Paul L. Sousa

Long-term Followup of Surgically Treated Knee Dislocations: Stability Restored, but Arthritis Is Common

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

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

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

The Effect of Cartilage Injury After Arthroscopic Stabilization for Shoulder Instability

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

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

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

All-Inside Posterior Cruciate Ligament Reconstruction: GraftLink Technique

1,664 (range:

Unicompartmental Knee Arthroplasty Provides Higher Activity and Durability Than Valgus-Producing Proximal Tibial Osteotomy at 5 to 7 Years.

100-

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

5,000) whereas the cost of interviews (travel, food, etc.) was

Increased Risk of Second Anterior Cruciate Ligament Injury for Female Soccer Players

3,656 (range:

Is MRI Subchondral Acetabular Edema or Cystic Change a Contraindication for Hip Arthroscopy in Patients with FAI

15-

Technological Aids in Total Knee Arthroplasty: Navigation, Patient-Specific Instrumentation, and Robotics

20,000). Total expenditures ranged from