Evaluation of Social Media and Online Utilization Among Members of the American Orthopaedic Society for Sports Medicine: Implications in Practice.

Background: Social media has the potential to act as an avenue for patient recruitment, patient and surgeon education, and expansion of the physician-patient relationship. Purpose: To evaluate the existing social media presence among members of the American Orthopaedic Society for Sports Medicine (AOSSM) to describe trends in different subgroups within the membership. Study Design: Cross-sectional study. Methods: The AOSSM database was queried for a complete membership list. Members were excluded from analysis if they were not orthopaedic sports medicine surgeons practicing in the United States. Demographic characteristics, online media profiles, and levels of online presence were evaluated, and an online media presence score was calculated. Bivariate analysis was performed to compare demographic variables and levels of online presence. Results: A total of 2870 surgeons were included in the analysis. LinkedIn was the most used platform (56%), while YouTube was the least used (10%). Surgeons in academic practice had a significantly greater overall social media presence than their private practice counterparts. Female surgeons had a more significant active online presence on Twitter, Instagram, and Facebook than male surgeons. Surgeons practicing in the Northeast had a greater social media presence than those in any other United States region, and surgeons in the earlier stages of practice (0-14 years) were more likely to utilize social media than their more senior colleagues (≥15 years of practice). On multivariate analysis, surgeons in the earlier stages of practice were more likely to have active Twitter, Instagram, and Facebook accounts, and female surgeons were more likely to have an active Facebook account. Additionally, multivariate analysis revealed that a greater number of ResearchGate publications were associated with male sex and having an academic practice. Comparatively, active Twitter and Instagram use was associated with having an academic practice. Conclusion: The most used platform in this surgeon population was LinkedIn. Orthopaedic surgeons in academic practice, female surgeons, those early in their career, and those practicing in the Northeast highlighted a subset of the sports medicine community who were more likely to have an active online presence compared to the rest of the AOSSM.

Meniscal and Articular Cartilage Predictors of Outcome After Revision ACL Reconstruction: A 6-Year Follow-up Cohort Study.

BACKGROUND: Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction. PURPOSE: To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patient's outcome at 6-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction. RESULTS: An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P≤ .04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P = .04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation (P < .05). Articular cartilage pathology significantly impaired all KOOS subscale scores (P < .05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years. CONCLUSION: Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery.

Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting.

BACKGROUND: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. PURPOSE: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. RESULTS: A total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. CONCLUSION: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Returning to Activity After Anterior Cruciate Ligament Revision Surgery: An Analysis of the Multicenter Anterior Cruciate Ligament Revision Study (MARS) Cohort at 2 Years Postoperative.

BACKGROUND: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). HYPOTHESES: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. RESULTS: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. CONCLUSION: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Lateral Harvest of an Osseous-Based Quadriceps Tendon Autograft Results in Thinner Remaining Patellar Bone.

Background: Patellar fracture after quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR) has been reported in up to 8.8% of patients. Purpose: To determine the thickness of the remaining patellar bone across the QT graft harvest location while providing clinical guidance for safely harvesting a patellar bone block when using a QT graft in ACLR. Study Design: Descriptive laboratory study. Methods: Medial and lateral QT graft boundaries were marked using a bone saw on 13 cadaveric patellae, and 3-dimensional computed tomography models were created. After the harvest of a virtual bone block with a maximum depth of 10 mm, the thickness of the remaining bone was measured across the graft harvest location in 9 zones. The thickness of the remaining bone was analyzed according to zone, graft harvest location, and patellar facet length. Risk zones were defined as <50% total patellar depth remaining. Results: We observed substantial variability in QT bone block harvest location, in which the distance between the lateral boundary of the harvest location and the lateral patellar cortex was from 21.2% to 49.2% of the axial patellar width. There was significantly less bone remaining in the lateral columns (mean ± SD, 7.56 ± 2.19 mm) compared with the medial columns (9.83 ± 2.10 mm) of the graft harvest location (P = .028). The number of risk zones was significantly associated with distance to the lateral cortical edge, with an increase in 0.59 zones with every 1-mm decrease in distance to the lateral cortex edge (b = -0.585; R 2 = 0.620; P = .001). With every 1-mm increase in the distance of the lateral cortex to the lateral graft boundary, the thickness of bone remaining in the lateral column increased by 0.412 mm (P < .001). No risk zones were encountered when the lateral boundary of the harvest location was created 18.9 mm from the lateral edge of the patella or 43% of the total patellar width from the lateral edge. Conclusion: Harvest of a more laterally based QT autograft bone block resulted in thinner remaining patellar thickness, increasing the potential of encountering a risk zone for fracture. Clinical Relevance: Care should be taken to avoid harvesting the patellar bone block too laterally during ACLR.

