Young Active Patients Research Articles

Anteromedialisation tibial tubercle osteotomy for recurrent patellar instability in young active patients: A retrospective case series

IntroductionRecurrent patellar instability can be a source of continued pain and functional limitation in the young, active patient population. Instability in the setting of an elevated tibial tubercle–trochlear groove (TT–TG) distance can be effectively managed with a tibial tubercle osteotomy. At the present time, clinical outcome data are limited with respect to this surgical approach to patellar instability. MethodsA retrospective chart review was performed to identify all cases of tibial tubercle osteotomy for the management of patellar instability performed at our institution with at least 1 year of post-operative follow-up. Patient demographic information was collected along with relevant operative data. Each patient was evaluated post-operatively with their outcomes assessed utilising a visual analogue score of pain, patient satisfaction, Tegner Activity Scale and Kujala score. Results31 patients (23 females and 8 males) with mean age of 27 years (17–43 years) and a mean BMI of 26.3kg/m2 (19.6–35.8) at time of surgery who underwent a tibial tubercle osteotomy as treatment for recurrent patellar instability were identified. The cohort had a mean follow up of 4.4 years (1.5–11.8 years). The mean pre-operative TT–TG distance was 18mm (10–22mm). The mean VAS pain score demonstrated a significant improvement from 6.8 (95% CI 6.1–7.5) at baseline to 2.8 (95% CI 1.9–3.7) post-operatively (p<0.001). The Tegner score improved from 4.1 (95% CI 3.4–4.8) pre-operatively to 5.2 (95% CI 4.5–5.9) at the time of final follow up (p<0.04). The Kujala score for anterior knee pain improved postoperatively from 62 (95% CI 55.4–68.7) to 76.5 (95% CI 69.5–83.5) at final follow up (p<0.001). 26 of the 31 patients (83.8%) had good to excellent Kujala scores. 27 of 31 patients (87.1%) reported that they would undergo the procedure again if necessary. ConclusionFor the management of recurrent patellar instability in the setting of an increased tibial tubercle–trochlear groove distance, a corrective tibial tubercle osteotomy is an effective treatment modality to reliably prevent patellar instability while reducing pain and improving function in this cohort of young, active patients.

Metal-on-polyethylene versus metal-on-metal bearing surfaces in total hip arthroplasty

The long term biological effects of wear products following total hip arthroplasty (THA) are unclear. However, the indications for THA are expanding, with increasingly younger patients undergoing the procedure. This prospective, randomised study compared two groups of patients undergoing THA after being randomised to receive one of two different bearing surfaces: metal-on-polyethylene (MoP) n = 22 and metal-on-metal (MoM) n = 23. We investigated the relationship between three variables: bearing surface (MoP vs MoM), whole blood levels of chromium (Cr) and cobalt (Co) and chromosomal aberrations in peripheral lymphocyte pre-operatively and at one, two and five years post-surgery. Our results demonstrated significantly higher mean cobalt and chromium (Co and Cr) blood levels in the MoM group at all follow-up points following surgery (p &lt; 0.01), but there were no significant differences in the chromosomal aberration indices between MoM and MoP at two or five years (two years: p = 0.56, p = 0.08, p = 0.91, p = 0.51 and five years: p = 0.086, p = 0.73, p = 0.06, p = 0.34) for translocations, breaks, loss and gain of chromosomes respectively. Regression analysis showed a strong linear relationship between Cr levels and the total chromosomal aberration indices in the MoM group (R2 = 0.90016), but this was not as strong for Co (R2 = 0.68991). In the MoP group, the analysis revealed a poor relationship between Cr levels and the total chromosomal aberration indices (R2 = 0.23908) but a slightly stronger relationship for Co (R2 = 0.64292). Across both groups, Spearman’s correlation detected no overall association between Co and Cr levels and each of the studied chromosomal aberrations. There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. While THA continues to be very successful at alleviating pain and restoring function, the long-term biological implications of the procedure still require further scrutiny. Cite this article: Bone Joint J 2015;97-B:1183–91.

Degenerative Spondylolisthesis.

