Marc Haro

Incidence of Subsequent Injury to Either Knee Within 5 Years After Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft

Background The risk of subsequent anterior cruciate ligament injury to either knee after surgery based on sex, age, and activity has not been extensively studied. Hypotheses Women have a higher incidence of anterior cruciate ligament injury to the contralateral knee after surgery than men but do not have a difference in injuries to the reconstructed knee. Young, competitive athletes have a higher incidence of injury than older patients. The time to return to full activities does not affect injury rate. Study Design Cohort study (prognosis); Level of evidence, 2. Methods The authors prospectively followed 1820 patients after primary anterior cruciate ligament reconstruction to determine if patients suffered an injury to either knee within 5 years after surgery. Subsequent injury was evaluated based on sex, age, and activity level. Results Minimum 5-year follow-up was obtained on 1415 patients (78%). Seventy-five patients (5.3%) had an injury to the contralateral knee, and 61 patients (4.3%) suffered an injury to the reconstructed knee (P =. 2185). Women suffered more injuries (7.8%) to the contralateral normal knee than men (3.7%; P <. 001) but not more injuries to the reconstructed knee (4.3% vs 4.1%; P =. 5543). The risk of subsequent injury to either knee was 17% for patients <18 years old, 7% for patients aged 18 to 25 years, and 4% for patients older than 25 years. There was no difference in injury rate between patients who returned before and after 6 months postoperatively. Conclusion Women have a higher incidence of anterior cruciate ligament injury to the contralateral knee than men after reconstruction. The incidence of injury to either knee after reconstruction is associated with younger age and higher activity level, but returning to full activities before 6 months postoperatively does not increase the risk of subsequent injury.

Clinical and Functional Outcomes After Anterior Cruciate Ligament Reconstruction Using Cortical Button Fixation Versus Transfemoral Suspensory Fixation: A Systematic Review of Randomized Controlled Trials

PURPOSE To compare clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction using cortical button versus transfemoral suspensory fixation. METHODS This systematic review was conducted following the Cochrane handbook guidelines and PROSPERO registration. Only Level I and II randomized controlled trials comparing cortical button and transfemoral suspensory fixation in hamstring ACL reconstruction were included. A literature search was performed using electronic databases. The methodologic quality of included studies was assessed using The Cochrane Collaborations risk-of-bias tool. All outcomes reported by each study were evaluated. Primary outcome measures were postoperative International Knee Documentation Committee (IKDC) and Lysholm knee scores. Statistical analysis was performed using RevMan software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Dichotomous data were reported as risk ratio and 95% confidence intervals. Heterogeneity was assessed using I(2). RESULTS Five studies involving 317 patients were included. The mean follow-up period was 21.7 ± 7.0 months (range, 12 to 38 months). The mean age of participants was 26.7 ± 1.89 years (range, 16 to 48 years). The Lysholm score, Tegner activity score, and IKDC score were compiled. Clinical assessment was performed by Lachman testing, assessment of side-to-side differences on KT-1000 (MEDmetric, San Diego, CA) testing, and measurements of thigh atrophy, as well as imaging (radiography and computed tomography) to assess for femoral tunnel widening. Pooled statistical analysis was possible only for postoperative IKDC and Lysholm scores. No significant differences were found between the cortical button and transfemoral fixation groups. Included studies did not report differences in clinical outcomes between the 2 groups. Radiographic results suggest increased femoral tunnel widening in the cortical button group. However, tunnel widening was not found to affect clinical results. CONCLUSIONS The present evidence suggests that there are no short- to medium-term differences in knee-specific outcome measures between patients treated with cortical button femoral graft fixation and those treated with suspensory transfemoral fixation when undergoing ACL reconstruction. In addition, radiologic evidence of tunnel widening does not seem to affect short- to medium-term clinical outcomes. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.

