BACKGROUND:Stable osteochondritis dissecans (OCD) lesions are primarily treated nonoperatively. Nonoperative treatment includes several recommendations, including the use of an unloader brace. However, little is known about the clinical effectiveness of unloader bracing and its influence on OCD healing, return to sports, and patient-reported outcomes (PROs). The purpose of this investigation was to evaluate the impact of unloader bracing on patients with stable medial femoral condyle (MFC) OCD lesions treated nonoperatively. PURPOSE:To investigate the influence of valgus unloader bracing on the success of treating stable MFC OCD with nonoperative treatment strategies. STUDY DESIGN:Cohort study; Level of evidence, 2. METHODS:The authors used a prospective cohort of patients receiving nonoperative care for stable MFC knee OCD lesions. The primary variable of interest was the efficacy of bracing. The primary outcomes were transition from nonoperative care to surgical intervention, return-to-play (RTP) clearance, and PROs. Bivariate testing was used to determine if there were differences between groups. Chi-square testing was used to determine if there were differences in rates of transition to surgery by group. The timing of the transition by each group was assessed using a Wilcoxon rank-sum test, given the nonparametric nature of the data. Kaplan-Meier survival analysis was used to calculate time at risk, incidence rate, and survival times for each group. RESULTS:A total of 185 knees (bracing group: 123 [66.5%] knees; no-bracing group: 62 [33.5%] knees) were analyzed. Overall, 142 (76.8%) knees were successfully treated nonoperatively. Transition to surgery occurred in 43 (23.2%) knees. There were no differences in transition to surgery by groups, with no differences seen by group. Of the knees that did not transition to surgical care, 65 (71.4%) in the bracing group and 38 (74.5%) in the no-bracing group received RTP clearance (P = .693). PRO scores were similar between the 2 groups at the time of RTP clearance. CONCLUSION:The inclusion of an unloader brace in the nonoperative treatment for stable MFC OCD lesions did not decrease the likelihood of patients undergoing surgical intervention or improve their PRO scores at the time of RTP clearance. REGISTRATION:NCT02771496 (ClinicalTrials.gov identifier).

Two-incision anterior cruciate ligament reconstruction (ACLR) is a well-established technique used to perform an arthroscopically assisted ACLR. Historically, this approach to ACLR was once considered the benchmark; however, with evolving arthroscopic technology and the rise of more minimally invasive techniques, this approach to ACLR has become less popular. The two-incision technique still has notable clinical utility because it can (1) increase the surgeon's ability to perform a single-stage revision ACLR and (2) help avoid graft-tunnel mismatch in primary ACLR with a patellar tendon autograft when encountering a long tendon. This technique, when coupled with metal screws and an autograft tendon, is also the lowest cost ACLR technique that allows independent femoral tunnel positioning and thus should be considered as an option for primary ACLR by surgeons prioritizing cost containment without compromising surgical outcomes.

