Contemporary Outcomes of Transfemoral Amputation After Total Knee Arthroplasty.

BACKGROUND: Transfemoral amputation (TFA) is a salvage procedure for unreconstructable failed total knee arthroplasty (TKA). Prior studies have reported poor outcomes, patient survival, and prosthetic use. The purpose of this study was to analyze patient outcomes and prosthetic utilization in a contemporary group of patients undergoing TFA in the setting of a TKA. METHODS: We reviewed 112 patients undergoing TFA with a prior TKA. Indications for amputation and postoperative functional measures were captured through chart review. Patients were contacted by survey to assess the quality of life. The mean follow-up after TFA was 4 years. RESULTS: Amputations were performed for a chronically infected TKA (n = 87, 78%) and an ischemic limb without signs of an infected TKA (n = 22, 20%). The 10-year survival after TFA was 21%. Of the patients not lost to follow-up, 53 (47%) patients were fitted for a prosthesis. Patients who underwent a TFA after the year 2000 were more likely to be fit for a prosthesis (odds ratio 7.27, P < .01); however, patients were likely to be ambulatory before TFA than after TFA (odds ratio 3.68, P < .01). After TFA, the mean 12-Item Short Form Survey scores for the mental and physical components were 54 ± 13 and 34 ± 7, with no difference in scores between patients fitted for a prosthesis and those who were not (P > .05). CONCLUSION: Patients undergoing a TFA after TKA due to failure of the TKA are more likely to be fit for a prosthesis; however, they reported no better quality of life and satisfaction compared with patients not fit for a prosthesis. LEVELS OF EVIDENCE: Level III, Therapeutic.

Can Prior Episode-of-Care Costs Predict the Future? Identifying High-Cost Outliers for Subsequent Total Hip and Knee Arthroplasty.

BACKGROUND: It remains unknown if a patient's prior episode-of-care (EOC) costs for total hip (THA) or knee (TKA) arthroplasty procedure can be used to predict subsequent costs for future procedures. The purpose of this study is to evaluate whether there is a correlation between the EOC costs for a patient's index and subsequent THA or TKA. METHODS: We reviewed a consecutive series of 11,599 THA and TKA Medicare patients from 2015 to 2019 and identified all patients who underwent a subsequent THA and TKA during the study period. We collected demographics, comorbidities, short-term outcomes, and 90-day EOC claims costs. A multivariate analysis was performed to identify whether prior high-EOC costs were predictive of high costs for the subsequent procedure. RESULTS: Of the 774 patients (6.7%) who underwent a subsequent THA or TKA, there was no difference in readmissions (4% vs 5%, P = .70), rate of discharge to a skilled nursing facility (SNF) (15% vs 15%, P = .89), and mean costs ($18,534 vs $18,532, P = .99) between EOCs. High-cost patients for the initial TKA or THA were more likely to be high cost for subsequent procedure (odds ratio 14.33, P < .01). Repeat high-cost patients were more likely to discharge to an SNF for their first and second EOC compared to normative-cost patients (P < .01). CONCLUSION: High-cost patients for their initial THA or TKA are likely to be high cost for a subsequent procedure, secondary to a high rate of SNF utilization. Efforts to reduce costs in repeat high-cost patients should focus on addressing post-operative needs pre-operatively to facilitate safe discharge home.

Nonoperative Management of Minimally Displaced Patellar Sleeve Fractures.