Patients Follow 3 Different Rate-of-Recovery Patterns After Anterior Cruciate Ligament Reconstruction Based on International Knee Documentation Committee Score.

PURPOSE: To determine whether subgroups of patients exist based on the rate-of-recovery pattern of International Knee Documentation Committee (IKDC) scores after anterior cruciate ligament reconstruction (ACLR) and to determine clinical predictors for these subgroups. METHODS: Patients who underwent primary or revision ACLR at a single institution from January 2014 to January 2019 were identified. Latent class growth analyses and growth mixture models (GMMs) with 1 to 6 classes were used to identify subgroups of patients based on functional rate-of-recovery patterns by use of preoperative, 1-year postoperative, and 2-year postoperative IKDC scores. RESULTS: A total of 245 patients who underwent ACLR were included in the analysis. A 3-class GMM was chosen as the final model after 6 different models were run. Class 1, showing improvement from preoperatively to 1-year follow-up, with sustained improvement from 1 to 2 years postoperatively, constituted 77.1% of the study population (n = 189), whereas class 2, showing functional improvement between 1- and 2-year follow-up, was the smallest class, constituting 10.2% of the study population (n = 25), and class 3, showing slight improvement at 1-year follow-up, with a subsequent decline in IKDC scores between 1- and 2-year follow-up, constituted 12.7% of the study population (n = 31). Revision surgery (P = .005), a psychiatric history (P = .025), preoperative chronic knee pain (P = .024), and a subsequent knee injury within the follow-up period (P = .011) were the predictors of class 2 and class 3 rate-of-recovery patterns. Patient demographic characteristics, graft type, and concomitant ligament, meniscus, or cartilage injury at the time of surgery were not associated with the different recovery patterns described in this study. CONCLUSIONS: Patients may follow different rate-of-recovery patterns after ACLR. By use of the GMMs, 3 different rate-of-recovery patterns based on IKDC scores were identified. Although most patients follow a more ideal rate-of-recovery pattern, fewer patients may follow less favorable patterns. Revision surgery, a history of psychiatric illness, preoperative chronic knee pain, and a subsequent knee injury within the follow-up period were predictive of less favorable rate-of-recovery patterns. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

PURPOSE: The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. METHODS: Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. RESULTS: A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. CONCLUSION: Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. LEVEL OF EVIDENCE: Level IV: case series.

Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement.

BACKGROUND: The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery. METHODS: Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05. RESULTS: 379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID). CONCLUSION: Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort.

BACKGROUND: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. HYPOTHESIS: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. RESULTS: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87). CONCLUSION: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Rate of infection following revision anterior cruciate ligament reconstruction and associated patient- and surgeon-dependent risk factors: Retrospective results from MOON and MARS data collected from 2002 to 2011.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR.

ACL Reconstruction Graft Angle and Outcomes: Transtibial vs Anteromedial Reconstruction.