Background: Medial meniscal repair performed at the time of primary anterior cruciate ligament reconstruction (ACLR) has been shown to be significantly associated with subsequent surgery, and subsequent surgery has been associated with increased Knee injury and Osteoarthritis Outcome Score (KOOS) pain score and decreased patient satisfaction. Hypothesis/Purpose: The purpose was to determine if medial meniscal repair decreases KOOS pain 10 years after ACLR and to assess the consequences of subsequent surgery on the development of KOOS pain. The authors hypothesized that medial meniscal repair performed at the time of primary ACLR decreases the likelihood of developing KOOS pain. It was further hypothesized that surgery performed subsequent to medial meniscal repair and primary ACLR increases KOOS pain 10 years after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Our inclusion criteria were all patients undergoing unilateral primary ACLR from 2002 to 2008 who were enrolled in the Multicenter Orthopaedic Outcomes Network without a history of medial or lateral meniscal surgery and contralateral ACLR. Causal mediation analysis using R software (Version 4.2.3) was employed to compare 2 effects on the development of significant knee pain, as represented by a KOOS pain score <80, at 10-year follow-up: (1) medial meniscal repair for longitudinal tears >10 mm in medial-to-lateral length and (2) medial meniscal excision at baseline of ACLR. A directed acyclic graph was constructed to provide a qualitative representation of the influence of known confounders that have been shown to affect the outcome of interest. Missing data were multiply imputed using multivariate imputation by chained equations. All tests were 2-sided, assuming a type I error rate of .05. Results: In total, 2387 participants (1074 female [45%]; 1313 male [55%]) were included in the final analysis. In 1502 (62.9%) cases, there was no medial meniscal tear reported. Of the 885 cases with medial meniscal tears, no treatment was performed in 109 (12.4%), meniscal excision was performed in 396 (44.7%), and meniscal repair was performed in 380 (42.9%). An overall 1825 of 2387 (76.5%) patients reported KOOS pain at 10-year follow-up: 252 (13.8%) had KOOS pain <80 and 1573 had ≥80. In the KOOS pain <80 group, 75 (29.8%) had subsequent surgery. In the KOOS pain ≥80 group, 223 (14.2%) had subsequent surgery. The step-by-step approach to causal mediation analysis demonstrated that a medial meniscal procedure (ie, no treatment for the tear, repair, or excision) significantly affected the likelihood of subsequent surgery (χ 2 = 28.9; P < .001) and subsequent surgery significantly increased the likelihood of KOOS pain <80 (χ 2 = 17.3; P < .001). However, the direct effect of a successful medial meniscal repair without subsequent surgery decreased the likelihood of KOOS pain <80 by 7.1% when compared with medial meniscal excision (95% CI, –13.3% to −1%; P = .024). When subsequent surgery was performed after medial meniscal repair and ACLR, the likelihood of KOOS pain <80 increased by 2.9% (95% CI, 1.1%-5.3%; P < .001.) Conclusion: Successful medial meniscal repair performed at the time of primary ACLR decreased clinically significant knee pain 10 years postoperatively. However, the mediating effect of subsequent surgery was significant and diminished the overall contribution of medial meniscal repair in decreasing the likelihood of KOOS pain. Continued efforts should be made to decrease the likelihood of subsequent surgery after medial meniscal repair performed at the time of primary ACLR.

Purpose:To evaluate changes in limb symmetry index (LSI) in thigh circumference and single-leg hop for distance (SLHD) after anterior cruciate ligament reconstruction (ACLR) out to 18 months postoperatively and their association to changes in dynamic postural stability after ACLR out to 24 months. Methods:Patients were prospectively enroled after ACLR and followed up at 3-month intervals. Thigh circumference was measured preoperatively out to 18 months postoperatively, dynamic postural stability out to 24 months, and SLHD from 6 to 18 months following ACLR. LSI was calculated from the thigh circumference and SLHD measurements. Dynamic postural stability (DPS) was measured on a multidirectional platform that tracked the patient's centre of mass, creating a dynamic motion analysis (DMA) score that reflected ability to maintain their centre of mass. Results:A total of 47 patients with mean age of 19.1 ± 5.8 years completed the study. LSI in thigh circumference worsened initially and improved at longer follow-up. LSI in SLHD improved significantly at 9- and 12-months consecutively. Overall mean DMA scores improved significantly at 3- and 6-month postoperatively. No significant correlation between LSI and DMA scores was appreciated at any time point. Conclusions:LSI in thigh circumference decreases initially after ACLR and then improves, while LSI in SLHD and dynamic postural stability improved after ACLR. DPS improved primarily in translational planes of motion. No significant association between LSI in thigh circumference/SLHD and DPS was found at any follow-up point. Level of Evidence:Level IV, case series.

