David M. Dare

Mechanisms of post-traumatic osteoarthritis after ACL injury.

Anterior cruciate ligament (ACL) rupture is a common and devastating injury with long-term sequelae that include meniscal tears, chondral injury, and an increased risk of knee osteoarthritis (OA). ACL reconstruction is recommended to protect against knee instability, reduce the likelihood of meniscal tears and further surgery, and enable earlier return to sporting activities. ACL reconstruction, however, does not reduce the incidence of early-onset OA. In this review, we discuss the factors before and after surgery that are believed to contribute to the premature development of degenerative joint disease.

Increased Lateral Tibial Slope Is a Risk Factor for Pediatric Anterior Cruciate Ligament Injury: An MRI-Based Case-Control Study of 152 Patients

Background: Increased posterior tibial slope is associated with increased risk of anterior cruciate ligament (ACL) injury in adults. A similar association has not been rigorously examined in children and adolescents. Purpose: To determine whether alterations in posterior tibial slope are associated with ACL tears in pediatric and adolescent patients and to quantify changes in tibial slope by age. Study Design: Case-control study; Level of evidence, 3. Methods: Magnetic resonance imaging (MRI) studies of the knee were reviewed by 3 raters blinded to each other in a 1:1 sample of cases and age- and sex-matched controls. A total of 76 skeletally immature ACL-injured knees were compared with 76 knees without ACL injury; the mean age of the study population was 14.8 ± 1.3 years. The posterior slope of the articular surface of the medial tibial plateau and lateral tibial plateau was measured by use of a method similar to that used in previous studies in adult populations. The current study technique differed in that the slope was measured on the cartilage surface, not the subchondral bone. Comparisons between knees were made with t tests, and Spearman correlation analysis was used to assess changes in tibial slope with advancing age. Results: Increased slope of the lateral tibial plateau (LTS) was significantly increased in ACL-injured patients compared with controls (5.7° ± 2.4° vs 3.4° ± 1.7°; P < .001). There was no statistically significant difference in the slope of the medial tibial plateau (MTS) in the ACL-injured and control knees (5.4° ± 2.2° vs 5.1° ± 2.3°; P = .42). There was no difference in LTS between male and female patients (4.46° vs 4.58°; P = .75). Receiver operating characteristic (ROC) analysis of the LTS revealed that a posterior tibial slope cutoff of >4° resulted in a sensitivity of 76% and a specificity of 75% for predicting ACL tears in this cohort. Spearman correlation analysis revealed that MTS and LTS decreased, or flattened, by 0.31° (P = .028, correlation coefficient r = −0.18) and 0.37° (P = .009, correlation coefficient r = −0.21) per year, respectively, as adolescents age. Conclusion: The LTS was significantly associated with an increased risk of ACL injury in pediatric and adolescent patients. The MTS was not associated with risk of injury. Posterior slope was found to decrease, or flatten, with age. A cutoff of >4° for the posterior slope of the lateral compartment is 76% sensitive and 75% specific for predicting ACL injury in this cohort. The LTS did not influence the incidence of ACL injury differently between sexes.

Is Deltoid and Lateral Ligament Reconstruction Necessary in Varus and Valgus Ankle Osteoarthritis, and How Should These Procedures be Performed?

Varus and valgus ankle deformities represent a challenge to the foot and ankle surgeons. The presence of degenerative changes of the tibiotalar joint articular surfaces introduces an additional layer of complexity. Reconstruction of such deformities requires a customized approach to each patient. Surgical intervention often requires joint-sparing realignment, arthroplasty, and/or arthrodesis, depending on the severity of deformity and the joint surface integrity. The ligamentous stability of the ankle plays an essential role in the preservation and optimization of function. This article reviews the role of deltoid and lateral ligament reconstruction in the treatment of varus and valgus ankle osteoarthritis.

Arthroscopically Assisted Open Reduction–Internal Fixation of Ankle Fractures: Significance of the Arthroscopic Ankle Drive-through Sign

Standalone open reduction-internal fixation (ORIF) of unstable ankle fractures is the current standard of care. Intraoperative stress radiographs are useful for assessing the extent of ligamentous disruption, but arthroscopic visualization has been shown to be more accurate. Concomitant arthroscopy at the time of ankle fracture ORIF is useful for accurately diagnosing and managing syndesmotic and deltoid ligament injuries. The arthroscopic ankle drive-through sign is characterized by the ability to pass a 2.9-mm shaver (Smith & Nephew, Andover, MA) easily through the medial ankle gutter during arthroscopy, which is not usually possible with both an intact deltoid ligament and syndesmosis. This arthroscopic maneuver indicates instability after ankle reduction and fixation and is predictive of the need for further stabilization. Furthermore, when this sign remains positive after fracture fixation, it may guide the surgeon to further evaluate the adequacy of fixation for the possible need for further fixation of the syndesmosis or deltoid. We present the case of an ankle fracture managed with arthroscopy-assisted ORIF and describe the clinical utility of the arthroscopic ankle drive-through sign.