BACKGROUND: The importance of creating an anatomic anterior cruciate ligament (ACL) reconstruction has been receiving significant attention. The best technique by which to achieve this anatomic reconstruction continues to be debated. The two most common methods are the transtibial (TT) and anteromedial (AM) techniques. Each has its advantages and disadvantages, and the literature comparing the two remains uncertain. QUESTIONS/PURPOSES: In this prospective comparative study, we aimed to compare the ACL graft and tunnel angles achieved using the anatomic transtibial (TT) and anteromedial (AM) techniques; compare the ACL graft and tunnel angles in knees that have undergone ACL reconstruction and knees with intact ACLs; and determine whether differences in the graft or tunnel angle produce differences in clinical outcomes, as measured using both physical exam and patient-reported outcomes, after ACL reconstruction. METHODS: Patients who underwent primary ACL reconstruction with bone-tendon-bone grafts using a TT or AM technique were included. Femoral graft angle (FGA), tibial graft angle (TGA), and sagittal orientation of the reconstructed ACL and contralateral native ACL were measured on post-operative magnetic resonance imaging. Post-operatively, patients underwent measurement of knee stability and completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) survey. RESULTS: Twenty-nine patients were enrolled (AM group, 14; TT group, 15); at follow-up, KOOS data were available for 26 patients (13 in each group). There were no differences in sagittal ACL graft angle between groups or in comparison with the normal knee. The FGA was more vertical after TT reconstructions; the TGA was comparable between groups. There were no significant differences in 2-year post-operative physical exam measurements or in KOOS scores. CONCLUSION: Anatomic ACL angle was restored after reconstruction with both the TT and AM techniques, despite different FGAs. No significant differences in clinical outcome were noted between groups on physical exam or KOOS at 2 years after surgery. These results suggest that TT reconstruction results in a graft position similar to that seen in AM reconstruction and that the location of the intra-articular tunnel aperture matters more than the orientation of the tunnel.

Meniscal Repair in the Setting of Revision Anterior Cruciate Ligament Reconstruction: Results From the MARS Cohort.

BACKGROUND: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. PURPOSE: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. RESULTS: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. CONCLUSION: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both <10% and consistent with success rates of primary ACL reconstruction meniscal repair. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears.

Trapezoidal Achilles Tendon Allograft Plug for Revision Quadriceps Tendon Repair With a Large Tendon Defect.

Revision quadriceps tendon repair presents a challenging problem for the treating surgeon because of associated anatomic defects such as large tendon-gap deficits and preexistent poor tissue quality. Current methods for revision quadriceps tendon repair use tendon autograft, which may predispose to additional morbidity because the repair relies only on soft tissue fixation. In this Technical Note, we describe a technique for revision of a failed quadriceps tendon repair with a large tendon gap using a trapezoidal plug Achilles tendon allograft. This technique constitutes a safe and effective approach to revising failed primary quadriceps tendon repairs, is suitable for large-gap defects, and has the ability to withstand large force transmissions.

Predictors of Patient-Reported Outcomes at 2 Years After Revision Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Patient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients. PURPOSE/HYPOTHESIS: The purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery. RESULTS: A total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery. CONCLUSION: PROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures.

BACKGROUND: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. HYPOTHESES: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. RESULTS: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS-Sports and Recreation (P = .04), and KOOS-Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. CONCLUSION: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Iliotibial Band Tenodesis With a Tenodesis Screw for Augmentation of Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament reconstruction with lateral extra-articular tenodesis using a strip of the iliotibial band (ITB) has been shown to increase postoperative stability of the knee. This Technical Note describes a method of ITB tenodesis in which a central slip of the ITB is passed deep to the lateral collateral ligament and then rerouted anteriorly for fixation at a location anterior and proximal to the lateral femoral epicondyle. Five whipstitches are passed through the ITB, and a second distal suture is tied around the distal end. Of the 4 suture tails, 3 are passed through a tenodesis screwdriver, and the screw is placed in the previously reamed bone socket. A closed loop is formed around the tenodesis screw by tying off the suture tails. This technique creates a sling around the lateral collateral ligament, which serves as a checkrein to internal rotation in cases in which increased stability is warranted, such as revision anterior cruciate ligament reconstruction in an athlete.

Do Female Athletes Return to Sports After Hip Preservation Surgery for Femoroacetabular Impingement Syndrome?: A Comparative Analysis.