Evaluating the Quality of Internet Information for Femoroacetabular Impingement

PURPOSE The Internet has become a ubiquitous source of medical information for both the patient and the physician. However, the quality of this information is highly variable. We evaluated the quality of Internet information available for femoroacetabular impingement (FAI). METHODS Four popular search engines were used to collect 100 Web sites containing information on FAI. Web sites were evaluated based on authorship, various content criteria, and the presence of Health On the Net Code of Conduct (HONcode) certification. By use of a novel evaluation system for quality, Web sites were also classified as excellent, high, moderate, poor, or inadequate and were subsequently analyzed. Web sites were evaluated as a group, followed by authorship type, by HONcode certification, and by quality level. RESULTS Of the Web sites, 73 offered the ability to contact the author, 91 offered a considerable explanation of FAI, 54 provided surgical treatment options, 58 offered nonsurgical treatment options, 27 discussed possible complications, 11 discussed eligibility criteria, 31 discussed rehabilitation, 67 discussed a differential diagnosis, and 48 included peer-reviewed citations. We categorized 40 Web sites as academic, 33 as private, 9 as industry, 9 as public education, and 9 as blogs. Our novel quality evaluation system classified 16 Web sites as excellent, 18 as high, 17 as moderate, 18 as poor, and 31 as inadequate. Only 8% of all evaluated Web sites contained HONcode certification. CONCLUSIONS We found that the quality of information available on the Internet about FAI was dramatically variable. A significantly large proportion of Web sites were from academic sources, but this did not necessarily indicate higher quality. Sites with HONcode certification showed as much variability in quality as noncertified sites. CLINICAL RELEVANCE This study increases clinician competence in the available Internet information about FAI and helps them to confidently guide patients to formulate appropriate medical decisions based on high-quality information.

Arthroscopic Technique for the Treatment of Pigmented Villonodular Synovitis of the Hip

Open synovectomy remains the treatment of choice for pigmented villonodular synovitis (PVNS) of the hip but has shown modest results compared with the treatment of other joints. Recent advances in hip arthroscopy permit a thorough evaluation of the joint surfaces, improved access, and decreased postoperative morbidity. We describe an arthroscopic synovectomy technique for PVNS of the hip. The use of additional arthroscopic portals and creation of a large capsulotomy enable successful visualization and extensive synovectomy of the entire synovial lining of the hip. The T-capsulotomy enables extensive soft-tissue retraction for complete exposure. The midanterior portal enables use of an arthroscopic grasper and shaver to directly access and excise the synovial lining of the peripheral compartment while avoiding damage to the medial and lateral retinacular vessels. Technical innovations in hip arthroscopy have enhanced visualization in the central and peripheral compartments, as well as instrument management and diagnostic evaluation of the capsule, therefore allowing enhanced management of PVNS of the hip.

Fifty Most Cited Articles for Femoroacetabular Impingement and Hip Arthroscopy

Growing awareness of femoroacetabular impingement (FAI) and recent innovations in management have resulted in hip arthroscopy becoming one of the fastest-growing orthopedic subspecialties. The purpose of this study was to identify the 50 most cited articles related to the topic of FAI and hip arthroscopy and to analyze their characteristics. The overall number of citations within these articles ranged from 99 to 820. Citation density ranged from 4.41 to 74.55. Seven countries produced these articles with the majority attributed to the United States (n = 26) and Switzerland (n = 18). Clinical studies made up more than half of the top articles (n = 27). The Journal of Bone and Joint Surgery level of evidence most commonly encountered was level IV (n = 24), while the remaining articles were level III (n = 3). No randomized controlled trials or non-randomized controlled trials were encountered in this search. The level of evidence was not significantly correlated with the overall number of citations, publication year, or citation density. The current top 50 list provides orthopedic surgeons interested in hip arthroscopy with an up-to-date core list of the most cited articles in the scientific literature and represents a foundation to use to develop their knowledge regarding hip arthroscopy and FAI.

Application of the Goutallier/Fuchs Rotator Cuff Classification to the Evaluation of Hip Abductor Tendon Tears and the Clinical Correlation With Outcome After Repair.