Patellar sleeve fractures primarily occur in the adolescent population from a rapid contraction of the quadriceps with the knee in a flexed position. Several small case reports describe operative reduction and fixation for displaced fractures. However, there is sparse literature on nonoperative management of these injuries. Retrospective review and prospective follow-up of all patients diagnosed with patellar sleeve fracture between 1991 and 2014 at a single institution. Patients with superior pole avulsion fractures, history of prior knee surgery, and fractures managed operatively were excluded. Patients with a clinical diagnosis without support of advanced imaging were also excluded. Radiographs and magnetic resonance imaging (MRI) were reviewed for initial fracture displacement, time until fracture union, and the presence of patellar tendon ossification. Outcome was assessed using the Tegner's activity scale, Kujala's Score and the International Knee Documentation Committee (IKDC) subjective knee evaluation score at final follow-up. Eighteen nonoperatively treated distal patellar pole sleeve fractures were identified, while five patients had advanced imaging to support their diagnosis. All were males with a mean age of 15.1 (range: 12-18). Traumatic and sport-related injuries were noted in the majority of patients. Only one patient had any appreciable displacement, but still < 2 mm. Final radiographic evaluation revealed fracture healing without patellar tendon ossification in all patients. All five patients had full terminal knee extension and symmetric range of motion. Mean IKDC score was 96.4 (range: 82-100) mean Tegner's activity score was 60 (range: 5-8), and mean Kujala's score was 89.7 (range: 63-100) at final follow-up. Of the five cases, three patients presented in a delayed fashion, and all went on to have surgical treatment. Two required arthroscopic loose body removal, while the other had an open patellar debridement and platelet-rich plasma (PRP) injection. Minimally displaced patellar sleeve fractures can be successfully managed nonoperatively with excellent clinical outcomes. However, delayed in presentation may be associated with worse outcome. This study of case series reflects level of evidence IV.

Robots in the Operating Room During Hip and Knee Arthroplasty.

PURPOSE OF THE REVIEW: The utilization of technology has increased over the last decade across all surgical specialties. Robotic-assisted surgery, among the most advanced surgical technology, applied to hip and knee arthroplasty has experienced rapid growth in utilization, surgical applications, and robotic platforms. The goal of this study is to provide a comprehensive review of the most commonly utilized robotic platforms for hip and knee arthroplasty and the most up to date literature on the benefits and limitations of robotic arthroplasty. RECENT FINDINGS: Studies consistently demonstrate that that robotic-assisted surgery during total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) improves component position and alignment. There is also growing evidence that robotic-assisted UKA improves clinical outcomes and implant survivorship and, therefore, may be cost-effective. However, there remains to be convincing evidence that robotic-assisted arthroplasty improves clinical outcome measures or reduces revision rates for THA and TKA. Potential disadvantages of robotic arthroplasty remain, including a learning curve, potential for additional radiation exposure preoperatively, and the financial costs. Robotic hip and knee arthroplasty remains attactive as studies show that it consistently improves implant position and alignment over conventional techniques. There is growing evidence that robotic UKA may improve patient outcomes and reduce revision rates, but further study is needed. In addition, further and longer-term studies are needed to determine if improved component position and alignment in TKA and THA leads to improved clinical outcomes and reduced revision rates.

Incidence of Patella Baja Before and After Primary Total Knee Arthroplasty Based on Body Mass Index.

In the setting of total knee arthroplasty, patella baja has been associated with decreased range of motion and increased risk of certain extensor mechanism complications. The goal of this study was to determine whether obese patients had an increased prevalence of patella baja before and/or after primary total knee arthroplasty. A multicenter retrospective review of 5089 unilateral total knee arthroplasties performed between 1998 and 2012 for osteoarthritis was conducted. Only total knee arthroplasties with cemented modular, metal-backed constructs and patellar resurfacing were included. An a priori power analysis determined that 500 patients (stratified into 5 World Health Organization body mass index groups, matched by age and sex) were needed to detect a significant Insall-Salvati ratio difference of 0.07. Patella baja was defined as an Insall-Salvati ratio of less than 0.8. Preoperative and postoperative Insall-Salvati ratios were compared between groups and analyzed using linear regression and analysis of variance. Preoperatively, there was a higher prevalence of patella baja in the higher body mass index groups (>25 kg/m2) compared with normal weight patients (10% vs 6%; P=.02). Postoperatively, there was no difference in the prevalence of patella baja between the 2 groups (5% vs 5%; P=.91). On comparison of postoperative Insall-Salvati ratio with preoperative Insall-Salvati ratio, the higher body mass index groups had a greater change in Insall-Salvati ratio (Δ 0.10 vs Δ 0.07; P=.01). This is the first study to report an increased prevalence of patella baja in obese patients and to show that the prevalence normalizes to that of a control group after total knee arthroplasty. Obese patients undergoing primary total knee arthroplasty had a higher rate of preoperative patella baja. [Orthopedics. 2019; 42(2):90-94.].

Increased Risk of Revision, Reoperation, and Implant Constraint in TKA After Multiligament Knee Surgery.