Degenerative spondylolisthesis (DS) is one of the more commonly encountered spine conditions. The diagnosis of DS has changed little in the last 30 years. However, there has been an evolution in the treatment of this disease entity. There have been several landmark papers that helped govern our treatment. These helped serve as the basis for the treatment arms of the Spine Patient Outcomes Research Trial (SPORT), which offers the highest quality evidence to date. Although few would argue that the fusion of the diseased segment appears to offer the best and most durable results, treatment of this disease is best tailored to the individual. Fusion may offer the best results in the young active patient, but the same results may never become evident in the medically infirm patient. Laminectomy or unilateral laminoforaminotomy still plays a role in disease treatment. This review will focus on the diagnosis and the treatment of DS as well as discuss the author's preferred treatment of this disease.

Effect of malunited fractured distal end of radius on the morphometric parameters of distal radioulnar joint

Abstract Introduction: Malunion is the most frequent complication of fracture distal radius. Fracture malunion has been shown to associate with altered morphometric anatomy of distal radioulnar joint. Objective: This study aims to identify normal radiographic morphometry reference values and variations according to age and sex of distal radioulnar joint. This study was also carried out to determine the radiological correlation between normal and malunited distal radius in patient with unilateral malunited fracture to find out the effect of malunited fractured distal end of radius on the morphometric parameters of distal radioulnar joint. Materials and Methods: After twelve weeks of injury x-ray of injured wrist was compared with the radiograph of the contra lateral normal wrist for the difference in radial length, radial inclination, ulnar variance and palmar tilt. Results: Results of this study showed that there were signiicant difference in distal radius parameters between genders for both groups except for the difference in palmer tilt i.e. since value of P&lt; 0.0001 so there is significant difference between two group 1% level of significant suggesting that with 99% confidence, there is significant difference between mean of normal male and female right wrist parameters of both age group except for palmer tilt. Similarly there were variations in all parameter measurements for those x-ray films showing severe malunion and signiicant differences were noted for all parameters distal radius between normal and malunited wrist in both age groups i.e. since value of P&lt; 0.0001 so there is significant difference between two group 1% level of signiicant suggesting that with 99% conidence, there is signiicant difference for all parameters between mean of normal and malunion group. Conclusion: These results can be used in treatment of the malunited distal radius for correction of deformity at the wrist and achieving the best possible anatomical reduction in the young active patient and at minimizing the intervention in the low demand elderly patient with multiple comorbidities. These data also can be used for clinical research in the designing of wrist implants.

Modification of Practice Patterns after Analysis of Risk Factors Improved ACLR Outcomes

Objectives:Retear of an ACL after an ACL reconstruction (ACLR) is devastating for all involved. Understanding risk factors and predictors of subsequent graft tear after an ACLR is vital for patient education of subsequent risk of injury and if modifiable risk factors are identified, adjustments can be made to minimize the risk of repeat ACL tear. The objective of this study was to compare retear risk between 2002-2003 and 2007-2008 MOON cohorts to determine if after an analysis of risk factors in the 2002-2003 cohort, a shift in clinical practice changed the risk profile of ACL graft tear in the 2007-2008 cohort. The 2002-2003 and 2007-2008 cohorts are subsets of a larger MOON cohort.Methods:The prospectively collected data of the 2002-2003 and 2007-2008 primary ACLRs with >80% two year follow-up was analyzed. Graft type (autograft bone patellar bone (BTB), autograft hamstring, allograft), age, Marx score at time of index surgery, and sex were evaluated to determine their relative contributions to ipsilateral retear in the 2002-2003 cohort and 2007-2008 cohort separately. An ANOVA with post-hoc analysis was performed to detect significant differences in age and Marx score at time of index surgery by graft type between the 2002-2003 and 2007-2008 cohorts.Results:A total of 1758 subjects met all inclusion/exclusion criteria. The mean age of subjects that received allograft rose by 8 years (p<0.01) from the 2002-2003 cohort to the 2007-2008 cohort, whereas the mean age of subjects that received BTB and hamstring remained constant over time [Fig 1]. The mean Marx score of subjects receiving allograft dropped by 2.7 points (p<0.01) from the 2002-2003 cohort to the 2007-2008, whereas the mean Marx score of cohort subjects that received BTB and hamstring remained constant over time [Fig 2]. Thus in 2002-2003, there were 38/815 (4.7%) retears compared to 34/943 (3.6%) in 2007-2008. The odds of retear for allograft subjects was 9.27 times higher compared to BTB autograft in the 2002-2003 cohort (p<0.01), which decreased to 5.63 times higher in the 2007-2008 cohort (p=0.01) [Table 1].Conclusion:Age, activity, and graft type have been identified as predictors of increased risk of ipsilateral graft failure after ACLR. Allograft use in young active patients was shown to be a risk factor for graft tear in the 2002-2003 cohort. Subsequent to this determination, graft choice changed to use allografts in older and less active patients, which resulted in an associated decrease in graft tear risk in the 2007-2008 cohort. The risk of ACL graft retear was lower for all graft types in the 2007-2008 cohort compared to 2002-2003 cohort.