BACKGROUND: Female patients undergoing surgery for femoroacetabular impingement syndrome (FAIS) often experience inferior clinical outcomes and higher failure rates when compared with male patients. The influence of athletic status on hip arthroscopic outcomes in female patients, however, is unclear. PURPOSE: To compare patient-reported outcomes (PROs) of athletic and nonathletic female patients undergoing hip arthroscopic surgery for FAIS, and to determine the return-to-sports rate in the athlete group. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Two-year PROs were assessed in female patients who had undergone hip arthroscopic surgery for FAIS by a single surgeon. Patients who self-identified as athletes were compared with nonathletes. Preoperative and postoperative PRO scores including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport-Specific (HOS-SS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction were analyzed and compared between athletes and nonathletes. Subanalysis was performed based on patient age and body mass index (BMI). RESULTS: A total of 330 female patients undergoing hip arthroscopic surgery for FAIS were identified. Of these, 221 patients identified as athletes (mean age, 29.1 ± 11.1 years; mean BMI, 23.0 ± 3.5 kg/m2) and 109 as nonathletes (mean age, 39.3 ± 11.4 years; mean BMI, 27.8 ± 5.8 kg/m2). Both groups demonstrated improvements in HOS-ADL, HOS-SS, mHHS, VAS for pain, and VAS for satisfaction scores (P < .001 for all). Athletes had significantly higher postoperative PRO scores compared with nonathletes (P < .001 for all). A 1:1 matched-pair subanalysis of 97 athletes and 97 nonathletes controlling for age and BMI indicated that these relationships held independently of potential demographic confounders (P < .001 for all). The number of patients meeting the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the HOS-ADL, HOS-SS, and mHHS was significantly higher in athletes aged ≤25 years versus those aged >25 years and for athletes versus nonathletes (P < .05 for all). Further, 189 of 194 athletes returned to sports at a mean of 6.0 ± 3.9 months postoperatively, with 93.7% reporting returning to the same or higher level of competition. CONCLUSION: Among female patients undergoing hip arthroscopic surgery for FAIS, patients considered athletes achieved superior clinical outcomes compared with patients considered nonathletes. In addition, younger female athletes had higher rates of achieving the MCID and PASS for all PRO measures.

Predictors of Persistent Postoperative Pain at Minimum 2 Years After Arthroscopic Treatment of Femoroacetabular Impingement.

BACKGROUND: Hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is a rapidly expanding field, and preoperative factors predictive of persistent postoperative pain are currently unknown. PURPOSE: To identify predictors for persistent postoperative pain at the site of surgery after hip arthroscopy for FAIS. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients who underwent hip arthroscopy for FAIS and had a minimum 2-year follow-up with patient-reported outcomes (PROs) were included in this study. Patients with previous open hip surgery and diagnoses other than FAIS were excluded. Patients were grouped by visual analog scale scores for pain as limited (<30) and persistent (≥30). Patient factors and outcomes were analyzed with univariate and correlation analyses to build a logistic regression model to identify predictors of persistent postoperative pain. RESULTS: The limited pain (n = 514) and persistent pain (n = 174) groups totaled 688 patients (449 females). There was a statistically significant difference in age between groups, with the persistent pain group being older than the low pain group (35.9 ± 12.2 vs 32.4 ± 12.6, respectively; P = .002). Patients with persistent postoperative pain demonstrated significantly lower preoperative PRO scores in the Hip Outcome Score-Activities of Daily Living (57.6 ± 21.2 vs 67.7 ± 16.8), Hip Outcome Score-Sport Specific (35.9 ± 23.9 vs 44.1 ± 22.7), modified Harris Hip Score (51.6 ± 16.2 vs 59.6 ± 12.9), and International Hip Outcome Tool (32.0 ± 16.8 vs 40.0 ± 17.82) but no significant differences in preoperative visual analog scale scores for pain (7.3 ± 1.8 vs 7.2 ± 1.7). Mean postoperative PRO differences between pain groups were all statistically significant. Bivariate logistic regression analysis demonstrated that history of anxiety or depression (odds ratio, 1.8; 95% CI, 1.02-3.32; P = .042), revision hip arthroscopy (odds ratio, 8.6; 95% CI, 1.79-40.88; P = .007), and a low preoperative modified Harris Hip Score (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .30) were predictors of persistent postoperative pain. CONCLUSION: Independent predictors for persistent postoperative pain include revision hip arthroscopy and mental health history positive for anxiety and depression. Our analysis demonstrated significant improvements in pain and functional PROs in the limited pain and persistent pain groups; however, those with persistent pain demonstrated significantly lower PRO scores.