Osteochondral Allograft Transplantation of the Knee in Patients with an Elevated Body Mass Index

Objective To characterize the graft survivorship and clinical outcomes of osteochondral allograft transplantation (OCA) of the knee in patients with an elevated body mass index (BMI). Design Prospective data on 38 consecutive patients with a BMI ≥30 kg/m2 treated with OCA from 2000 to 2015 were reviewed. Complications, reoperations, and patient responses to validated outcome measures were examined. Failures were defined by any removal/revision of the allograft or conversion to arthroplasty. Results Thirty-one knees in 31 patients (mean age, 35.4 years [range, 17-61 years]; 87% male) met the inclusion criteria. Mean BMI was 32.9 kg/m2 (range, 30-39 kg/m2). Mean chondral defect size was 6.4 cm2 (range, 1.0-15.3 cm2). Prior to OCA, 23 patients (74%) had undergone previous surgery to the ipsilateral knee. Mean duration of follow-up was 4.1 years (range, 2-11 years). After OCA, 5 knees (13%) underwent conversion to unicompartmental (1) or total (4) knee arthroplasty. Two- and 5-year graft survivorship were 87% and 83%, respectively. At final follow-up, clinically significant improvements were noted in the pain (49.3-72.6) and physical functioning (52.9-81.3) subscales of the Short Form–36 (P ≤ 0.001), International Knee Documentation Committee subjective form (43.5-67.0; P = 0.002), Knee Outcome Survey–Activities of Daily Living (58.2-80.4; P = 0.002), and overall condition subscale of the Cincinnati Knee Rating System (4.7-6.9; P = 0.046). Conclusions OCA can be a successful midterm treatment option for focal cartilage defects of the knee in select patients with a BMI ≥30 kg/m2.

Displaced Proximal Humerus Fractures: is a Sling as Good as a Plate?

The treatment of displaced proximal humerus fractures is challenging and complex, as its success is predicated on multiple factors. While it is clear that a majority of proximal humerus fractures may be treated nonoperatively, it is less clear which patients benefit from surgical management. The PROFHER trial, a randomized controlled study, used patient-reported outcomes to compare surgical to nonsurgical management of displaced proximal humerus fractures. The purpose of this review is to highlight the strengths and weaknesses of the PROFHER trial and to assess the validity of its conclusion in the context of existing literature. The authors found no difference in the Oxford Shoulder Score (OSS) between the surgical and nonsurgical groups. Additionally, no difference was found between groups in any of the secondary outcomes, which included the Short-Form 12 (SF-12) health survey, surgical and fracture-related complications, additional surgery or therapy, inpatient medical complications, and mortality. They concluded that the recent increase in surgical management of proximal humerus fractures is perhaps unwarranted. While the randomization was successful and the pragmatic design may enable greater generalizability, this study possesses numerous flaws inherent in such an ambitious endeavor, including an inability to identify specific factors which explain the lack of superiority of surgical management. Despite its weaknesses, this study is a valuable datapoint which encourages surgeons to reexamine their surgical indications for this injury.

Further Research Is Needed to Define the Benefits of Non-operative Rotator Cuff Treatment

Kukkonen et al.’s “Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up” compared the efficacy of physical therapy, acromioplasty, and rotator cuff repair for the treatment of degenerative supraspinatus tendon tears in patients aged over 55. This review examines the authors’ findings and their implications on clinical practice. Kukkonen et al. reported no significant difference in clinical outcome among patients treated operatively versus non-operatively for degenerative rotator cuff tears. The authors concluded that non-operative treatment is an appropriate option for patients aged 55 or older. Rotator cuff treatment outcomes are closely linked to patient age, and while this level I study found no evidence of a benefit of surgical treatment, the age range in the studied demographic was perhaps too wide to draw generalizable conclusions. Furthermore, 2-year follow-up may be inadequate to fully demonstrate the differences in outcomes between these treatment options.

Long-Term Follow-Up of Arthroscopic Treatment of Discoid Lateral Meniscus in Children

Objectives: The discoid meniscus, occurring almost exclusively on the lateral side, can lead to pain, popping, snapping, and decreased knee extension. The purpose of this study was to examine the long-term clinical outcomes of arthroscopic partial meniscectomy for the treatment of discoid lateral meniscus in children. Methods: A previous study at our institution identified 27 consecutive patients who underwent arthroscopic meniscal saucerization by one of two surgeons between 1997 and 2002. These patients were included in this study if they were willing and able to complete the five outcomes questionnaires (IKDC Subjective Knee Evaluation, Kujala Scoring Questionnaire, Lysholm Knee Scoring Scale, Marx Activity Rating Scale and Tegner Activity Scale). Seven additional patients that were treated consecutively at least 10 years ago were also included in the study. Patients were also given the opportunity to receive a knee exam performed by one of the two treating surgeons. The exam was documented as per the IKDC knee examination protocol. Associations between outcome scores and discoid type, meniscal stability, location of instability, and age at time of surgery were identified. Results: Of the 34 eligible patients (23 female, 11 male), 22 patients were contacted, and 21 agreed to participate. The average length of follow-up was 13.7 years, ranging from 10.3 years to 16.6 years. Average age at the time of surgery was 9.3 years. Long-term follow-up revealed average IKDC, Kujala, and Lysholm scores of 82.87, 86.63 and 83.73, respectively. Additionally, average Marx and Tegner scores were 5.36 and 5.63, respectively. Stratifying the Lysholm scores revealed outcomes that were 45.4% excellent, 18.2% good, 27.3% fair, and 9.1% poor. The average IKDC Knee Examination score was A (normal). In total, 20.6% (7 of 34) of eligible patients underwent a subsequent surgical procedure on the affected knee. Conclusion: Numerous studies have demonstrated good to excellent short-term outcomes after arthroscopic treatment of discoid meniscus. At an average follow-up of nearly 14 years, our data suggests that clinical outcome scores decline over time. Compared to our previous study with 2-year follow-up, there is an increased rate of knee pain, mechanical symptoms, and functional limitations. Despite excellent post-operative IKDC examination scores, approximately 40% of our patient cohort demonstrated relatively low Lysholm scores (fair and poor).