PURPOSE To assess the reliability and reproducibility of the Goutallier/Fuchs classification for the evaluation of abductor tendon tears of the hip, as well as to identify the relation between preoperative tear size, abductor muscle quality, and the success of endoscopic tendon repair. METHODS This is a retrospective review of 30 consecutive endoscopic abductor tendon repairs performed by a single surgeon over a 2-year period. Preoperative magnetic resonance imaging scans were reviewed, and the muscle was assigned a grade according to the Goutallier/Fuchs classification. Patient-rated outcome scores--visual analog scale score, Hip Outcome Score (HOS), and modified Harris Hip Score (mHHS)--were collected preoperatively and at a minimum of 2 years postoperatively. Intraobserver and interobserver reliability for muscle grading was calculated. Postoperative outcome measures were compared with preoperative tear size, muscle grade, and repair type to assess for correlations. RESULTS Of the 30 hips included in the study, over 75% were classified as grade 1 (n = 15) or grade 2 (n = 8). The intraobserver reliability and interobserver reliability of the classification system averaged 0.872 and 0.916, respectively. Two patients (grades 3 and 4) had repair failure and underwent muscle transfer. In the remaining 28 hips, improvement was seen in the visual analog scale score (6.0 v 1.7, P < .0001), HOS-Activities of Daily Living subscale score (58.8 v 83.4, P < .0001), HOS-Sport-Specific subscale score (40.0 v 75.0, P < .0001), and mHHS (55.6 points v 81.1 points, P < .0001) postoperatively. Increasing preoperative fatty infiltration and atrophy correlated with increased postoperative pain levels (regression coefficient, 0.93; P < .001) and decreased postoperative HOS-Activities of Daily Living subscale scores (regression coefficient, -3.36; P = .011), HOS-Sport-Specific subscale scores (regression coefficient, -5.63; P = .016), mHHS values (regression coefficient, -3.50; P = .0008), and patient satisfaction (regression coefficient, -1.04; P < .0001). Patient age, tear size, or repair type (double v single row) did not affect postoperative outcomes. CONCLUSIONS The Goutallier/Fuchs classification system can be reliably and reproducibly applied to the evaluation of abductor tendon tears of the hip and appears to correlate with patient-rated outcomes after repair. Increasing preoperative muscle fatty atrophy correlates with increased patient pain and decreased patient satisfaction and functional outcomes after repair. LEVEL OF EVIDENCE Level IV, prognostic case series.

Closure of patellar tendon defect in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: systematic review of randomized controlled trials.

PURPOSE This study aimed to systematically review the highest level of evidence on anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autografts with patellar tendon defect closure versus no closure after surgery. METHODS We performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Level I and Level II randomized controlled trials comparing patellar tendon defect closure to no closure during ACL reconstruction with BPTB autografts were included. Two independent reviewers analyzed all studies. Descriptive statistics were calculated. Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS) and Jadad scale. RESULTS Four studies with a combined 221 patients (154 male patients and 67 female patients) with an average age of 26.6 ± 2.4 years (range, 17 to 54 years) were included. All studies randomized patients before surgery into ACLR with BPTB autografts either with patellar tendon defect closure or without closure. There were no differences in clinical outcomes (Lysholm score, Tegner scale, International Knee Documentation Committee [IKDC] classification, modified Larsen score, and Lauridsen rating) between groups. There were no significant differences in knee pain between groups. All studies reported imaging findings of the patellar tendon defect, with 2 studies showing no difference in appearance between groups, one study showing excessive scar formation with defect repair, and one study showing improved restoration of normal tendon appearance with defect repair. The overall quality of the studies was poor, with all studies scoring less than 46 (average, 40.5 ± 4.7) on the MCMS and scoring 1 on the Jadad scale. CONCLUSIONS Based on this systematic review of 4 randomized trials, there are no statistically significant or clinically relevant differences in outcomes between patients who have the patellar tendon defect closed and those who have it left open after ACLR with BPTB autografts. The methodology of the included studies limits the interpretation of the data, as evidenced by low MCMS and Jadad scores. LEVEL OF EVIDENCE Level II, systematic review of Level I and Level II studies.

