Bioabsorbable Screw Fixation Provides Good Results With Low Failure Rates at Mid-term Follow-up of Stable Osteochondritis Dissecans Lesions That Do Not Improve With Initial Conservative Treatment.

Purpose: To evaluate the clinical and radiographic outcomes of patients who have undergone bioabsorbable screw fixation for intact, stable grade I and II osteochondritis dissecans (OCD) lesions for which at least 6 months of conservative management has failed. Methods: A retrospective review of prospectively collected data from a single institution was performed to identify patients who underwent internal fixation of stable grade I and II OCD lesions (according to the Guhl classification) between January 2010 and January 2020. Patients were included regardless of the presence of concomitant procedures. The inclusion criteria consisted of (1) primary surgery, (2) failure of at least 6 months of conservative management, (3) the use of a bioabsorbable screw (or screws), and (4) minimum 2-year clinical follow-up. Radiographs were obtained at a minimum of 1 year postoperatively. Patient demographic characteristics, clinical patient-reported outcomes, complications, and failure rates were noted. Results: Twenty-four knees among 23 patients (96% follow-up) were analyzed and followed up for 6.36 ± 3.42 years (range, 2.0-12.7 years). Patients showed statistically significant postoperative improvements in all patient-reported outcomes including the Lysholm score, International Knee Documentation Committee score, and Knee Injury and Osteoarthritis Outcome Score subscales (P < .05). In 3 knees (12%), a reoperation was required due to failure at an average of 3.64 years after the index procedure. No specific complications were attributed to the use of bioabsorbable screws. Patients in whom primary surgical treatment failed did not differ in demographic characteristics, arthroscopic findings, or surgical treatment from those who had successful treatment. Conclusions: Internal fixation of stable grade I and II OCD lesions with bioabsorbable screws produces reliable results with a 12% rate of failure in appropriately indicated patients in whom at least 6 months of conservative management has failed. Clinical outcomes improved significantly during the mid-term follow-up period. Level of Evidence: Level IV, therapeutic case series.

Revision and Primary Meniscal Allograft Transplantations Provide Clinical Benefit at Mid-Term Follow-Up: A Matched-Cohort Analysis of Patient-Reported Outcomes, Reoperations, and Failures.

PURPOSE: To report the mid-term outcomes of patients who underwent revision meniscal allograft transplantation (RMAT) and compare survivorship free from reoperation and failure with a matched cohort of patients who underwent primary meniscal allograft transplantation (PMAT). METHODS: A retrospective review of prospectively collected data identified patients who underwent RMAT and PMAT between 1999 and 2017. A cohort of PMAT patients matched at a ratio of 2:1 with respect to age, body mass index, sex, and concomitant procedures served as the control group. Patient-reported outcome measures (PROMs) at baseline and at a minimum of 5 years postoperatively were collected. PROMs and the achievement of clinically significant outcomes were analyzed within groups. Graft survivorship free from meniscal reoperation and failure (arthroplasty or subsequent RMAT) was compared between cohorts using log-rank testing. RESULTS: During the study period, 22 RMATs were performed in 22 patients. Of these RMAT patients, 16 met the inclusion criteria (73% follow-up rate). The mean age of RMAT patients was 29.7 ± 9.3 years, and the mean follow-up period was 9.9 ± 4.2 years (range, 5.4-16.8 years). There were no differences between the RMAT cohort and the 32 matched PMAT patients with respect to age (P = .292), body mass index (P = .623), sex (P = .537), concomitant procedures (P ≥ .286), or baseline PROMs (P ≥ .066). The patient acceptable symptomatic state was achieved by the RMAT cohort for the subjective International Knee Documentation Committee score (70%), Lysholm score (38%), and Knee Injury and Osteoarthritis Outcome Score subscales (Pain [73%], Symptoms [64%], Sport [45%], Activities of Daily Living [55%], and Quality of Life [36%]). In the RMAT cohort, 5 patients (31%) underwent subsequent reoperation at a mean of 4.7 ± 2.1 years (range, 1.7-6.7 years) and 5 patients met the criteria for failure at a mean of 4.9 ± 2.9 years (range, 1.2-8.4 years). There were no significant differences in survivorship free from reoperation (P = .735) or failure (P = .170) between the RMAT and PMAT cohorts. CONCLUSIONS: At mid-term follow-up, most patients who underwent RMAT achieved the patient acceptable symptomatic state for the subjective International Knee Documentation Committee score and the Knee Injury and Osteoarthritis Outcome Score subscales of Pain, Symptoms, and Activities of Daily Living. Additionally, there were no differences in survival free from meniscal reoperation or failure between the PMAT and RMAT cohorts. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort.

