Michael K. Ryan

Evaluation and Management of Osteochondral Lesions of the Talus

Osteochondral lesions of the talus are common injuries that affect a wide variety of active patients. The majority of these lesions are associated with ankle sprains and fractures though several nontraumatic etiologies have also been recognized. Patients normally present with a history of prior ankle injury and/or instability. In addition to standard ankle radiographs, magnetic resonance imaging and computed tomography are used to characterize the extent of the lesion and involvement of the subchondral bone. Symptomatic nondisplaced lesions can often be treated conservatively within the pediatric population though this treatment is less successful in adults. Bone marrow stimulation techniques such as microfracture have yielded favorable results for the treatment of small (<15 mm) lesions. Osteochondral autograft can be harvested most commonly from the ipsilateral knee and carries the benefit of repairing defects with native hyaline cartilage. Osteochondral allograft transplant is reserved for large cystic lesions that lack subchondral bone integrity. Cell-based repair techniques such as autologous chondrocyte implantation and matrix-associated chondrocyte implantation have been increasingly used in an attempt to repair the lesion with hyaline cartilage though these techniques require adequate subchondral bone. Biological agents such as platelet-rich plasma and bone marrow aspirate have been more recently studied as an adjunct to operative treatment but their use remains theoretical. The present article reviews the current concepts in the evaluation and management of osteochondral lesions of the talus, with a focus on the available surgical treatment options.

Clinical Outcomes of Hip Arthroscopy in Patients 60 or Older: A Minimum of 2-Year Follow-up.

PURPOSE To examine clinical outcomes and survivorship in patients aged 60 years or older who underwent hip arthroscopy for management of hip pain. METHODS Prospectively collected data for patients 60 or older undergoing hip arthroscopy were obtained. All patients were indicated for hip arthroscopy based on standard preoperative examination as well as routine and advanced imaging. Demographic data, diagnosis, and details regarding operative procedures were collected. Baseline preoperative modified Harris Hip Scores (mHHS) and Non-arthritic Hip Scores (NAHS) were compared to mHHS and NAHS at the 2-year follow-up. Survivorship was assessed to determine failure rates, with failure defined as any subsequent ipsilateral revision arthroscopic surgery and/or hip arthroplasty. RESULTS Forty-two patients met inclusion criteria. Mean age (standard deviation) and body mass index were 65.8 years (4.5 years) and 26.1 (4.7), respectively. Baseline mean mHHS and NAHS for all patients improved from 47.8 (±12.5) and 47.3 (±13.6) to 75.6 (±17.6) and 78.3 (±18.6), respectively (P < .001 for both). Five patients (11.9%) met failure criteria and underwent additional surgery at an average of 14.8 (8-30) months. Three underwent conversion to total hip arthroplasty (7.1%), whereas 2 had revision arthroscopy with cam/pincer resection and labral repair for recurrent symptoms (4.7%). One- and 2-year survival rates were 95.2% and 88.9%, respectively. CONCLUSIONS Our results suggest that in patients 60 or older with Tonnis grade 0 or 1 osteoarthritic changes on initial radiographs-treatment with hip arthroscopy can lead to reliable improvement in early outcomes. As use of hip arthroscopy for treatment of mechanical hip pain increases, additional studies with long-term follow-up are needed. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Evaluation, Treatment, and Outcomes of Meniscal Root Tears: A Critical Analysis Review

Meniscal root tears or avulsions compromise the biomechanical function of the menisci to a greater extent than simple meniscal tears do. As such, if left untreated, root injuries render the menisci incapable of properly distributing axial load and resisting rotation and translation.The clinical diagnosis of meniscal root abnormalities may be difficult as the signs and symptoms typically associated with meniscal body injuries, such as mechanical locking and catching, may not be present in patients with root injury and there may not be a history of an acute traumatic event. Treating practitioners need to have a high suspicion for meniscal root abnormalities in patients presenting with joint line tenderness and pain with deep flexion activities.Magnetic resonance imaging (MRI) signs indicative of meniscal root abnormality include a radial tear of the meniscal root (on axial imaging), a vertical linear defect in the meniscal root (truncation sign on coronal imaging), meniscal extrusion >3 mm outside the peripheral margin of the joint (on coronal imaging), and increased signal within the meniscal root (ghost sign on sagittal sequences).Two main approaches for meniscal root repair have evolved. One approach involves the use of a transtibial pullout technique, and the other involves the use of a suture anchor repair. The goal of both approaches is to restore an anatomical attachment of the meniscal root to bone that is capable of converting axial weight-bearing loads into hoop stresses.In a recent systematic review of meniscal root repairs, healing (partial and complete) was reported to have occurred in 96% of cases, with all studies demonstrating improvements in terms of subjective and functional scores at a mean of 30.2 months postoperatively.