Inflammation and Neovascularization in Hip Impingement

Background: Femoroacetabular impingement (FAI) is a significant cause of osteoarthritis (OA) in young active patients, but the pathophysiology remains unclear. Increasingly, mechanistic studies point toward an inflammatory component in OA. Purpose: This study aimed to characterize inflammatory cell subtypes and neovascularization in FAI by exploring the phenotype and quantification of inflammatory cells and neovascularization in FAI versus OA samples. Study Design: Descriptive laboratory study. Methods: Ten samples of the labrum were obtained from patients with FAI (confirmed diagnosis) during open osteochondroplasty or hip arthroscopic surgery. Control samples of the labrum were collected from 10 patients with OA who were undergoing total hip arthroplasty. Labral biopsy specimens were evaluated immunohistochemically by quantifying the presence of macrophages (CD68, CD206, interleukin-13 [IL-13]), T cells (CD3), mast cells (mast cell tryptase), and vascular endothelium (CD34, vascular endothelial growth factor). Results: Labral biopsy specimens obtained from patients with FAI exhibited significantly greater macrophage, mast cell, and vascular endothelium expression compared with control OA labral samples (P < .05). The most significant difference was noted in macrophage (P < .01) and mast cell (P < .05) expression. Further subtyping of macrophages in FAI using the CD206 tissue marker and IL-13 revealed an M2 phenotype, suggesting that these cells are involved in a regenerate versus degenerate process. There was a modest but significant correlation between mast cells and CD34 expression (r = 0.4, P < .01) in FAI samples. Conclusion: This study provides evidence for an inflammatory cell infiltrate in FAI along with significant neovascularization. In particular, the significant infiltration of mast cells and macrophages was demonstrated, suggesting a role for innate immune pathways in the events that mediate hip impingement. Clinical Relevance: Further mechanistic studies to evaluate the net contribution and hence therapeutic utility of these cellular lineages and their downstream processes may reveal novel therapeutic approaches to the management of early hip impingement.

An Unusual Presentation of Bilateral Hypothenar Hammer Syndrome

popliteal artery with medial displacement suggestive of PAES. The patient was taken to the operating room for right popliteal artery exploration via posterior approach. A type III PAES was identified intraoperatively (Fig). The accessory slip of muscle from the medial head of gastrocnemius muscle was divided. A balloon thromboembolectomy was performed through a longitudinal arteriotomy and the artery was patched with bovine pericardium. Results: Postoperatively, the patient recovered well and was neurologically intact with normal pedal pulses. She was seen by obstetrics and underwent fetal heart rate monitoring. She was started on 81-mg aspirin daily and was discharged home on postoperative day 4. She was seen in follow-up by vascular surgery and in consultation with maternal fetal medicine because she was previously cared for by nurse midwives. Conclusions: Nonatheromatous popliteal artery pathology should be considered in young active patients who present with intermittent claudication or acute limb ischemia. The pregnant woman warrants a discussion of safe imaging modalities to establish a diagnosis and anesthesia considerations for surgical repair. Although we know strenuous exercise predisposes patients to symptomatic PAES, pregnancy is a hypercoagulable state and may be an independent risk factor.