Revision and Conversion to Arthroplasty Are Low Among Adolescents Undergoing Meniscal Allograft Transplantation Using the Bridge-In-Slot Technique at Midterm Follow-Up.

PURPOSE: To report midterm outcomes after primary medial and lateral meniscal allograft transplantation (MAT) with fresh-frozen allografts implanted with the bridge-in-slot technique in the adolescent patient population. METHODS: Adolescent patients less than 18 years old at the time of primary MAT from 1999 to 2016 were retrospectively identified. International Knee Documentation Committee (IKDC) subjective form, Lysholm, and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales scores were collected before surgery and at 1-year, 2-year, and a minimum 5-year follow-up. Thresholds for achieving clinically significant outcomes were calculated, and the proportion of patients achieving minimal clinically important difference (MCID), patient-acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) was determined. Meniscus reoperation (partial, subtotal, or total meniscectomy, repair, or failure) and failure (revision MAT or conversion to arthroplasty) rates were determined. RESULTS: Forty-four (female n = 33; male n = 11) of 62 identified patients met inclusion criteria and were followed for a mean of 9.5 ± 3.8 years (range, 5.0-17.7). Lateral MAT was performed in most patients (n = 35/44 [80%]). Isolated MAT was performed in 27 (61%) patients. Common concomitant procedures included osteochondral allograft transplantation (32%), autologous chondrocyte implantation (18%), and anterior cruciate ligament reconstruction (14%). MCID, PASS, and SCB were achieved by patients at a minimum 5-year follow-up for IKDC (62%; 76%; 31%), Lysholm (62%; 79%; 23%), and KOOS questionnaires (Pain [65%; 81%; 41%], Symptoms [58%; 81%; 47%], Activities of Daily Living [53%; 77%; 35%], Sport [86%; 75%; 50%], and Quality of Life [59%; 81%; 59%]), respectively. Fourteen patients (32%) underwent reoperation at an average of 5.0 ± 4.3 years (range, 0.8-14.0) after MAT. Three (7%) patients met criteria for failure, requiring revision MAT an average of 3.8 ± 1.1 years (range, 2.8-4.9) after transplantation. No patients underwent arthroplasty. Overall survival free from failure at 1, 2, 5, and 10 years was 100%, 100%, 93%, and 93%, respectively. At the time of final follow-up, 80% of patients reported satisfaction with their current physical status. CONCLUSIONS: Primary MAT in adolescent patients resulted in significant and durable functional improvements at mid- to long-term follow-up. At an average of 9.5 years after surgery, meniscal reoperation rate was 32% whereas graft survival free of revision MAT was 93%. Adolescents undergoing MAT demonstrated similar functional outcomes and graft survivability when compared to available adult MAT literature. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Minimum 10-Year Clinical Outcomes and Survivorship of Meniscal Allograft Transplantation With Fresh-Frozen Allografts Using the Bridge-in-Slot Technique.

BACKGROUND: Meniscal allograft transplantation (MAT) has been shown to provide clinical benefits in patients with symptomatic meniscal deficiency in the short term and midterm. There is, however, a paucity of data regarding long-term outcomes after MAT using fresh-frozen allografts and the bridge-in-slot technique. PURPOSE: To report clinical outcomes and revision rates after primary MAT with fresh-frozen allografts and the bridge-in-slot technique in a large case series of patients at a 10-year minimum follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of prospectively collected data was performed on patients undergoing primary MAT between 2001 and 2012. Lysholm, International Knee Documentation Committee subjective form, and Knee injury and Osteoarthritis Outcome Score subscales were collected preoperatively and at 1-, 2-, 5-, and minimum 10-year follow-ups. Cox proportional hazards modeling was used to identify variables associated with reoperation and failure, defined as revision MAT or conversion to arthroplasty. Reoperation was defined as a subsequent surgical intervention on the transplanted meniscus, including partial or total meniscectomy, meniscal repair, or failure as defined in the previous sentence. RESULTS: A total of 174 patients undergoing MAT met the inclusion criteria and were followed for a mean of 12.7 ± 2.7 years (range, 10.0-21.0 years). The mean age at surgery was 28.3 ± 10.1 years. The patients were predominantly female (n = 92; 53%), and medial MAT was the most commonly performed procedure (n = 91; 52%). Concomitant procedures were performed in 115 patients (66%), with the most common procedure being osteochondral allograft transplantation (n = 59; 34%). Patients demonstrated statistically significant postoperative improvements at all time points for all patient-reported outcome measures (P≤ .0001). A total of 65 patients (37%) underwent a meniscal reoperation at a mean time of 6.6 ± 5.5 years (range, 0.3-16.7 years) postoperatively. A total of 40 patients (23%) met the criteria for failure at a mean time of 7.3 ± 5.0 years (range, 1.0-17.4 years) after MAT, with 22 of these patients having undergone a previous meniscal reoperation. At the final follow-up, 13 patients (7%) had undergone revision MAT and 27 (15%) had converted to arthroplasty. The MAT survival rates free of meniscal reoperation and failure were 73% and 85% at 10 years and 60% and 72% at 15 years, respectively. At the time of the final follow-up, 86% of patients reported that they were satisfied with their overall postoperative condition. CONCLUSION: Primary MAT demonstrates efficacy and durability with high rates of patient satisfaction at a minimum 10-year follow-up. Patients should be counseled that although reoperation rates may approach 40% at 15 years, rates of overall revision MAT and conversion to arthroplasty remain low at long-term follow-up.