Hip Arthroscopy for Femoroacetabular Impingement Improves Sleep Quality Postoperatively.

PURPOSE: To describe the prevalence of abnormal sleep quality in patients with femoroacetabular impingement syndrome and to determine whether arthroscopic hip preservation surgery with cam/pincer correction, labral preservation, and capsular plication can improve sleep quality postoperatively. METHODS: All patients undergoing primary hip arthroscopy for cam/pincer correction who failed nonoperative management between March 1, 2017, and July 1, 2017, were administered a validated sleep quality questionnaire-the Pittsburgh Sleep Quality Index (PSQI)-preoperatively and at 3, 6, 12, and 24 weeks postoperatively. Exclusion criteria included patients undergoing revision arthroscopy, gluteus medius repair, or a contralateral procedure during the follow-up period and those with known sleep disorders. A global (total) PSQI score >5 indicates poor sleep quality. The Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific Subscale, modified Harris Hip Score, and International Hip Outcome Tool-12 were used to assess functional outcomes. A repeated measures analysis of variance with post hoc Greenhouse-Geisser and Bonferroni corrections was conducted to determine statistically significant changes in sleep patterns. RESULTS: A total of 52 patients (94.6%) were included in the final analysis. The mean (± standard error) patient age was 37.8 ± 1.9 years, and body mass index was 27.6 ± 0.7. Preoperatively, 49 (94.2%) of patients experienced poor sleep quality, defined as a global PSQI score >5, with a mean PSQI score of 9.8 ± 0.6. At 24 weeks postoperatively, 10 (21.7%) of patients experienced poor sleep quality with a mean PSQI score of 2.2 ± 0.2. All patients had significant improvements in all hip outcome instruments at 24 weeks postoperatively (P < .001). CONCLUSIONS: Preoperatively, patients with femoroacetabular impingement syndrome have a high prevalence of sleep disturbance. These patients experience subsequent improvement in sleep disturbance after arthroscopic hip surgery early in the postoperative period. LEVEL OF EVIDENCE: Level IV, case series.

Effect of prior ipsilateral lower extremity surgery on 2-year outcomes following hip arthroscopy for femoroacetabular impingement syndrome.

The purpose of this study was to determine the influence of prior lower extremity surgery on patient reported outcomes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Consecutive patients who underwent hip arthroscopy for FAIS and a prior history of ipsilateral lower extremity surgery were identified and matched 2:1 by age, gender, and body mass index (BMI) to controls without a history of lower extremity surgery. The minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) were calculated for HOS-ADL, HOS-SS, and mHHS. Preoperative and 2-year postoperative patient reported outcomes of both groups were compared, and logistic regression was performed to determine whether lower extremity surgery influenced achieving MCID and PASS. A total of 102 patients (24.94%) with prior history of ipsilateral lower extremity surgery were identified. Ipsilateral orthopaedic knee surgery accounted for more than half (53.92%) of all prior surgeries. Patients with a history of ipsilateral lower extremity surgery had significant lower 2-year PROs, satisfaction, and greater pain when compared to patients without lower extremity surgery (P < 0.001 all). A history of ipsilateral lower extremity surgery was a negative predictor of achieving MCID for HOS-ADL and HOS-SS, as well as PASS for HOS-ADL, HOS-SS, and mHHS (P < 0.001 all). In conclusion, patients with prior lower extremity surgery were found to have inferior outcome scores and a lower likelihood of achieving clinically significant outcome improvement compared to patients without a history of lower extremity surgery at two years postoperatively.