Open treatment of dysplasia-other than PAO: does it have to be a PAO?

Hip dysplasia is a developmental disorder that results in anatomic abnormalities in which the acetabular coverage is insufficient. In the absence of severe degenerative changes, younger active patients with these symptomatic structural abnormalities are increasingly managed with joint-preserving operations. Historically there have been numerous reconstructive pelvic osteotomies. In recent years, the Bernese periacetabular osteotomy (PAO) has become the preferred osteotomy by many surgeons. Even so, as our understanding of the hip advances and new diagnostic and treatment techniques are developed, we sought to put a focus on the long-term results of augmental osteotomies and pelvic osteotomies other than the PAO, to see if any of these surgeries still have a place in the current algorithm of treatment for the dysplastic hip. As the longevity of the treatment is the focal point for joint preservation surgeries for the dysplastic hip, these authors have searched databases for articles in the English literature that reported results of long-term follow-up with a minimum of 11-year survivorship after surgical treatment of developmental dysplasia of the hip. Reconstruction osteotomies for the dysplastic hip are intended to restore normal hip anatomy and biomechanics, improve symptoms and prevent degenerative changes, in this manuscript each procedure is independently assessed on the ability to achieve these important characteristics.

The future role of metal-on-metal hip resurfacing.

The purpose of this review was to assess the ten to 15-year outcomes of metal-on-metal hip resurfacing (MoM HR) when performed at designing and independent centres, and make recommendations for the future use of MoM HR. Studies reporting ten to 15-year outcomes for modern MoM HR devices from both designing and independent centres were reviewed. Outcomes from these studies were assessed to allow the formulation of recommendations for the future use of MoM HR. Two MoM HR designs, the Birmingham Hip Resurfacing (BHR) and Conserve Plus, have outcomes reported at a minimum of ten years. The BHR was the only device with outcomes reported at a minimum of ten years by both designing (overall survival of up to 95.8 % at 15 years) and independent surgeons (overall survival of 87.1-94.5 % at ten years). Implant survival in these seven BHR studies was influenced by the pre-operative diagnosis (primary osteoarthritis had better outcomes), gender (male patients had better outcomes), and femoral component head size (larger sizes had better outcomes). In contrast to independent centres, designing surgeons reported acceptable outcomes in female patients undergoing BHR. There remains a role for MoM HR in young active male patients with primary osteoarthritis, provided the surgeon has sufficient experience in the procedure, the implant has an established record, and the patient is aware of the potential risks associated with MoM bearings and HR. Very experienced HR surgeons may also consider this procedure in females provided they meet the refined inclusion criteria described (including femoral head sizes of 46 mm and above).

Polyethylene in knee arthroplasty: A review.

Polyethylene (PE) has been used extensively in knee arthroplasty since the mid 20th century. Progress in material manufacturing and processing has led to newer polyethylenes over last few decades with different material properties. It has been established that PE wear in knee arthroplasty causes particle induced osteolysis which is the main reason for late failure and requires revision surgery. Although there are various causes of wear, the properties of PE have long been a matter of investigation as a contributory factor. The advent of newer highly cross linked PE has been shown to improve wear rates in hip arthroplasty but the benefits have not been shown to be of the same degree in knee arthroplasty. The laboratory and clinical studies so far are limited and slightly conflicting in their conclusions. The risks of using highly cross linked PE in knee arthroplasty include tibial post fracture, disruption of locking mechanism, liner fracture which can lead to increased wear and osteolysis. The current evidence suggests that highly cross linked polyethylenes should be used with caution and only considered in younger active patients. The results of a recently completed randomized trial to compare the conventional with high molecular weight PE in knee arthroplasty are awaited.

Biceps Tenotomy Versus Tenodesis in Active Patients Younger Than 55 Years: Is There a Difference in Strength and Outcomes?

