ICRS scores worsen between 2-year short term and 5-year mid-term follow-up after transtibial medial meniscus root repair despite maintained functional outcomes
PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the mid-term results of posterior medial meniscal root tear (PMMRT) repair through assessment of functional outcome scores and magnetic resonance imaging (MRI). METHODS:This was a single-center, retrospective study evaluating patients that had undergone a PMMRT. This was a follow-up to a previously published 2-year outcome study (all original patients were invited to participate). Clinical outcomes included pre- and postoperative International Knee Documentation Committee (IKDC) and Lysholm scores. Root healing, meniscal extrusion, and cartilage degeneration via International Cartilage Repair Society Scale (ICRS) grades were assessed on MRI by two musculoskeletal fellowship-trained radiologists. RESULTS:10 of the original study's 18 patients were able to participate. Mean age and BMI was 48.4â€‰Â±â€‰12.0Â years and 29.5â€‰Â±â€‰4.5, respectively, with mean follow-up 65.5â€‰Â±â€‰8.3Â months (range 52.0-75.8) (60% female). The IKDC significantly increased from 43â€‰Â±â€‰13 preoperatively to 75â€‰Â±â€‰16 at 5-year follow-up (pâ€‰<â€‰0.001). There was no significant change in IKDC score between 2-year and 5-year follow-up [75â€‰Â±â€‰16 vs 73â€‰Â±â€‰20, (n.s)]. TheÂ Lysholm also significantly increased between preoperative and 5-year follow-up (49â€‰Â±â€‰7 vs 84â€‰Â±â€‰11, pâ€‰<â€‰0.001). There was no significant change between Lysholm score at 2-year and 5-year follow-up [84.0â€‰Â±â€‰11 vs 82â€‰Â±â€‰13, (n.s)]. Mean extrusion did not significantly change from the preoperative state to 5-year follow-up [4.80Â mmâ€‰Â±â€‰1.9 vs 5.0Â mmâ€‰Â±â€‰2.5, (n.s.)]. Extrusion also did not significantly change between 2-and 5-year follow-up [6.1â€‰Â±â€‰3.2Â mm vs 5.0Â mmâ€‰Â±â€‰2.5, (n.s.)]. No patients withâ€‰>â€‰3Â mm of extrusion on preoperative MRI hadâ€‰<â€‰3Â mm of extrusion on postoperative MRI. Both medial femoral condyle and medial tibial plateau ICRS grades significantly increased from preoperative to 2-year follow-up (pâ€‰=â€‰0.038, pâ€‰=â€‰0.023, respectively). Medial femoral condyle and medial tibial plateau ICRS grades again significantly increased between 2-year and 5-year follow-up (pâ€‰=â€‰0.014, pâ€‰=â€‰0.034). CONCLUSION/CONCLUSIONS:Patients treated with the transtibial suture pullout technique with two locking cinch sutures had maintenance of clinical outcome improvements at 5-year follow-up. However, extrusion was widely prevalent,Â with worsening progression of femoral and tibial chondral disease. LEVEL OF EVIDENCE/METHODS:Level 4.
Posterior tibial tubercle measured by the sagittal TT-TG distance correlates with increased risk for patellofemoral chondral lesions
PURPOSE/OBJECTIVE:To evaluate the variation in tibial tubercle sagittal alignment in patients with and without patellofemoral (PF) cartilage wear. METHODS:This was a single-centre, retrospective review of patients that underwent a cartilage restoration procedure for isolated PF cartilage wear from 2014 to 2020. Patients were matched in a 1:2 ratio for age, sex and BMI to partial meniscectomy patients as controls. The sagittal TT-TG (sTT-TG) distance was measured on preoperative axial T2 magnetic resonance imaging (MRI) and was defined as the distance between a point at the nadir of the trochlear cartilage and the most anterior point of the tibial tubercle. RESULTS:One hundred and forty patients (47 cartilage restoration, 94 meniscectomy) were included. Mean age, BMI, and height for the total cohort were 34.01â€‰Â±â€‰8.7, 26.6â€‰Â±â€‰6.4, and 173.0â€‰Â±â€‰17.7 respectively, with 78 males (55%) and 63 females (45%). There were no significant differences between groups for age, BMI or sex (n.s). The cartilage restoration group (-â€‰2.5Â mmâ€‰Â±â€‰5.9) was found to have a significantly more posterior (negative) sTT-TG compared to the meniscectomy group (1.72Â mmâ€‰Â±â€‰6.7) (pâ€‰<â€‰0.001). Interrater reliability was excellent (ICCâ€‰=â€‰0.931, pâ€‰<â€‰0.001). Patients with less than -â€‰3.4Â mm sTT-TG were 2.74 times more likely to have a cartilage restoration procedure compared to those with greater thanâ€‰-â€‰3.4Â mm (OR 2.7, 95% CI 1.3-5.85). Patients with <â€‰-â€‰10Â mm posterior translation were 13.7Ã— (CI 1.6-111.1) more likely to have a cartilage restoration procedure. CONCLUSION/CONCLUSIONS:Patients that underwent isolated cartilage restoration procedures had a significantly more posterior tibial tubercle than partial meniscectomy controls based on the sagittal TT-TG. The more posterior the tubercle, the more likely the patient had a cartilage restoration procedure. Surgeons should consider the sTT-TG measurement in patients presenting with anterior knee pain, particularly patellofemoral lesions. LEVEL OF EVIDENCE/METHODS:III.
