between primary and revision hip arthroscopy was 27.8 ± 7.0 months (range, 2 to 193 months). Residual femoroacetabular impingement was the most common indication for and operative finding of revision hip arthroscopy (81% of cases). The most commonly reported revision procedures were femoral osteochondroplasty (24%) and acetabuloplasty (18%). The modified Harris Hip Score was used in all 5 analyzed studies, with significant (P < .05) improvements observed in all 5 studies (weighted mean, 56.8 ± 3.6 preoperatively v 72.0 ± 8.3 at final follow-up [22.4 ± 9.8 months]; P = .01). Other patient-reported outcomes (Non-Arthritic Hip Score, Hip Outcome Score, 33-item International Hip Outcome Tool, Short Form 12) showed significant improvements but were not used in all 5 analyzed studies. After revision hip arthroscopy, subsequent reported operations were hip arthroplasty in 11 patients and re-revision hip arthroscopy in 8 patients (5% total reoperation rate). CONCLUSIONS:Revision hip arthroscopy is most commonly performed for residual femoroacetabular impingement, with statistically significant and clinically relevant improvements shown in multiple patient-reported clinical outcome scores at short-term follow-up. The reoperation rate after revision hip arthroscopy is 5% within 2 years, including further arthroscopy or conversion to hip arthroplasty. LEVEL OF EVIDENCE/METHODS:Level IV, systematic review of Level III and IV studies.

BACKGROUND:Although metal-on-metal (MoM) bearing surfaces provide low rates of volumetric wear and increased stability, evidence suggests that certain MoM hip arthroplasties have high rates of complication and failure. Some evidence indicates that women have higher rates of failure compared with men; however, the orthopaedic literature as a whole has poorly reported such complications stratified by gender. QUESTIONS/PURPOSES/OBJECTIVE:This systematic review aimed to: (1) compare the rate of adverse local tissue reaction (ALTR); (2) dislocation; (3) aseptic loosening; and (4) revision between men and women undergoing primary MoM hip resurfacing arthroplasty (HRA). METHODS:Systematic MEDLINE and EMBASE searches identified all level I to III articles published in peer-reviewed journals, reporting on the outcomes of interest, for MoM HRA. Articles were limited to those with 2-year followup that reported outcomes by gender. Ten articles met inclusion criteria. Study quality was evaluated using the Modified Coleman Methodology Score; the overall quality was poor. Heterogeneity and bias were analyzed using a Mantel-Haenszel statistical method. RESULTS:Women demonstrated an increased odds of developing ALTR (odds ratio [OR], 5.70 [2.71-11.98]; p<0.001), dislocation (OR, 3.04 [1.2-7.5], p=0.02), aseptic loosening (OR, 3.18 [2.21-4.58], p<0.001), and revision (OR, 2.50 [2.25-2.78], p<0.001) after primary MoM HRA. CONCLUSIONS:A systematic review of the currently available literature reveals a higher rate of complications (ALTR, dislocation, aseptic loosening, and revision) after MoM HRA in women compared with men. Although femoral head size has been frequently implicated as a prime factor in the higher rate of complication in women, further research is necessary to specifically probe this relationship. Retrospective studies of data available (eg, registry data) should be undertaken, and moving forward studies should report outcomes by gender (particularly complications). LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.