Background: As machine learning becomes increasingly utilized in orthopaedic clinical research, the application of machine learning methodology to cohort data from the Multicenter ACL Revision Study (MARS) presents a valuable opportunity to translate data into patient-specific insights. Purpose: To apply novel machine learning methodology to MARS cohort data to determine a predictive model of revision anterior cruciate ligament reconstruction (rACLR) graft failure and features most predictive of failure. Study Design: Cohort study; Level of evidence, 3. Methods: The authors prospectively recruited patients undergoing rACLR from the MARS cohort and obtained preoperative radiographs, surgeon-reported intraoperative findings, and 2- and 6-year follow-up data on patient-reported outcomes, additional surgeries, and graft failure. Machine learning models including logistic regression (LR), XGBoost, gradient boosting (GB), random forest (RF), and a validated ensemble algorithm (AutoPrognosis) were built to predict graft failure by 6 years postoperatively. Validated performance metrics and feature importance measures were used to evaluate model performance. Results: The cohort included 960 patients who completed 6-year follow-up, with 5.7% (n = 55) experiencing graft failure. AutoPrognosis demonstrated the highest discriminative power (model area under the receiver operating characteristic curve: AutoPrognosis, 0.703; RF, 0.618; GB, 0.660; XGBoost, 0.680; LR, 0.592), with well-calibrated scores (model Brier score: AutoPrognosis, 0.053; RF, 0.054; GB, 0.057; XGBoost, 0.058; LR, 0.111). The most important features for AutoPrognosis model performance were prior compromised femoral and tibial tunnels (placement and size) and allograft graft type used in current rACLR. Conclusion: The present study demonstrated the ability of the novel AutoPrognosis machine learning model to best predict the risk of graft failure in patients undergoing rACLR at 6 years postoperatively with moderate predictive ability. Femoral and tibial tunnel size and position in prior ACLR and allograft use in current rACLR were all risk factors for rACLR failure in the context of the AutoPrognosis model. This study describes a unique model that can be externally validated with larger data sets and contribute toward the creation of a robust rACLR bedside risk calculator in future studies. Registration: NCT00625885 (ClinicalTrials.gov identifier).

Venous thromboembolism (VTE), comprising pulmonary embolism and deep vein thrombosis, is one of the most common complications after knee arthroscopy. Sequelae of VTE include VTE recurrence, postthrombotic syndrome, and potential for loss of limb or life. Given the increasing volume of knee arthroscopy procedures worldwide and the considerable morbidity and mortality associated with VTE, it is important to prevent, diagnose, and treat VTEs efficiently and effectively. Risk factors such as history of VTE, family history of VTE, genetic coagulopathy, oral contraceptive use, cancer history, and old age increase the risk of postoperative VTE and warrant consideration of prophylaxis. Diagnosis and treatment should be initiated rapidly in the setting of concerning symptoms and positive imaging diagnosis, respectively. The purpose of this review was to provide a framework to individualized VTE risk, weigh prophylaxis options, expedite diagnostic pathways, and implement outpatient treatment algorithms.

Objective:The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears. Methods:This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis. Results:A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear. Conclusions:Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients. Level of Evidence:III.

The Multicenter Orthopaedic Outcomes Network Shoulder Group conducted a prospective cohort study of 452 patients with symptomatic atraumatic rotator cuff tears treated with a physical therapy program to determine the predictors of failure of nonsurgical treatment, to provide insight into indications for surgery. After 10 years, we found the following: (1) Physical therapy was effective for over 70% of patients. (2) PROMs showed statistical and clinical improvement after 12 weeks of therapy and did not decline over 10 years. (3) Cuff tear severity did not correlate with pain, duration of symptoms, or activity level. (4) Of those who had surgery, 56.7% had surgery in the first 6 months while 43.3% had surgery between 6 months and 10 years. (5) Early surgery was primarily driven by low patient expectations regarding the effectiveness of therapy. (6) Later surgery predictors included workers' compensation status, activity level, and patient expectations. (7) Only 1 patient had a reverse arthroplasty (0.2% of the cohort). These data suggest that physical therapy is an effective and durable treatment of atraumatic symptomatic rotator cuff tears and most patients successfully treated with physical therapy do not exhibit a decline in patient-reported outcomes over time. Reverse arthroplasty after nonsurgical treatment is exceptionally rare.