BACKGROUND: The risk of major complications and revision arthroplasty after TKA in patients who previously underwent multiligament knee surgery have been poorly characterized. QUESTIONS/PURPOSES: Is multiligament knee surgery before TKA associated with (1) worse implant survival, (2) increased use of TKA design constraint, (3) a greater risk for major complications, and (4) poorer scores for pain and function compared with similar patients receiving TKA for primary osteoarthritis? METHODS: Fifty-nine TKAs were performed at our institution between 1985 and 2014 in 59 patients (36 men, 23 women; mean age, 53 years) with a history of previous multiligament knee surgery (≥ two ligaments). Of those, we had followup for 39 (66%), 18 (31%), and six (10%) patients at 5, 10, and 15 years, respectively; mean followup was 5.4 years (range, 1-25 years). A two-to-one matched control group consisting of patients undergoing primary TKA for the diagnosis of osteoarthritis was selected for comparison. Patients were matched based on gender, age at primary TKA (within 5 years), and date of the TKA (within 5 years). Medical records were reviewed for survivorship, TKA design, complications (reoperation, revision, infection, manipulation under anesthesia, and periprosthetic joint infection), TKA design, and clinical outcomes (Knee Society Scores [KSS], Knee Society Function Score [KSS-F]). RESULTS: The overall 15-year revision-free survival in patients with prior multiligament knee surgery was decreased in comparison to the matched controls (42% [95% CI, 16%-73%] vs 94% [95% CI, 81%-99%]; p < 0.001). Varus-valgus constraint implant design was used for more patients in the multiligament cohort at index TKA than in the matched control group (9/59 [15%] vs 0/110 [0%], respectively; odds ratio [OR], 45; 95% CI, 3-781; p = 0.009). Patients with a history of multiligament knee surgery also were at increased risk of reoperation for any cause (14/59 [24%] vs 7/118 [6%]; OR, 5; 95% CI, 2-14; p = 0.001). With the numbers available, there was no difference in the frequency of manipulation under anesthesia after TKA (10% [6/59] versus 3% [4/118]; p = 0.08) A higher proportion of patients in the multiligament cohort had infections develop compared with the matched controls (4/59 [7%] vs 1/118 [< 1%)], respectively; p = 0.04). There was no difference in the KSS improvement after TKA between the multiligament group and the control group (34 ± 18 vs 28 ± 15; p = 0.088). The final KSS and KSS-F scores likewise showed no difference between those groups (88 ± 13 vs 85 ± 10; p = 0.232) (85 ± 17 vs 84 ± 14; p = 0.75). CONCLUSIONS: A history of multiligament surgery is associated with lower long-term survivorship, higher use of constrained TKA designs, and higher risk of major complications, including reoperation and infection. Further research is necessary to determine if a particular multiligamentous surgical technique can prevent posttraumatic arthritis and TKA complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Return to sport: Does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes?

PURPOSE: The purpose of this study was to determine whether patients with excellent 6-month functional testing after ACL reconstruction had (1) higher risk of subsequent ACL tears, (2) superior knee function, and (3) increased activity levels compared to those with delayed clearance for return to sports at midterm follow-up. METHODS: A total of 223 patients underwent primary ACL reconstruction by a single surgeon and had functional and isokinetic testing performed 6 months post-operatively between 1998 and 2005. Of the 223 patients, 52 (23 %) made the excellent group and were allowed return to sport at 6 months, and the remaining 171 (77 %) constituted the delayed group. Rate of ACL graft tear and native contralateral ACL tear was compared between groups. In addition, IKDC and Tegner scores were compared at a mean 4-year follow-up. RESULTS: The graft rupture rate was similar in the excellent group (3.8 %, n = 2) compared to the delayed group (4.7 %, n = 8; p = 0.30). However, there was a higher rate of contralateral ACL tear in the excellent group (15.4 %, n = 8 vs. 5.3 %, n = 9; p = 0.003). The excellent 6-month group had superior IKDC scores (94.3 ± 6.4 vs. 90.9 ± 9.7; p = 0.04) and Tegner scores (6.6 ± 1.8 vs. 5.7 ± 1.6; p = 0.01). CONCLUSION: Patients with an excellent performance on their isokinetic strength and functional testing at 6 months after ACL reconstruction have superior knee function and higher activity levels at midterm follow-up. However, these patients appear to be at greater risk of contralateral ACL injury, which may be related to their increased activity level. When isokinetic and functional testing is used for return-to-sport decisions, physicians should caution patients about the risk of contralateral ACL injury for high performing patients. LEVEL OF EVIDENCE: Retrospective Review with Control, Level III.