Background:Proximal biceps pathology is a significant factor in shoulder pain. Surgical treatment options include biceps tenotomy and subpectoral biceps tenodesis. Tenotomy is a simple procedure, but it may produce visible deformity, subjective cramping, or loss of supination strength. Tenodesis is a comparatively technical procedure involving a longer recovery, but it has been hypothesized to achieve better outcomes in younger active patients (<55 years).Hypothesis:This study investigated the outcomes of younger patients who underwent either a biceps tenotomy or tenodesis as part of treatment for shoulder pain. The hypothesis was that, apart from cosmetic deformity, there will be no difference in outcome between the 2 treatment options.Study Design:Cohort study; Level of evidence, 3.Methods:Isometric strength and endurance testing of operative and nonoperative shoulders for forearm supination (FS) and elbow flexion (EF) were tested utilizing an isometric dynamometer. Objective physical assessment was also performed. Subjective outcomes using the modified American Shoulder and Elbow Surgeons score (ASES); Disability of the Arm, Shoulder, and Hand (DASH); visual analog scale (VAS); and perceived biceps symptoms were collected.Results:A total of 42 patients (22 tenotomy, 20 tenodesis) with an average follow-up of 3.3 years were studied. The average age at follow-up was 49.9 years. Thirty-five percent (7/20) of tenotomy patients exhibited a “Popeye” deformity, compared with 18.2% (4/22) of tenodesis patients. Strength prior to fatiguing exercise was similar between tenodesis and tenotomy for FS (6.9 vs 7.3 lbs; P < .05), EF in neutral (35.4 vs 35.4 lbs), and EF in supination (33.8 vs 34.2 lbs). Strength was not significantly different between groups for isometric strength and endurance measures. Subjective functional outcome measured by the DASH, ASES, and VAS scores were similar between groups. Frequency of complaints of cramping was higher in the tenotomy group (4/20 vs 1/22), and complaints of pain were higher in the tenodesis group (11/22 vs 5/20).Conclusion:Despite increased demands and activity placed on biceps function in a younger population, this study showed no differences in functional and subjective outcome measurements. The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference.

Analysis of hip range of motion in everyday life: a pilot study.

Patients undergoing total hip arthroplasty are increasingly younger and have a higher demand concerning hip range of motion. To date, there is no clear consensus as to the amplitude of the "normal hip" in everyday life. It is also unknown if the physical examination is an accurate test for setting the values of true hip motion. The purpose of this study was: 1) to precisely determine the necessary hip joint mobility for everyday tasks in young active subjects to be used in computer simulations of prosthetic models in order to evaluate impingement and instability during their practice; 2) to assess the accuracy of passive hip range of motion measurements during clinical examination. A total of 4 healthy volunteers underwent Magnetic Resonance Imaging and 2 motion capture experiments. During experiment 1, routine activities were recorded and applied to prosthetic hip 3D models including nine cup configurations. During experiment 2, a clinical examination was performed, while the motion of the subjects was simultaneously captured. Important hip flexion (mean range 95°-107°) was measured during daily activities that could expose the prosthetic hip to impingement and instability. The error made by the clinicians during physical examination varied in the range of ±10°, except for flexion and abduction where the error was higher. This study provides useful information for the surgical planning to help restore hip mobility and stability, when dealing with young active patients. The physical examination seems to be a precise method for determining passive hip motion, if care is taken to stabilise the pelvis during hip flexion and abduction.

The Impact of Total Joint Arthroplasty on Sexual Function in Young, Active Patients

There is limited information regarding sexual function following total hip (THA) and knee arthroplasty (TKA). A multicenter study of 806 THA, 542 TKA, and 181 control patients less than 60 years of age was conducted using an independent survey center to question subjects about their sexual function. Only 1.3% of THA and 1.6% of TKA patients stated they were not sexually active due to their operation. No significant differences were noted in sexual function based on the bearing surface, femoral head size, or use of surface replacement arthroplasty in the hip cohort. Multivariate analysis revealed no difference in the percentage of patients sexually active following a THA or TKA (OR 1.19, P=0.38). Most young active patients return to sexual activity after hip and knee arthroplasty.

Understanding risks and complications in the management of ankle fractures.

Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.

High frequency of posterior and combined shoulder instability in young active patients

The purpose of this study was to describe the epidemiology and demographics of surgically treated shoulder instability stratified by direction. We hypothesized that there would be an increased frequency of posterior and combined shoulder instability in our population compared with published literature. Secondarily, we assessed preoperative magnetic resonance imaging (MRI) reports to determine how accurately they detected the pathology addressed at surgery. A retrospective review was conducted at a single facility during a 46-month period. The study included all patients who underwent an operative intervention for shoulder instability. The instability in each case was characterized as isolated anterior, isolated posterior, or combined, according to pathologic findings confirmed at arthroscopy. The findings were retrospectively compared with official MRI reports to determine the accuracy of MRI in characterizing the clinically and operatively confirmed diagnosis. A consecutive series of 231 patients (221 men, 10 women) underwent stabilization for shoulder instability over 46 months. Patients were a mean age of 26.0 years. There were 132 patients (57.1%) with isolated anterior instability, 56 (24.2%) with isolated posterior instability, and 43 (18.6%) with combined instability. Overall, MRI findings completely characterized the clinical diagnosis and arthroscopic pathology in 149 of 219 patients (68.0%). The rate of posterior and combined instability in an active population is more common than has been previously reported, making up more than 40% of operatively treated instability, including a previously unreported incidence of 19% for combined instabilities. In addition, MRI was often incomplete or inaccurate in detecting the pathology eventually treated at surgery.

Clinical Outcome of Revision Meniscal Allograft Transplantation: Minimum 2-Year Follow-up

The purpose of this study was to assess the clinical and radiographic outcomes after revision meniscal allograft transplantation (RMAT). Eleven patients underwent RMAT performed by the senior author (B.J.C.). These patients were studied prospectively and completed standardized outcome surveys (including International Knee Documentation Committee [IKDC], Cincinnati Knee-Rating System, Tegner score, Lysholm score, Short Form-12, Knee Injury and Osteoarthritis Outcome Score [KOOS], and overall satisfaction) preoperatively and annually thereafter for a minimum of 2years. Radiographic analysis before surgery and at the most recent follow-up included anteroposterior, Rosenberg, lateral, and sunrise views graded by the Kellgren and Lawrence (K & L) scale. The status of the articular cartilage was graded intraoperatively using the Outerbridge classification. Two patients were lost to follow-up and one declined further participation. The average time to RMAT from the index procedure was 3.45 ± 2.52years, with a mean follow-up after RMAT of 3.83 ± 1.3years. One patient progressed to arthroplasty during follow-up and was not included in subjective outcome score follow-up. Clinical outcome scores that demonstrated significant improvements included IKDC (43 ± 12 to 61 ± 16; P= .03) and KOOS pain score (66 ± 12 to 79 ± 11; P= .047). Along with this, the subjective symptom rate significantly improved from 5.0 ± 0.9 preoperatively to 6.7 ± 1.8 postoperatively (P= .011). Radiographic (P= .7) and Outerbridge (P= .809) grading did not show progression. Seven of 8 patients would have surgery again, and satisfaction at final follow-up was 7.6 ± 2.6. In this small series with short-term follow-up, RMAT resulted in high patient satisfaction and significant symptom reduction on validated outcome scores (IKDC and KOOS pain score), proving the original hypothesis that outcomes after RMAT would be improved compared with preoperative conditions. Identifiable causes of MAT failure may help predict response to RMAT. Because arthroplasty is still not favored in young active patients, a thorough discussion with the patient is necessary to best align their goals with those of the surgery when considering revision meniscus transplantation. Level IV, therapeutic case series.