BACKGROUND:Revision anterior cruciate ligament (ACL) reconstruction has been documented to have inferior outcomes compared with primary ACL reconstruction. The reasons why remain unknown. PURPOSE:To determine whether surgical factors performed at the time of revision ACL reconstruction can influence a patient's outcome at 6-year follow-up. STUDY DESIGN:Cohort study; Level of evidence, 2. METHODS:Patients who underwent revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline patient characteristics, surgical technique and pathology, and a series of validated patient-reported outcome instruments: Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) subjective form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity rating score. Patients were followed up for 6 years and asked to complete the identical set of outcome instruments. Regression analysis was used to control for baseline patient characteristics and surgical variables to assess the surgical risk factors for clinical outcomes 6 years after surgery. RESULTS:A total of 1234 patients were enrolled (716 men, 58%; median age, 26 years), and 6-year follow-up was obtained on 79% of patients (980/1234). Using an interference screw for femoral fixation compared with a cross-pin resulted in significantly better outcomes in 6-year IKDC scores (odds ratio [OR], 2.2; 95% CI, 1.2-3.9; P = .008) and KOOS sports/recreation and quality of life subscale scores (OR range, 2.2-2.7; 95% CI, 1.2-4.8; P < .01). Use of an interference screw compared with a cross-pin resulted in a 2.6 times less likely chance of having a subsequent surgery within 6 years. Use of an interference screw for tibial fixation compared with any combination of tibial fixation techniques resulted in significantly improved scores for IKDC (OR, 1.96; 95% CI, 1.3-2.9; P = .001); KOOS pain, activities of daily living, and sports/recreation subscales (OR range, 1.5-1.6; 95% CI, 1.0-2.4; P < .05); and WOMAC pain and activities of daily living subscales (OR range, 1.5-1.8; 95% CI, 1.0-2.7; P < .05). Use of a transtibial surgical approach compared with an anteromedial portal approach resulted in significantly improved KOOS pain and quality of life subscale scores at 6 years (OR, 1.5; 95% CI, 1.02-2.2; P≤ .04). CONCLUSION:There are surgical variables at the time of ACL revision that can modify clinical outcomes at 6 years. Opting for a transtibial surgical approach and choosing an interference screw for femoral and tibial fixation improved patients' odds of having a significantly better 6-year clinical outcome in this cohort.

Objectives: Even young patients without prior injury to the knee develop radiographic changes during the first two years after anterior cruciate ligament reconstruction (ACLR), but it’s unknown whether these early changes are predictive of increased pain over the next several years. The purpose of this study is to determine whether radiographic changes at 2 years are predictive of increased pain at 6 years while controlling for factors known to be predictive of worse pain after ACLR. We hypothesized that worse radiographic changes would not be predictive of increased pain. Methods: Patients were part of a nested cohort who underwent ACLR for an athletic injury, had no prior injury to their knee, and were 35 years of age or younger at 2-year follow-up. These patients underwent standardized posteroanterior semi-flexed knee radiographs using the metatarsophalangeal (MTP) positioning technique at 2 years and completed questionnaires at baseline (at time of enrollment, just prior to their ACL surgery), 2 years, and 6 years. These questionnaires included demographic questions, the SF-36, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Marx Activity Level Scale. Surgeons completed an intraoperative data form that included physical examination and arthroscopy findings and treatments administered to the knee. Radiographs were graded by 2 graders using the semiquantitative atlas-based Osteoarthritis Research Society International (OARSI) scoring system, where scores of 0-3 are assigned in the medial and lateral compartments for features including osteophytes, joint space narrowing, sclerosis, and bony attrition. A directed acyclic graph (DAG) was used to plan the statistical models to assess the direct effect of radiographic change on pain at 6 years. A model was built using proportional odds logistic regression, and missing data were imputed using multivariate imputation via chained equation (MICE) for 20 cycles. The model controlled for baseline pain, age, sex, body mass index, years of education, baseline Marx, baseline SF-36, medial and lateral meniscus treatment, presence of cartilage lesion(s), allograft use, and incidence of subsequent surgery before 2 years. Results: A total of 421 subjects were included in the analysis cohort. The median age was 18 years at the time of enrollment (interquartile range [IQR]16-21 years), and 216 (51.3%) were female. 297 subjects (70.5%) had a normal medial meniscus, 85 (20.2%) had a repair, and 39 (9.3%) had a partial meniscectomy. A total of 257 subjects (61.0%) had a normal lateral meniscus, 30 (7.1%) had a repair, and 134 (31.8%) had a partial meniscectomy. 107 subjects (25.4%) had at least 1 Outerbridge grade 2 or worse cartilage lesion. Fifty-three subjects (12.6%) had subsequent surgery prior to their 2-year follow-up. The median total radiographic score on the 2-year radiographs was 4 (IQR 2.0-5.5) and ranged from 0 to 12.5. Median KOOS pain (where 100 = no pain) was 75 (IQR 63.9 to 86.1) at baseline, 96.9 (IQR 91.7 to 100) at 2 years, and 97.2 (IQR 88.9 to 100) at 6 years. Marx activity level (where 16 points = highest activity level) at baseline was 16 (IQR 12 to 16). After controlling for the other variables in the model, subjects with a total radiographic score of 5.5 had 6% increased odds of having increased KOOS pain at 6 years compared to patients with a total radiographic score 2, but this effect was not statistically significant (odds ratio = 1.06, 95% CI, 0.79-1.42, p = .698). Greater baseline pain (odds ratio 1.41, 95% CI 1.06-1.86, p = .018) and subsequent surgery prior to 2 years (odds ratio 0.52, 95% CI, 0.3-0.93, p = .026) were both statistically significant predictors of worse pain at 6-year follow-up. Conclusions: Even young, active patients begin to develop radiographic changes by 2 years after ACLR; however, these changes are not associated with increased pain up to 6 years postoperatively. This information is important for counseling patients who may be concerned about radiographic changes that are seen on x-rays obtained during the first few years after ACLR. In addition, this study suggests that treatment decisions around the time of surgery that can minimize baseline pain and decrease the incidence of subsequent surgery may improve patient pain levels at 6 years postoperatively.