The Cost of Getting Into Orthopedic Residency: Analysis of Applicant Demographics, Expenditures, and the Value of Away Rotations.

OBJECTIVES: Little is known about the demographics and expenditures of applicants attempting to match into the competitive field of orthopedic surgery. In attempt to better inform potential applicants, the purposes of this work are to (1) better understand the demographics of successfully matched applicants, (2) determine the monetary cost of applying, and (3) assess the value of away rotations for improving chances of a successful match. DESIGN: Prospective comparative survey. SETTING: Mayo Clinic Department of Orthopedic Surgery, Rochester, MN. PARTICIPANTS: A week following the 2015 Orthopedic Surgery Residency Match, a survey was sent to 1,091. The survey focused on applicant demographics, number of programs applied to, cost of applying, and the value of away rotations. RESULTS: A total of 408 applicants completed the survey (response rate = 37%). Of these, 312 (76%) matched and 96 (24%) did not match into a US Orthopedic Surgery Residency. Of the matched applicants, 300 (96%) were from US allopathic medical schools, 9 (3%) US Osteopathic Schools, and 3 (1%) were international graduates. Males comprised 84% of these applicants whereas 16% were female. The mean number of programs applied to was 71 (range: 20-140). On average, applicants were offered 16 interviews (range: 1-53) and they attended 11 (range: 0-12). Completing a rotation at a program increased an applicant׳s chances of matching into that program by a factor of 1.5 (60% vs 40%). Of the applicants who matched, most applicants matched to an orthopedic residency in the same region where the applicant attended medical school (58%). The average cost of the application was $1,664 (range: $100-$5,000) whereas the cost of interviews (travel, food, etc.) was $3,656 (range: $15-$20,000). Total expenditures ranged from $450 to $25,000 (mean = $5,415). Over 8% of matched applicants spent >$10,000. CONCLUSIONS: Gaining acceptance into orthopedic surgery residency remains a very competitive process. Away rotations appear to correlate strongly with match status; however, the process remains quite expensive for applicants.

Intra-articular Diagnostic Injection Exhibits Poor Predictive Value for Outcome After Hip Arthroscopy.

PURPOSE: To determine whether the amount of pain relief after preoperative intra-articular (IA) anesthetic injection predicts clinical and functional outcomes after hip arthroscopy, especially when controlling for the presence of chondral degeneration. METHODS: We identified patients who underwent IA injection and subsequent hip arthroscopy for labral pathology between 2007 and 2013 performed by a single surgeon. Inclusion criteria were ultrasound- or fluoroscopic-guided IA anesthetic injection performed at our institution, prospectively documented pre- and postinjection numerical rating scale pain scores, and minimum 1-year follow-up postoperatively. Patients were divided into 2 groups, those who received >50% pain relief from preoperative IA anesthetic injection and those who received ≤50% relief. Preoperative radiographs were reviewed, and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome. RESULTS: Of the 319 arthroscopic hip surgeries performed between 2007 and 2013, 115 (37%) patients were lost to follow-up, 16 (5%) patients did not receive an IA injection, 16 (5%) patients had an injection containing gadolinium, and 40 (13%) patients completed injections at an outside institution. Five (2%) patients were excluded for a history of ipsilateral hip surgery, and 3 (1%) for a history of contralateral hip surgery, leaving 96 hips in 96 patients. There were 71 females (74%) and 25 males (26%) with a mean age of 37.6 ± 14.0 years. Tonnis was grade 0, 1, and 2 for 26 (27%), 55 (56%), and 16 (17%) patients, respectively. Fifty-one (53%) of the injections contained a corticosteroid. The mean pain relief after IA injection was 73% ± 36% (range, 0% to 100%). Twenty-six hips (26%) had ≤50% pain relief, whereas 70 (73%) had >50% pain relief, and the median time interval from injection to surgery was 3 (range, <1 to 20) months. Outcome scores were obtained at a mean 14.8 (range, 11 to 30) months after arthroscopic surgery. Postoperative mean Modified Harris Hip Score, HOS activities of daily living, and HOS-Sport scores were 79.2 ± 17.3, 82.6 ± 17.3, and 67.4 ± 28.2, respectively. There was no statistical correlation between percent pain relief and outcome. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. Multivariate regression analysis showed no significant predictors of outcome, including age, gender, Tonnis grade, percent relief with IA injection, or type of surgery. CONCLUSIONS: In this study of patients undergoing hip arthroscopy for labral pathology, our data indicate that the amount of pain relief from IA injection may be a poor predictor of short-term outcome, even when adjusting for chondral degeneration. Although anesthetic injections can be an important diagnostic tool in select patients, a combination of the clinical history, physical examination, and imaging findings is fundamental. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Orthopedic Surgery Applicants: What They Want in an Interview and How They Are Influenced by Post-Interview Contact.