Risk Factors and Predictors Of Subsequent ACL Injury After ACL Reconstruction: Prospective Analysis Of 2801 Primary ACL Reconstructions

Objectives:Retear of an ACL after an ACL reconstruction (ACLR) is devastating for all involved. Understanding risk factors and predictors of subsequent ACL tear after an ACLR is vital for patient education of subsequent risk of injury and if a predictor is modifiable, to make adjustments to minimize the risk of repeat ACL tear. The objectives of this study were 1) to identify the risk factors and predictors for ispilateral and contralateral ACL tears after primary ACLR and 2) to compare retear risk between the 2002/03 and 2007/08 cohorts. This is the largest and most comprehensive prospective analysis of this kind in the literature.Methods:Data from the 2002-2008 MOON database was used to identify risk factors for ACL retear. Subjects who had a primary ACLR with no history of contralateral knee surgery and had 2 year follow-up data were included. Subjects who had multiligament surgery were excluded. Graft type (auto-BTB, auto-hamstring, allograft), age, Marx score at time of index surgery, sport played post ACLR, sex, smoking status, lateral meniscus tear at the time of ACLR, medial meniscus tear at the time of ACLR, BMI, and MOON site were evaluated to determine their contribution to both ipsilateral retear and contralateral ACL tear. The analysis was repeated using the 2002/3 and 2007/8 cohort and included age, graft, sex, and Marx. An ANOVA with post-hoc analysis was performed to detect significant differences in age and Marx score by graft type over time.Results:A total of 2801 subjects met all inclusion/exclusion criteria. There were 165/2801 (5.89%) ipsilateral and 177/2801 (6.32%) contralateral ACL tears identified in the cohort at the two year follow-up. The odds of ipsilateral retear are 1.68 times greater for hamstring autograft (p=0.04) and 4.67 times greater for an allograft (p<0.001) compared to auto-BTB. The odds of ipsilateral retear decrease by 8% for every yearly increase in age (p < 0.001) and increases by 6% for every increased point on the Marx score (p = 0.017). The odds of contralateral ACL tear increase by 7% for every increased point on the Marx score (p = 0.004) and decreases by 5% for every one point increase in BMI (p = 0.03). In 2002/3, there were 61/815 (7.5%) retears compared to 37/1056 (3.5%) in 2007/8. The odds of retear by for the 2002/03 and 2007/08 cohorts are summarized in table 1. The mean age (figure 1) of subjects receiving BTB and hamstring remained constant over time whereas the mean age of subjects receiving allograft rose by seven years (p < 0.001). Hamstring use was a predictor of retear compared to BTB in the 02/03 group (7.9% vs. 4.2%), but not in the 07/08 group (4.1% vs. 3.4%).Conclusion:Age, activity, and graft type were predictors of increased risk of ipsilateral graft failure after ACLR. Higher activity and lower BMI were found to be risk factors in contralateral ACL tears. Allograft use in young active patients was shown to be a risk factor for graft retear in the 02/03 group, subsequent to this, graft choice changed to using allografts in older and less active patients with an associated decrease in graft retear risk in the 07/08 group. The contralateral ACL injury risk did not change from the early group to the later group. The risk of ACL graft retear was lower for all graft types in the 07/08 group compared to the 02/03 group. The relative decrease risk in hamstring autografts compared to BTB in 07/08 compared to 02/03 may be due to improved surgical techniques, rehabilitation, and/or slower return to play guidelines, and bears further investigation.

Fourth-generation ceramic-on-ceramic total hip arthroplasty in patients of 55 years or younger: short-term results and complications analysis.