Independent Risk Factors for Poor Outcome After Hip Arthroscopy

Objectives: Hip arthroscopy has been an increasingly used tool in the treatment of labral tears, chondral defects and ligamentum teres lesions and has demonstrated efficacy in returning patients to function and relieving their pain. Despite this, failures continue to occur. Our understanding of risk factors for failure or poor outcome continues to evolve as larger cohorts of patients are available for study. We sought to identify risk factors for poor outcome in our patient population. Methods: Prospectively collected data for all patients undergoing hip arthroscopy by a single fellowship-trained surgeon was obtained. All patients were indicated for hip arthroscopy based on standard pre-operative examination as well as routine and advanced imaging. Baseline demographic data regarding patient age, gender, BMI was collected. Patients without two year follow-up were excluded. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to mHHS at two-year follow-up. “Poor outcome” of initial hip arthroscopy was defined as any combination of: requiring a revision procedure or conversion to THA or mHHS below 70. Multivariate logistic regression was performed to identify independent risk factors for “poor outcome.” Results: 258 patients met inclusion criteria. Mean age (SD) and body mass index (BMI) were 40.4 years (12.7 years) and 25.6 (4.7) respectively. 62.8% (162/258) of the sample was female. Mean preoperative baseline mHHS was 49.6 (12.5) and average mHHS at two year follow-up was 83.6 (15.6), resulting in a mean improvement of 34.1 (p<0.001). Baseline and 2 year differencess in mHHS by demographic be found in Figures 1,2,3,. Overall revision/THA conversion rate was 16.7% (43/258), while another 10.5% (27/258) of patients reported outcome scores <70, resulting in 27.31% (70/258) having poor outcomes. Independent risk factors for poor outcome were female gender (OR 1.79; p=0.03), obesity (OR 2.1; p=0.04), and pre-operative mHHS lower than 40 (OR 3.34, p<0.001). Conclusion: Our findings that female gender, obesity and poorer preoperative functional status increase the risk for failure of hip arthroscopy coincide and add to an increasing volume of literature examining risk factors for poor outcome after hip arthroscopy. These factors should be taken into consideration with operative indications as well as in counseling patients.

Concomitant Lumbar Spine Pathology in Patients Undergoing Hip Arthroscopy: A Matched Cohort Analysis

Objectives: Hip arthroscopy for femoroacetabular impingement (FAI) and related hip pathology is increasing in volume. Variable presentations of hip pain often lead to confusion with lumbar spine pathology however. We sought to define the relationship between the lumbar spine and the hip joint. Our hypothesis is that patients with concurrent lumbar spine pathology will experience inferior outcomes after hip arthroscopy when compared to patients without lumbar spine pathology. Methods: Prospectively-collected data from a single-surgeon database from 2010 to 2014 was used to identify patients who had undergone hip arthroscopy and had documented concurrent lumbar spine pathology. Patients with spine pathology were matched by age, gender, and BMI in a 3:1 fashion to patients without spine pathology. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to scores at two-year follow-up. “Poor outcome” of initial hip arthroscopy was defined as any combination of: requiring a revision procedure, conversion to THA, or mHHS below 70. Results: 167 patients met inclusion criteria: 72.5% were “normal” while 27.5% had spine pathology. Baseline demographics were appropriately matched between cohorts (Table I). Preoperative and two-year mHHS scores were significantly different between cohorts (Figure 1). Both cohorts demonstrated significant within-group improvement at two-year follow-up, however normal patients had greater improvements than those with spine pathology (34.0 vs 31.76, p<0.001). Overall revision/THA conversion rate for entire cohort was 14.97%, with nearly twice as many spine co-pathology patients requiring additional surgery than those in the normal cohort (23.91% vs 11.57%, p=0.045). Patients with spine pathology were significantly more likely to have “poor outcomes” than those without spine pathology (36.96% vs 21.49%, p=0.048). Conclusion: Our results demonstrate that patients undergoing hip arthroscopy with concomitant lumbar spine pathology demonstrate significantly lower total improvement, significantly higher revision/THA conversion rates and significantly higher rates of suboptimal outcomes after hip arthroscopy than patients without spine pathology. Table 1: Baseline Demographic Data Between Cohorts Normal (n=121) Spine pathology (n=46) p value Mean (SD) Age 38.78 (11.38) 42.39 (12.03) P=0.14 BMI 24.03 (3.6) 25.32 (4.9) P=0.13 Gender: present female 62.8% (n=76) 63.1% (n=29) P=0.98 Figure 1: Differences in mHHs scores between Cohorts

Clinical Outcomes Following Arthroscopic Micro Fracture of the Hip

Objectives: Objective and clinical results of microfracture for treatment of chondral defects of the knee is well documented, yet outcomes for microfracture of the hip have not been extensively studied. Recently, several studies demonstrated clinical improvements in patients treated with microfracture of the hip. The purpose of this study is to examine clinical outcomes and survivorship in patients who underwent microfracture during arthroscopic hip surgery. Methods: A retrospective analysis of a prospectively collected database was performed. Thirty-eight patients with a mean age of 41 (range, 17-64) who underwent microfracture during arthroscopic hip surgery by a single surgeon (senior author) were identified. Demographic data, diagnosis, and details regarding operative procedures were collected. All patients were indicated for hip arthroscopy based on standard pre-operative examination as well as routine and advanced imaging. Baseline pre-operative modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS) were compared to mHHS and NAHS at two-year follow-up. Additionally, survivorship data was assessed to determine failure, defined as any subsequent revision arthroscopic surgery and/or hip arthroplasty of the same hip. Results: Thirty-four of the 38 (89.5%) patients were available for two-year clinical follow-up. Baseline mean mHHHS and NAHS for all patients improved from 50.6 (+/- 12.7) and 46.9 (+/-12.8) to 84.7 (+/- 12.5) and 85.6 (+/- 11.2) respectively. Both improvements were statistically significant (p < 0.05). Eight patients (23.5%) met failure criteria and underwent additional surgery at an average of 23.9 months. Two patients (5.8%) underwent revision arthroscopic surgery, and six patients (17.7%) underwent hip arthroplasty. Conclusion: Significant improvements in clinical outcomes are seen at two-year follow-up after microfracture treatment of chondral lesions of the hip. Despite overall success, failure rates are relatively high. As with microfracture of the knee, results favor short-term clinical improvements, but results may decline at two years. Larger studies are needed to fully assess the efficacy of microfracture in arthroscopic hip surgery.