OBJECTIVES: Common strategies for orthopedic residency programs to attract competitive applicants include optimizing the interview day and contacting favorably ranked applicants postinterview. The purpose of this work was to determine (1) applicants' perspectives on the ideal interview day, (2) how frequently applicants are contacted postinterview, and (3) the influence of this contact on rank order lists (ROL). DESIGN: Prospective Comparative Survey SETTING: Mayo Clinic Department of Orthopedic Surgery, Rochester, MN, USA PARTICIPANTS: A survey was completed by 312 successfully matched orthopedic surgery residency applicants following the 2015 match regarding their views of the ideal interview day, components they valued most, post-interview contact, and how that contact influenced their ROL. RESULTS: Applicants stated they preferred interviews that lasted 15 (55%) minutes, a mean of 1.7 (range: 1-5) interviewers present per interview, 5 total interviews (range: 1-10) in a day, an interview with residents (96%), and interviews days lasting only a half day (88%). The majority (94%) desire a social event attended by only residents (54%) or staff and residents (46%). Few wanted an assessment of surgical skills (36%) or orthopedic knowledge (23%). The interview day was rated very valuable in determining their ROL (4.4 out of 5.0). Applicants told a mean of 1.7 (range: 0-11) programs they were "ranking the program highly" and 0.8 (range: 0-5) programs they were "going to rank them #1." Of the 116 (40%) applicants contacted by programs following interviews, 24 (21%) moved programs higher and 3 (3%) moved programs lower on their ROL. CONCLUSIONS: Orthopedic Surgery applicants have clear preferences for what they consider to be the ideal interview day and many alter their ROL following post-interview contact. These data may be beneficial to programs looking to optimize the interview experience for applicants.

Is Subchondral Acetabular Edema or Cystic Change on MRI a Contraindication for Hip Arthroscopy in Patients With Femoroacetabular Impingement?

BACKGROUND: The outcome for arthroscopic treatment of femoroacetabular impingement (FAI) can worsen with increasing arthritis. However, there remains a subset of hips with relatively maintained joint space but with acetabular subchondral edema and cystic change with unknown outcome on magnetic resonance imaging (MRI). PURPOSE: (1) To correlate MRI findings of subchondral acetabular edema/cystic change with arthroscopy grading of articular cartilage and (2) to determine whether postoperative outcome was worse for patients with subchondral edema/cystic change compared with a matched control group. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The records of all patients who underwent arthroscopic hip surgery for FAI at a single institution between 2007 and 2013 were reviewed for subchondral edema/cyst on preoperative MRI. Lesions were characterized by grade using an established classification system and were correlated with arthroscopic articular cartilage changes. A matched cohort of patients without evidence of subchondral edema or cyst was identified. Minimum 2-year outcomes were compared using prospectively collected Hip Outcome Score (HOS) activities of daily living and sport subscales as well as the modified Harris Hip Score (mHHS). RESULTS: Overall, 104 patients were included. Thirty-six patients (18 men, 18 women) with a mean age of 41 years (range, 19-67 years) had subchondral edema, with or without the presence of cystic acetabular changes, at minimum 2-year follow-up (range, 24-60 months). Two patients who underwent total hip replacement were excluded in the outcome score comparison. Thirty-one of 34 patients (91%) had a grade 4 full-thickness cartilage lesion at the time of diagnostic arthroscopy. The mean mHHS was inferior for all patients with subchondral edema/cystic change (79.9 ± 18.7 vs 86.6 ± 12.5; P = .03), and the HOS was also lower (69.1 ± 27.0 vs 79.5 ± 21.4; P = .02). The overall success rate was 67% for all patients with subchondral edema/cystic change compared with 85% in the control group (P = .04). CONCLUSION: The presence of a subchondral edema with an acetabular cyst on MRI is indicative of a full-thickness cartilage lesion at the time of arthroscopy. These patients have inferior outcomes for arthroscopic treatment of FAI compared with patients with similar age and activity level without MRI subchondral cystic changes.