The incidence of total hip replacement in the younger and more active patients is ever increasing. The ceramic-on-ceramic (COC) bearing was developed to reduce wear debris-induced osteolysis and loosening and to improve the longevity of hip arthroplasties. Few studies have reported the clinical results and complications of the new zirconia-toughened ceramic total hip arthroplasty (THA). A consecutive series of 132 young patients (177 hips) that underwent primary cementless THAs between January 2010 and December 2012 were included in this study. These arthroplasties all had fourth-generation COC bearings performed through a posterolateral approach. The average age was (41.8 ± 8.3) years (ranging from 22 to 55 years), and the mean follow-up period was (24.5 ± 9.4) months (ranging from 12 to 47 months). The results were evaluated both clinically and radiographically. Harris hip score (HHS) was determined before surgery and at the time of each follow-up. Presence of postoperative groin or thigh pain and squeaking were recorded. Other complications such as dislocations, periprosthetic fractures, and ceramic components fractures were diagnosed and treated in emergency. The average HHSs improved from preoperative 60.3 ± 10.7 (ranging from 29 to 76) to 91.0 ± 5.1 (ranging from 74 to 100) at the final follow-up (t = 45.064, P < 0.05), and 97.7% of cases were scored as excellent and good results. At the last follow-up, incidental inguinal pain was found in three hips (1.7%) and thigh pain in 11 hips (6.2%). Radiographs showed a high rate of new bone formation around the acetabular and stem components. No obvious osteolysis or prosthesis loosening was detected. Complications occurred in six hips (3.4%): posterior dislocation in two hips (1.1%), periprosthetic femoral fracture in one hip (0.6%), asymptomatic squeaking in two hips (1.1%), and ceramic liner fracture in one hip (0.6%). The fourth-generation COC THA showed excellent clinical results in younger active patients with no osteolysis-related prosthesis failure at a short-term follow-up study. Surgeons should still be aware of the potential risks of complications such as dislocation, periprosthetic fracture, squeaking, and ceramic components fracture.

Management of recurrent multiple osteochondral lesions of the talus (OCLT) in a young active patient.

Management of recurrent osteochondral lesion of talus in a young active male is a challenging problem. We present one such case of recurrent talar osteochondral lesions treated by Autologous Matrix Induced Chondrogenesis (AMIC). Patient had a good functional outcome at short-term follow up. We also describe the technique and review the literature regarding this novel technique.

Success of High Tibial Osteotomy in the United States Military

Historically, high tibial osteotomy (HTO) has been performed to treat isolated medial gonarthrosis with varus deformity. More recently, HTO has been utilized in conjunction with chondral, ligamentous, and/or meniscal procedures in young active patients with subtle varus malignment. However, occupational outcomes in a high-demand military cohort are largely unknown. A retrospective analysis of active duty servicemembers undergoing high tibial osteotomy for coronal plane malalignment and/or intra-articular pathology were isolated from the Military Health System Management Analysis and Reporting Tool between 2003 and 2011. Demographic variables such as age, sex, rank, and branch of service were extracted, and extensive medical record review was performed to identify surgical variables, including the rates of perioperative complications, radiographic findings, secondary surgery (including revision), activity limitations, and medical discharge as confirmed by the U.S. Army Physical Disability Agency database. For the current study, cumulative failure was defined as conversion to knee arthroplasty, or medical discharge with persistent knee dysfunction after index HTO. Univariate and multivariate analysis were performed to identify statistical associations with cumulative failure after HTO. A total of 80 patients with 93 HTOs were identified at an average follow-up of 43.7 months (range, 24-93 months). The mean age of all servicemembers was 35.5 years (range, 20-55), and the majority were males (91%) and of enlisted rank (76%). Approximately 92% of surgeries involved plate fixation, while the remainder utilized circular or monolateral external fixation. Concomitant or staged procedures were performed in 45 servicemembers (56%), including 29 ligamentous, 24 meniscal, and 21 chondral procedures. Complications necessitating unplanned reoperation occurred in 10 cases (11%), including infection (n=3), nonunion (n=2), fracture (n=2), hardware failure (n=1), dehiscence (n=1), and flexion contracture (n=1). Additionally, symptomatic hardware was noted after 18 surgeries (19%) and occasional knee pain was noted in 26 extremities (28%). When considering those individuals remaining on active duty, 21(26%) servicemembers were unable to return to full duty and required permanent activity limitations. Of the 80 servicemembers, 7 individuals received medical discharge for persistent knee pain or disability, and an additional 7 underwent conversion to total knee arthroplasty. The cumulative failure rate for all servicemembers was 18% at 2-8 year follow-up. In a young, active military population, HTO is moderately effective for the treatment of medial unicompartmental disease with associated intra-articular knee pathology. At early to mid-term follow-up, 82% of patients returned to military duty and were free from conversion knee arthroplasty. High tibial osteotomy is a useful in the treatment of medial unicompartmental disease and has demonstrated success in an active US military population at a minimum of 2-year follow-up.