Objectives: Meniscal preservation has been demonstrated to contribute to long term knee health and has been a successful intervention in the isolated and ACL reconstructed patient. The long-term results of meniscus repair in the setting of revision ACL reconstruction have yet to be documented. The purpose of this study is to report the incidence of meniscal repair failures at 6-year follow-up in a cohort of patients who underwent concurrent revision ACL reconstruction and meniscal repair. Methods: All revision ACL reconstructions with concomitant meniscal repair cases from a multicenter group between 2006 and 2011 were selected. Six-year follow-up was obtained by both phone and email to determine whether any subsequent surgery had occurred to either knee since their initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify pathologic condition and treatment. Results: In total, 221 patients from 1234 revision ACL reconstructions underwent concurrent meniscal repairs (18% of the cohort). There were 238 repairs performed: 173 medial and 65 lateral. The vast majority of these repairs (n=181; 76%) were performed with an all-inside technique. Baseline patient and surgical characteristics of this group are reported (Tables 1, 2). Six-year surgical follow-up was obtained on 77% (171/221) of the cohort. Overall, the meniscal repair failure rate defined as reoperation was 13% (31/235) at 6 years. Of the 31 failures, 28 were medial (24 all-inside, 4 inside-out; 16% failure rate) and 3 were lateral (2 all-inside, 1 inside-out; 4.6% failure rate; Table 2). Three medial failures were treated in conjunction with a subsequent repeat revision reconstruction. The mean (SD) time to failure for the medial repairs was 2.6 (1.7) years, while the time to failure for the lateral repairs was 1.6 (1.8) years. Medial tears underwent reoperation for failure at a statistically significant higher rate than lateral tears (16% versus 4.6%; p<0.001). Conclusions: Meniscus repair in the revision ACL setting is a successful treatment option when clinically indicated with low failure rates. At 6-year follow-up, overall meniscal failure rate as defined by reoperation was 13% in this revision cohort. Failure rates for medial tears (16%) were higher than for lateral tears (4.6%), which aligns with previous studies both in the revision and primary setting.