The Effect of Cartilage Injury After Arthroscopic Stabilization for Shoulder Instability.

This study was undertaken to (1) determine the incidence of articular cartilage injuries in patients with instability of the glenohumeral joint, (2) determine whether recurrent dislocations increased the risk of articular damage, and (3) correlate these injuries with postoperative clinical outcomes. A cohort was identified of consecutive patients who underwent diagnostic magnetic resonance imaging and shoulder arthroscopy for glenohumeral instability with documented dislocation or subluxation between 1997 and 2006 at a single institution. Patients with moderate or severe osteoarthritis were excluded. Arthroscopic findings were recorded, including lesion location and Outerbridge grade. The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) was used to assess outcome in 61 patients who were available for follow-up. Outcomes were compared between shoulders with and without articular lesions. A total of 87 shoulders (83 patients) met the inclusion criteria, with 69 (83%) men and 14 (17%) women. Mean age was 26.1 years (range, 18-64 years), and mean follow-up was 36 months (range, 33-39 months). Cartilage injuries were found in 56 shoulders (64%). Previously documented shoulder dislocation requiring closed reduction (P=.046) and the number of discrete dislocations (P=.032) were significant for glenoid injury. A greater number of dislocations was associated with higher-grade lesions of the glenohumeral joint (P<.001). Overall, mean ASES score was 89.6 (range, 37-100). In patients with an articular cartilage lesion, mean ASES score was 90.4 (range, 58-100) compared with 88.1 (range, 37-100) in those without this injury (P=.75). Although clinical outcomes were not significantly affected, further investigation is warranted to establish a relationship between these injuries and longer-term outcomes.

Posterolateral Reconstruction of the Knee: Two-Tailed Surgical Techniques.

Reconstruction of the posterolateral corner of the knee using two-tailed techniques involved grafts originating from the femur and inserting on the proximal tibia and fibular head. This method reconstructs the fibular collateral ligament, popliteofibular ligament, and popliteus tendon using anatomically placed grafts. This article describes the history, anatomy, indications, and authors' preferred technique for a two-tailed posterolateral corner reconstruction. In addition, biomechanical and clinical outcomes of this technique will be compared.

Are meniscal tears and articular cartilage injury predictive of inferior patient outcome after surgical reconstruction for the dislocated knee?

PURPOSE: A paucity of data exists on the effects of articular cartilage and meniscal injury in the setting of knee dislocations. The purpose of this study is to determine whether concomitant intra-articular injuries at the time of multiligament reconstruction for knee dislocation are associated with inferior outcomes. METHODS: The records of patients who underwent surgical treatment for multiligament knee injury between 1992 and 2012 were retrospectively reviewed. Patients included had a PCL-based multiligament knee injury or a minimum of three disrupted ligaments, both indicative of knee dislocation. A logistic regression model was used to determine whether articular cartilage injuries (grade 2 involving ≥50 % of the condylar width or greater, or any grade III/IV lesions) and meniscus tears are predictors of IKDC outcome scores collected at a minimum of 2 years postoperatively. RESULTS: Of the 121 patients who met inclusion criteria, 2-year minimum follow-up was available on 95 patients (79 %). The cohort was 77 % male and had a median age of 32 years (16-62) at the time of surgery and was followed for an average of 6 years. Articular cartilage injury was present in 40 % of knees: medial femoral condyle (20 %); medial tibial plateau (9 %); lateral femoral condyle (5 %); lateral tibial plateau (4 %); patella (18 %); trochlear (5 %). Meniscal injury was present in 56 % of patients (isolated medial, 22 %; isolated lateral, 22 %; combined, 12 %). IKDC scores were significantly lower for patients with any cartilage damage (p = 0.03), combined medial and lateral meniscus tears (p = 0.02), medial-sided articular cartilage damage (p = 0.03), medial femoral condyle (p = 0.04) and trochlear (p = 0.03) lesions. CONCLUSION: Articular cartilage damage and meniscus tears are frequently associated with a knee dislocation. This study showed IKDC scores were significantly lower for patients with cartilage damage or combined medial and lateral meniscus tears at mid-term follow-up of 6 years. LEVEL OF EVIDENCE: IV.