Long-term outcomes after osteochondral allograft transplantation to the humeral head.

BACKGROUND: Long-term outcomes of osteochondral allograft (OCA) transplantation to the humeral head have been sparsely reported in the literature. PURPOSE: To evaluate outcomes and survivorship of OCA transplantation to the humeral head in patients with osteochondral defects at a minimum of 10 years of follow-up. METHODS: A registry of patients who underwent humeral head OCA transplantation between 2004 and 2012 was reviewed. Patients completed pre and postoperative surveys including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Short Form 12 (SF-12), and the visual analog scale. Failure was defined by conversion to shoulder arthroplasty. RESULTS: Fifteen of 21 (71%) patients with a minimum of ten year of follow-up (mean: 14.2 ± 2.40) were identified. Mean patient age was 26.1 ± 8.8 years at the time of transplantation and eight (53%) patients were male. Surgery was performed on the dominant shoulder in 11 of the 15 (73%) cases. The use of local anesthetic delivered via an intra-articular pain pump was the most often reported underlying etiology of chondral injury (n = 9; 60%). Eight (53%) patients were treated with an allograft plug, while seven (47%) patients were treated with a mushroom cap allograft. At final follow-up, mean American Shoulder and Elbow Surgeons (49.9 to 81.1; P = .048) and Simple Shoulder Test (43.1 to 83.3; P = .010) significantly improved compared to baseline. Changes in mean SF-12 physical (41.4 to 48.1; P = .354), SF-12 mental (57.5 to 51.8; P = .354), and visual analog scale (4.0 to 2.8; P = .618) did not reach statistical significance. Eight (53%) patients required conversion to shoulder arthroplasty at an average of 4.8 ± 4.7 years (range: 0.6-13.2). Kaplan-Meier graft survival probabilities were 60% at 10 years and 41% at 15 years. CONCLUSION: OCA transplantation to the humeral head can result in acceptable long-term function for patients with osteochondral defects. While patient-reported outcomes metrics were generally improved compared to baseline, OCA graft survival probabilities diminished with time. The findings from this study can be used to counsel future patients with significant glenohumeral cartilage injuries and set expectations about the potential for further surgery.

Meniscal ramp lesions - Skillful neglect or routine repair?

Background: Meniscal ramp lesions are injuries of the posterior horn of the medial meniscus at the meniscocapsular junction or the meniscotibial ligament and are frequently associated with concomitant anterior cruciate ligament (ACL) injury. Objective: To review the current literature on meniscal ramp lesion management to better define the indications for and outcomes of repair. Methods: A narrative literature review was performed using PubMed, Embase, and Scopus databases. Studies of all evidence levels (I-V) pertaining to meniscal ramp lesions were reviewed and included. Results: The incidence of ramp lesions has been reported between 16% and 42%. Arthroscopy remains the diagnostic gold standard as magnetic resonance imaging has limited sensitivity. Biomechanically, ramp lesions are known to increase anterior tibial translation and rotational laxity. Clinical investigations regarding optimal management are largely limited to studies of low evidence levels. While case series have demonstrated that repair is safe and efficacious, comparative studies have failed to suggest that repair of stable lesions results in superior outcomes when compared to conservative treatment approaches. However, repair may be warranted in unstable ramp lesion injuries despite the increased risk for revision surgery. Conclusion: While there is evidence to suggest that ramp lesion repair can restore joint kinematics, the current body of clinical literature fails to suggest that outcomes following repair are superior to injuries managed conservatively. The current body of clinical literature is limited, and further robust, long-term study is warranted to better guide injury diagnosis and management protocol.