Introduction: Anterior cruciate ligament (ACL) injuries in young, active patients generally require ACL reconstruction (ACLR) in order to restore mechanical and postural stability. The fear of movement or reinjury (kinesiophobia) has become increasingly recognized in the post-ACLR population, however the association between restoration of postural stability and kinesiophobia remains largely unknown. The purpose of this study was to investigate changes in mean TSK-11, DMA scores and time on the testing platform, as well as any correlation between TSK-11 and mean overall and individual translational and rotational DMA scores during the first 12 months following ACLR. Design: Cohort study Methods: Patients undergoing ACLR were prospectively enrolled and dynamic postural stability and kinesiophobia based on the Tampa Scale of Kinesiophobia-11 (TSK-11) were collected within 2 days prior to surgery and at 6- and 12-months following ACLR. Dynamic postural stability was quantified by calculating a dynamic motion analysis (DMA) score, with score calculated in three translational (anterior/posterior [AP], up/down [UD], medial/lateral [ML]) and three rotational (left/right [LR], flexion/extension [FE], and internal/external rotation [Rot]) independent planes of motions. Correlations between DMA and TSK-11 scores at each timepoint were analyzed. Results: A total of 25 patients meeting inclusion criteria were analyzed. Mean overall DMA and TSK-11 scores increased with each successive testing interval. At 6-month follow up, a weakly positive association between TSK-11 and DMA scores was appreciated based on overall DMA, AP, UD, ML and LR. At 12-months, a moderately positive correlation was appreciated between TSK-11 and the translational, but not rotational, planes of motion. Conclusions: Following ACLR, lower level of kinesiophobia were found to be moderately associated with improved dynamic stability, especially in the translation planes of motion. Keywords: Knee; Fear; Motion Analysis

BACKGROUND:A prospective cohort study was conducted to assess the predictors of failure of nonoperative treatment, defined as the patient undergoing surgery for symptomatic, atraumatic full-thickness rotator cuff tears. We present the 10-year follow-up data of this population to determine if predictors for surgery change over time, and secondarily we report the outcomes of the cohort. METHODS:At the time of enrollment, demographic, symptom, rotator cuff anatomy, and patient-reported outcome data were collected in patients with symptomatic, atraumatic full-thickness rotator cuff tears. Patients underwent a standard physical therapy protocol for 6 to 12 weeks. Patient data were then collected at 1, 2, 5, 7, and 10 years. Failure of nonoperative treatment was defined as the patient electing to undergo surgery. RESULTS:Of the 452 patients in the original cohort, 20 patients (5%) withdrew from the study, 37 (9%) died before 10 years, and 40 (9%) were otherwise lost to follow-up. A total of 115 patients (27.0%) underwent a surgical procedure at some point during the 10-year follow-up period. Of these patients, 56.5% underwent surgery within 6 months of enrollment and 43.5%, between 6 months and 10 years. Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery. Workers' Compensation status and activity level were more important predictors of later surgery. Patient-reported outcome measures all improved following physical therapy. For patients who did not undergo a surgical procedure, patient-reported outcome measures did not decline over the 10-year follow-up period. CONCLUSIONS:Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery, whereas Workers' Compensation status and activity level were predictors of later surgery. Physical therapy was successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears at 10 years. Outcome measures improved with physical therapy and did not decline over the 10-year follow-up period. LEVEL OF EVIDENCE:Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.

Background:Meniscal tear in older adults often accompanies knee osteoarthritis and is commonly treated with arthroscopic partial meniscectomy (APM) when patients have persistent pain after a trial of physical therapy. Cross-sectional evidence suggests that synovitis is associated with baseline pain in this patient population, but little is known about the relationship between synovitis and postoperative recovery or progression of knee osteoarthritis. Purpose/Hypothesis:Intra-articular extended-release triamcinolone may reduce inflammation and thereby improve outcomes and slow disease progression. This article presents the rationale behind the Corticosteroid Meniscectomy Trial (CoMeT) and describes its study design and implementation strategies. Study Design:Randomized controlled trial. Methods:CoMeT is a 2-arm, 3-center, randomized placebo-controlled trial designed to establish the clinical efficacy of extended-release triamcinolone administered via intra-articular injection immediately after APM. The primary outcome is change in Knee injury and Osteoarthritis Outcome Score Pain subscore at 3-month follow-up. Synovial biopsy, joint fluid aspirate, and urine and blood sample analyses will examine the associations between various objective measures of baseline inflammation and pre- and postoperative outcome measures and clinical responses to triamcinolone intervention. Quantitative 3-T magnetic resonance imaging will evaluate cartilage and meniscal composition and 3-dimensional bone shape to detect early joint degeneration. Results:We discuss methodologic innovations and challenges. Conclusion:To our knowledge, this is the first randomized double-blind clinical trial that will analyze the effect of extended-release triamcinolone acetonide on pain, magnetic resonance imaging measures of structural change and effusion/synovitis, soluble biomarkers, and synovial tissue transcriptomics after APM.