Incidence and Risk Factor Analysis of Symptomatic Venous Thromboembolism After Knee Arthroscopy.

PURPOSE: To (1) determine the incidence of symptomatic venous thromboembolic events (VTEs) after knee arthroscopy and arthroscopy-assisted procedures at a single institution and (2) determine associated risk factors for VTEs in these patients. METHODS: The records of patients who underwent knee arthroscopy at a single institution between 1988 and 2008 were reviewed. Chemoprophylaxis was not routinely used. Confirmed VTEs occurring within 4 weeks after the index arthroscopy procedure were included. A 2:1 matched control group was generated to include patients in whom knee arthroscopy was performed by the same surgeon either on the same day or immediately before each case resulting in a VTE. Preoperative and perioperative data were collected with respect to demographic data, medical history, medications, and surgical and anesthesia data. Univariate and multivariate analyses were performed. RESULTS: During the study period, 12,595 patients underwent knee arthroscopy. Among these patients, 43 cases of VTEs (35 deep venous thromboses [DVTs], 5 pulmonary embolisms [PEs], and 3 DVTs that progressed to PEs) occurred, resulting in an incidence of 0.30% (95% confidence interval [CI], 0.22% to 0.41%) for DVT, 0.06% (95% CI, 0.03% to 0.12%) for PE, and 0.34% (95% CI, 0.25% to 0.46%) for VTEs overall. Factors associated with an elevated risk of symptomatic postoperative VTEs included a history of malignancy (P = .01; odds ratio [OR], 6.3), a history of VTEs (P = .02; OR, 5.2), or the presence of more than 2 classic risk factors for VTEs (P = .01; OR, 13.6). CONCLUSIONS: In this study, symptomatic VTEs were rare and occurred infrequently, with an incidence of 0.34% (95% CI, 0.25% to 0.46%), after knee arthroscopy and arthroscopy-assisted cases in the absence of routine chemoprophylaxis. Patients with a history of VTEs, a history of malignancy, or 2 or more classic risk factors are at increased risk of VTEs after knee arthroscopy, and chemoprophylaxis should be considered in these select patients. LEVEL OF EVIDENCE: Level III, case-control study.

Patellar Fracture Following Patellofemoral Arthroplasty.

This study aims to report the incidence of patellar fracture after patellofemoral arthroplasty (PFA) and to determine associated factors as well as outcomes of patients with and without this complication. 77 knees in 59 patients with minimum two-year follow-up were included. Seven (9.1%) patients experienced a patellar fracture at a mean of 34 (range 16-64) months postoperatively. All were treated nonoperatively. Lower BMI (P = 0.03), change in patellar thickness (P < 0.001), amount of bone resected (P = 0.001), and larger trochlear component size (P = 0.01) were associated with a greater incidence of fracture. Fewer fractures occurred when the postoperative patellar height exceeded the preoperatively measured height. No statistically significant differences were found in outcome scores between groups at mean four-year follow-up.

Meniscal tears and articular cartilage damage in the dislocated knee.