Return to Play After Biceps Tenodesis for Isolated SLAP Tears in Overhead Athletes
BACKGROUND/UNASSIGNED:Performing open subpectoral biceps tenodesis in overhead athletes with a superior labrum anterior to posterior (SLAP) tear may affect their ability to return to overhead sports. PURPOSE/UNASSIGNED:To investigate clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex. STUDY DESIGN/UNASSIGNED:Case series; Level of evidence, 4. METHODS/UNASSIGNED:value of <.05 was considered to be statistically significant. RESULTS/UNASSIGNED:The current study included 44 overhead athletes. The mean age was 34.9 years (range, 16-46 years), 79.5% were male, and the mean follow-up was 49.0 months (range, 18-107 months). Overall, 81.8% of patients returned to play their overhead sport after biceps tenodesis, and 59.1% of patients returned to the same or higher level of play. It took patients, on average, 8.7 months to return to play after biceps tenodesis. The mean SLAP-RSI score was 69.4, and 70.5% of patients passed the SLAP-RSI threshold of 56. The mean ASES score, VAS score, SSV, and satisfaction were 92.0, 0.8, 80.6, and 87.9%, respectively. No patients in our cohort required revision surgery. CONCLUSION/UNASSIGNED:This study found that athletes undergoing biceps tenodesis for the treatment of a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery.
Female Gender Is Associated with Lower Satisfaction with Postoperative Telemedicine Visits in Sports Medicine
Increased time from injury to surgical repair in patients with proximal hamstring ruptures is associated with worse clinical outcomes at mid-term follow-up
INTRODUCTION/BACKGROUND:Prior studies of hamstring tendon tears have reported varied findings on whether increased delay from injury to surgery is associated with worse outcomes. The purpose of this study was to determine whether increased time from injury to surgical repair is associated with worse clinical outcomes in patients with proximal hamstring ruptures. MATERIALS AND METHODS/METHODS:Patients who underwent surgical repair of a proximal hamstring rupture from 2010 to 2019 were followed for a minimum of 24Â months from surgery. A cutoff of 6Â weeks from injury to the time of surgery was used to distinguish between acute and chronic ruptures. All patients completed patient-reported outcome measures (PROs) at the final follow-up. Multiple factors were analyzed for their effects on PROs including time to surgery, amount of tendon retraction, and demographics such as sex and age. RESULTS:Complete data sets were obtained for 38 patients at a mean follow-up of 4.9Â years. All data is reported as a meanâ€‰Â±â€‰standard deviation. Patients who underwent acute repair of proximal hamstring ruptures had significantly greater Perth Hamstring Assessment Tool (PHAT) scores than those who underwent chronic repair (76.9â€‰Â±â€‰18.8 vs 60.6â€‰Â±â€‰18.2, pâ€‰=â€‰0.01). Increased time to surgery was significantly correlated with worse PHAT scores (Ïâ€‰=Â -Â 0.47, pâ€‰=â€‰0.003). There was no difference in PROs based on the amount of tendon retraction, number of tendons torn, sex, smoking status, or BMI. CONCLUSIONS:This study found that acute repair performed within 6Â weeks of injury appears to yield improved PROs compared to chronic repair. These data highlight the importance of timely and accurate diagnosis of proximal hamstring ruptures and early operative intervention for surgical candidates.
Estimated Time to Maximum Medical Improvement of Intra-articular Injections in the Treatment of Knee Osteoarthritis-A Systematic Review
PURPOSE/OBJECTIVE:The purpose of the current study is to perform a systematic review of the literature and evaluate maximum medical improvement and minimal clinically important difference (MCID) of different injectables in the treatment of symptomatic knee osteoarthritis. METHODS:A systematic review was performed to evaluate maximum medical improvement and MCID in patients undergoing injections of different modalities for knee osteoarthritis. Demographic factors of the patients being reviewed were analyzed, with patient-reported outcomes as reported by visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) being used to evaluate the clinical trajectory of patients receiving intra-articular injections. RESULTS:Overall, 79 (level of evidence I: 79) studies met inclusion criteria, with 8761 patients. Corticosteroid (CS) injections, middle molecular weight hyaluronic acid (MMW-HA), and leukocyte-rich platelet rich plasma (LR-PRP) injections reached their maximum pain control at 4 to 6 weeks afterÂ injection, as measured by VAS. The lowest VAS scores were reached for low molecular weight hyaluronic acid (LMW-HA), high molecular weight hyaluronic acid (HMW-HA), and leukocyte-poor platelet rich plasma (LP-PRP) by 3 months after injection. Similarly, the WOMAC scores were lowest at 4 to 6 weeks after CS and MMW-HA injections, and at 3 months after HMW-HA and LP-PRP injections. LR-PRP demonstrated the most prolonged pain relief relative to the other injection types, with the lowest VAS score of all groups measured at final follow-up. LP-PRP showed the lowest WOMAC scores at final follow-up, one year post-injection. CONCLUSION/CONCLUSIONS:PRP injections provide continued pain relief at up to 1 year after injection. Corticosteroids and hyaluronic acid have good efficacy and are suitable for many patients but lack this longevity. LEVEL OF EVIDENCE/METHODS:Level I, a systematic review of Level I studies.