Background: Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis. Hypothesis/Purpose: The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects. Results: Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher. Conclusion: An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes. Registration: NCT02075775 (ClinicalTrials.gov identifier).

Background: Meniscal repair is the goal, whenever possible, for the treatment of meniscal injury. The purpose of this study was to evaluate the long-term clinical success of meniscal repair performed with a second-generation, all-inside repair device with a concomitant anterior cruciate ligament (ACL) reconstruction. Methods: This was a retrospective review of prospectively collected patients who underwent meniscal repair by a single surgeon using the all-inside FAST-FIX Meniscal Repair System (Smith & Nephew) in conjunction with a concurrent ACL reconstruction. Eighty-one meniscal repairs (81 patients) were identified: 59 medial repairs and 22 lateral repairs. Clinical failure was defined as repeat surgical intervention involving resection or revision repair. Clinical outcomes were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and Marx Activity Rating Scale score. Results: Ten-year follow-up was obtained for 85% (69) of 81 patients. Nine patients (13% of 69) underwent a failed meniscal repair (6 medial, 3 lateral), corresponding to a failure rate of 12% (6 of 50) for medial repairs and 16% (3 of 19) for lateral repairs. The mean time to failure was 2.8 years (range, 1.2 to 5.6 years) for the medial repairs and 5.8 years (range, 4.2 to 7.0 years) for the lateral repairs (p = 0.002). There was no difference in mean patient age, sex, body mass index, graft type, or number of sutures utilized between successful repairs and failures. Postoperative KOOS and IKDC outcome scores significantly improved over baseline scores (p < 0.001). There was no significant difference in patient-reported outcomes at 10 years between the group with successful repairs and those who had a failed repair. Conclusions: This report of long-term follow-up results of primary second-generation, all-inside meniscal repair demonstrates its relative success when it is performed with concurrent ACL reconstruction. After a minimum follow-up of 10 years, 84% to 88% of the patients continued to demonstrate successful repair. Failure of medial meniscal repairs occurred significantly earlier compared with lateral meniscal repairs. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Predictors of return to activity after anterior cruciate ligament reconstruction (ACLR) among patients with relatively high preinjury activity levels remain poorly understood. Purpose/Hypothesis: The purpose of this study was to identify predictors of return to preinjury levels of activity after ACLR, defined as achieving a Marx activity score within 2 points of the preinjury value, among patients with Marx activity scores of 12 to 16 who had been prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) cohort. We hypothesized that age, sex, preinjury activity level, meniscal injuries and/or procedures, and concurrent articular cartilage injuries would predict return to preinjury activity levels at 2 years after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: All unilateral ACLR procedures from 2002 to 2008 performed in patients enrolled in the MOON, with preinjury Marx activity scores ranging from 12 to 16, were evaluated with a specific focus on return to preinjury activity levels at 2 years postoperatively. Return to activity was defined as a Marx activity score within 2 points of the preinjury value. The proportion of patients able to return to preinjury activity levels was calculated, and multivariable modeling was performed to identify risk factors for patients' inability to return to preinjury activity levels. Results: A total of 1188 patients were included in the final analysis. The median preinjury Marx activity score was 16 (interquartile range, 12-16). Overall, 466 patients (39.2%) were able to return to preinjury levels of activity, and 722 patients (60.8%) were not able to return to preinjury levels of activity. Female sex, smoking at the time of ACLR, fewer years of education, lower 36-Item Short Form Health Survey Mental Component Summary scores, and higher preinjury Marx activity scores were predictive of patients' inability to return to preinjury activity levels. Graft type, revision ACLR, the presence of medial and/or lateral meniscal injuries, a history of meniscal surgery, the presence of articular cartilage injuries, a history of articular cartilage treatment, and the presence of high-grade knee laxity were not predictive of a patient's ability to return to preinjury activity level. Conclusion: At 2 years after ACLR, most patients with high preinjury Marx activity scores did not return to their preinjury level of activity. The higher the preinjury Marx activity score that a patient reported at the time of enrollment, the less likely he/she was able to return to preinjury activity level. Smoking and lower mental health at the time of ACLR were the only modifiable risk factors in this cohort that predicted an inability to return to preinjury activity levels. Continued effort and investigation are required to maximize functional recovery after ACLR in patients with high preinjury levels of activity.