PURPOSE: Knee dislocations can cause significant damage to intra-articular knee structures, but currently there are limited data reporting articular cartilage and meniscal injuries in this setting. The purpose of this study is to (1) report the rate of concomitant intra-articular injuries at the time of multiligament reconstruction for knee dislocation, (2) determine whether the pattern of ligament injury is associated with the presence of chondral and meniscal injuries, and (3) assess the relationship between timing of surgery and incidence of chondral and meniscal injuries. METHODS: The records of patients who sustained a knee dislocation between 1992 and 2013 were retrospectively reviewed. Patients included for further review had a PCL-based multiligament knee injury or a minimum of three disrupted ligaments, both indicative of knee dislocation. Patient demographics, ligament injury patterns, meniscal tears and chondral injuries at arthroscopy, and interval from injury to surgery were recorded. Early surgical intervention was defined as <3 months, delayed was between 3 and 12 months, and chronic was >12 months. Data analysis compared ligament injury pattern with chondral and meniscal injuries, as well as the rates of intra-articular injury by timing of surgery. RESULTS: One-hundred and twenty-one patients (122 knees) were included (93 males, 28 females) with a median age at time of surgery of 31 years (range 15-62). Ninety-three knees (76 %) had associated chondral or meniscal injury. Sixty-seven knees (55 %) presented with meniscal tears (26 isolated medial, 27 isolated lateral, and 14 combined medial/lateral), while 52 knees (48 %) had chondral damage, most commonly in the medial compartment. Schenck classification as well as side of injury did not demonstrate consistent relationships with intra-articular injury. A higher incidence of damage to the lateral femoral condyle (20 % vs 3 %; p = 0.02), lateral tibial plateau (20 % vs 2 %; p < 0.01), and patella (40 % vs 13 %; p = 0.01) was found in the chronic group compared to the early group. The chronic group contained significantly more patients with bicompartmental and tricompartmental chondral lesions (25 % vs 6 %; p = 0.03 and 10 % vs 0 %; p = 0.02, respectively). CONCLUSION: Meniscal tears and chondral damage occur frequently in patients with a knee dislocation. A longer interval from injury to surgical reconstruction is associated with higher rates of articular cartilage lesions, especially in multiple compartments. LEVEL OF EVIDENCE: IV.

All-Inside Posterior Cruciate Ligament Reconstruction: GraftLink Technique.

Posterior cruciate ligament (PCL) injuries account for nearly 20% of knee ligament injuries. PCL injuries can occur in isolation or, more commonly, in the setting of multiligamentous knee injuries. Isolated PCL disruptions are commonly treated nonoperatively; however, symptomatic grade III injuries, as well as PCL injuries found in multiligamentous injuries, are frequently treated surgically. Several reconstructive techniques exist for the treatment of PCL deficiency without a clear optimal approach. We describe our preferred operative technique to reconstruct the PCL using an all-inside arthroscopic approach with a quadrupled tibialis anterior or peroneus longus allograft with both tibial and femoral suspensory fixation.

Long-term followup of surgically treated knee dislocations: stability restored, but arthritis is common.

BACKGROUND: Surgical treatment of knee dislocations is intended to correct the anatomic injury and restore knee stability and patient function. Several studies have shown successful results with surgical treatment of knee dislocations with up to 10 years of followup, but longer-term studies are uncommon. QUESTIONS/PURPOSES: We evaluated patients treated surgically for knee dislocations at 10-year followup to assess (1) knee stability; (2) return to preinjury level of function; (3) development of arthrosis; and (4) range of motion (ROM) loss. METHODS: This study was a retrospective review of 127 combined PCL, ACL, and medial and/or lateral side reconstructions performed by a single surgeon (GCF) between 1990 and 2008. Of these, 44 were available for clinical and functional evaluation (35%) at a minimum 5-year followup. Inclusion criteria were combined PCL/ACL plus medial and/or lateral side reconstruction. Evaluation methods included arthrometer measurements, stress radiography, knee ligament rating and activity scales (Lysholm and Tegner), plain radiographs with osteoarthritic assessment, and physical examination. RESULTS: Of the 44 patients, there were nine ACL/PCL medial, 22 ACL/PCL lateral, and 13 ACL/PCL mediolateral reconstructions. Followup was at a minimum of 5 years (mean, 10 years; range, 5-22 years). The mean age at the time of injury was 31 years with a range of 13 to 65 years. The mean arthrometer-measured side-to-side differences were as follows: PCL screen, 1.9 mm; corrected posterior, 2.4 mm; corrected anterior, 0.8 mm; and anterior displacement at 30° of knee flexion, 1.7 mm. Stress radiographic measurements at 90° of knee flexion revealed a mean side-to-side difference of 1.9 mm. Mean Lysholm, and Tegner scores were 84 of 100 and 4.1 of 9, respectively. Ninety-three percent (41 of 44) of patients returned to their preinjury level of activity or one Tegner grade lower. Ten of the 44 knees (23%) developed degenerative joint disease. The mean flexion loss was 12.5°, and flexion contractures were not seen in any of the patients. CONCLUSIONS: We found that a high proportion of patients treated for these severe injuries achieved static and functional stability, allowing the return to physically demanding work and recreational activities, but that nearly one-fourth of them will develop arthritis at a mean of 10 years. We cannot extrapolate our results to an elite athlete population, but our results probably apply well to working class populations. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.