Topographic Analysis of the Capitellum and Distal Femoral Condyle: Finding the Best Match for Treating Osteochondral Defects of the Humeral Capitellum

PURPOSE The purpose of this study was to determine the donor zone of most congruent topographic match by comparing 4 donor sites from the femur with 4 potential recipient sites of osteochondritis dissecans at the capitellum. METHODS Computed tomography was performed on 5 right elbows and 6 right medial and 6 right lateral distal femoral hemicondyles, which included the femoral notch. Three-dimensional computed tomography models were created and exported into point-cloud models. A local coordinate map of the distal humerus and distal femoral articular surfaces was created. The capitellum was compared with the medial and lateral distal femoral condyles, with 2 donor zones in each condyle (medial trochlea and medial intercondylar notch or lateral trochlea and lateral intercondylar notch). In each capitellum 4 combinations of 10-mm defects were simulated (central and lateral, 30° and 45° anterior to shaft of humerus), resulting in 480 capitellum-femur comparative combinations being tested. The capitellum surfaces were virtually placed on a point on the femoral articular surface in 3-dimensional space. The least distances (i.e., the shortest distance from the point in question to the corresponding point in space) between the point clouds on the distal humerus and distal femoral articular surfaces were calculated. RESULTS There was a less than 0.1-mm difference in the topographic articular surface match among the 4 commonly used donor sites of the distal femur and 4 recipient sites of the capitellum. However, the best match for any given 10-mm capitellar defect (central 30°, central 45°, lateral 30°, and lateral 45°) was the same such that the lateral trochlea on the femur always yielded the best fit compared with the 3 other graft locations (P < .005). CONCLUSIONS Our results indicate that there is a less than 0.1-mm difference in the topographic articular surface match among the 4 commonly used donor sites of the distal femur and the capitellum. The findings suggest that all 4 donor sites provide close articular matching for the capitellum articular surface, with the lateral trochlea articular surface providing the best match. CLINICAL RELEVANCE These data suggest that a single donor plug may be obtained from multiple sites in the knee and placed into capitellar lesions with an excellent topographic articular surface match. The findings of our study will be useful to surgeons when managing capitellar osteochondritis dissecans lesions.

Stress Fractures of the Femur

Of all stress fractures, those involving the femur are the fourth most common. They are typically seen in athletes and military recruits who are involved in repetitive loading activities. Femoral stress fractures may occur anywhere along the length of the femur, most commonly at the femoral neck. There are several predisposing factors and medical conditions that may contribute to the development of femoral stress fractures including osteoporosis, the female athlete triad, and possibly certain medications. As with most stress fractures, those involving the femur are frequently associated with overtraining and improper conditioning. Diagnosing femoral stress fractures can prove difficult as athletes often present with vague symptoms that can be attributed to other injuries or conditions. Frequently, advanced imaging is required to help support the diagnosis. While most femoral stress fractures can be managed conservatively with excellent outcomes, in some cases, especially with displaced fractures or high-risk femoral neck stress fractures, operative intervention is recommended. Once athletes have had a period of relative rest, radiographic evidence of healing, and they are able to walk and perform activities of daily living without pain, a gradual return to activities may begin.

Tips for successful transtibial anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures performed in orthopedics. While results from ACL reconstruction have been highly successful in restoring knee stability and allowing patients to return to sports, a debate continues as to which technique is best for restoring native anatomy and biomechanics. Some have proposed that a transtibial (TT) technique is not able to restore an ACL graft to the native femoral footprint and have advocated independent drilling of the femoral tunnel. We propose that with careful technique it is possible to reliably and reproducibly place the femoral tunnel in the anatomic femoral footprint using a TT technique with excellent results. We describe this surgical technique in detail and review the literature regarding the debate over TT drilling of the femoral tunnel and describe the senior authors (B.R.B.) experience using this technique.