OBJECTIVE:Meniscal tear in persons aged ≥45 years is typically managed with physical therapy (PT), and arthroscopic partial meniscectomy (APM) is offered to those who do not respond. Prior studies suggest APM may be associated with greater progression of radiographic changes. METHODS:We assessed changes between baseline and 60 months in the Kellgren-Lawrence (KL) grade and OARSI radiographic score (including subscores for joint space narrowing and osteophytes) in subjects aged 45-85 years enrolled into a seven-center randomized trial comparing outcomes of APM with PT for meniscal tear, osteoarthritis changes, and knee pain. The primary analysis classified subjects according to treatment received. To balance APM and PT groups, we developed a propensity score and used inverse probability weighting (IPW). We imputed a 60-month change in the OARSI score for subjects who underwent total knee replacement (TKR). In a sensitivity analysis, we classified subjects by randomization group. RESULTS:We analyzed data from 142 subjects (100 APM, 42 PT). The mean ± SD weighted baseline OARSI radiographic score was 3.8 ± 3.5 in the APM group and 4.0 ± 4.9 in the PT group. OARSI scores increased by a mean of 4.1 (95% confidence interval [95% CI] 3.5-4.7) in the APM group and 2.4 (95% CI 1.7-3.2) in the PT group (P < 0.001) due to changes in the osteophyte component. We did not observe statistically significant differences in the KL grade. Sensitivity analyses yielded similar findings to the primary analysis. CONCLUSION:Subjects treated with APM had greater progression in the OARSI score because of osteophyte progression but not in the KL grade. The clinical implications of these findings require investigation.

Background:Failure rates up to 14% have been reported after arthroscopic posterior capsulolabral repair. It is unknown if revision arthroscopic posterior capsulolabral stabilization has inferior restoration of stability and return to sport when compared with primary repair. Optimal management of failed posterior capsulolabral stabilization is unknown. Purpose:To report outcomes of revision posterior capsulolabral repair and factors that contribute to failure and to determine optimal management of failed posterior stabilization procedures. Study Design:Systematic review; Level of evidence, 4. Methods:A computerized search of the PubMed, EMBASE, and Web of Science databases and manual screening of selected article reference lists were performed in January 2022. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision arthroscopic posterior capsulolabral repair were eligible. Patient characteristics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Owing to heterogeneity of reported outcomes, data were summarized and presented without pooled statistics. Results:Only 3 of the 990 identified studies met inclusion criteria. The included studies encompassed 26 revision arthroscopic posterior capsulolabral repairs, with follow-up ranging from 2.3 to 5.3 years. The failed index procedure was arthroscopic capsulolabral repair with suture anchors (n = 22) or posterior thermal capsulorrhaphy (n = 4). The primary indications for revision were recurrent instability and pain. Six patients experienced recurrent instability after revision. Patient satisfaction ranged from 15% to 25%. Conclusion:This systematic review of 3 studies demonstrated that the incidence of persistent pain and recurrent instability after revision arthroscopic posterior shoulder stabilization is common, and despite slight improvement in patient-reported outcomes, many patients are dissatisfied with their clinical outcomes. Revision arthroscopic posterior shoulder stabilization appears to have a significant failure rate, and there is need for additional prospective studies to help determine the best intervention for these patients.