The Latarjet-Patte Procedure Past, Present, and Future
The Latarjet-Patte procedure has a long and storied history that predates shoulder arthroscopy, but its popularity has increased over the past two decades as a treatment for anterior glenohumeral instability with bone loss. Transfer of the coracoid process and conjoint tendon to the anteroinferior glenoid creates a triple-blocking effect that is both static and dynamic, lending it biomechanical superiority over alternative bone block techniques. Patients undergoing the Latarjet-Patte procedure have low rates of recurrent instability compared to arthroscopic soft-tissue stabilization procedures, particularly in the setting of glenoid- and humeral-sided bone loss. A number of technical innovations have been developed in recent years to improve the efficacy of this procedure and to reduce its potential complications, although their associated learning curves and potential for widespread adoption remain unclear. In this article, we review the history, indications, outcomes, and future of this surgical technique.
High Rate of Satisfaction and Return to Play at 5-Year Following Arthroscopic Superior-Labrum Anterior-Posterior Repairs
PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the outcomes of patients 5-years post-operatively following arthroscopic superior-labrum anterior-posterior (SLAP) repair, and to evaluate factors associated with satisfaction. METHODS:A retrospective review of patients who underwent SLAP repair with a minimum of 5-year follow-up was performed. Recurrence, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, satisfaction, whether they would undergo the same surgery again, and the rate, level and timing of return to play (RTP) were evaluated. Multi-linear regression models were used to evaluate factors affecting postoperative satisfaction. RESULTS:Overall, 122 patients who underwent SLAP repair were included, with a mean age of 33.4 years. 81% were males, and 58.2% were participating in sport pre-operatively. The mean follow-up was 86.4 Â± 14.4 months. At final follow up, the mean satisfaction was 87.7%, and the mean SSV was 82.9. Overall, the rate of RTP was 85.9%, with 64.8% returning at the same level at a mean of 10.5 Â± 8 months. Ultimately, 13 (10.7%) patients had a further surgery, including 10 (8.2%) patient that had a biceps tenodesis. VAS during sport (p = 0.025), SSV (p < 0.001), and time to RTP (p = 0.0056), were associated with higher satisfaction. CONCLUSION/CONCLUSIONS:There was a high rate of satisfaction at 5-year follow-up, with excellent patient reported outcomes but with a tenth of patients requiring revision surgeries. Additionally, while there was an overall high rate of RTP, there was only a modest rate of RTP at their pre-injury level and overhead athletes took longer to RTP.
Open Subpectoral Biceps Tenodesis May Be an Alternative to Arthroscopic Repair for SLAP Tears in Patients Under 30
PURPOSE/OBJECTIVE:The purpose of the current study is to compare the outcomes of open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under the age of 30 years. METHODS:A retrospective review of patients under the age of 30 years who underwent either isolated BT or AR for a diagnosis of a SLAP tear between 2011 and 2019 was performed. Patients were included if they were >16 years old at the time of surgery, had an isolated SLAP tear involving instability of the biceps-labral anchor (types II-IV), were skeletally mature, and had a minimum follow-up of 12 months. The American Shoulder & Elbow Surgeons score, visual analog scale, Subjective Shoulder Value, patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A P value of <.05 was considered statistically significant. RESULTS:Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, and the mean follow-up duration was 60 months. At final follow-up, there was no difference between treatment groups in any of the functional outcome measures assessed (PÂ >Â .05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; PÂ = .53), timing of RTP (BT: 8.8 months, AR: 9.4 months; PÂ = .61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; PÂ >Â .99). Among those undergoing AR, 9 required a revision procedure (11.5%) compared to none treated with BT (PÂ =Â .11). CONCLUSIONS:In patients under the age of 30 years with a symptomatic isolated SLAP tear, BT may be a reliable alternative to AR. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.
Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement
PURPOSE/OBJECTIVE:The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. METHODS:A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS:The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. CONCLUSION/CONCLUSIONS:Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. LEVEL OF EVIDENCE/METHODS:Level V, expert opinion.