Chondral and Soft Tissue Injuries Associated to Acute Patellar Dislocation: A Systematic Review

Introduction: Chondral and soft tissue injuries can be associated with first time patellar dislocation, but it is unclear how common they are, and which tissues are affected. A systematic review of the literature was performed to investigate the frequency, location, and extent of chondral and medial patellofemoral ligament (MPFL) injuries in patients following first time patellar dislocation. Methods: This systematic review was conducted according to the PRISMA guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in November 2021. All the published clinical studies reporting the frequency, location, and extent of soft tissue lesions following first time patellar dislocation were accessed. Studies reporting data on habitual, congenital, or recurrent patellofemoral instability were excluded. Results: Data from 42 articles (2254 patients, mean age 21.6 ± 7.3 years) were retrieved. Ninety-eight percent of patients who experienced first time patellar dislocation demonstrated MPFL rupture at MRI. Forty-eight percent of MPFL ruptures were located at the patellar side, 34% at the femoral insertion site, and 18% in the midportion. Eighty-five percent of patients showed signs of patellar chondral damage at MRI, and trochlear chondral injuries were evidenced in 47% of patients. Intra-articular loose bodies were observed in 11.5% of patients. At arthroscopy, the medial facet and the crest of the patella more commonly exhibited chondral lesions than the lateral facet and femoral trochlea. Conclusions: Most patients suffer chondral damage and MPFL tears following after a first time patellar dislocation.

The role and clinical relevance of the ligamentum teres: long-term outcomes after hip arthroscopic surgery of cam-type femoroacetabular impingement

ABSTRACT We aimed to compare clinical and radiologic outcomes in patients with cam-type femoroacetabular impingement (FAI), with and without a partial ligamentum teres (LT) tear, who underwent hip arthroscopy (HA) with ≥10 years of follow-up. Among the patients who underwent HA for a cam-type FAI diagnosis with a labral tear, 28 patients (28 hips) with a partial LT tear and 87 patients (99 hips) with an intact LT were assigned to Groups A and B, respectively. All patients underwent partial labral debridement and femoroplasty. Debridement and thermal shrinkage were performed for LT tears. The grade of chondral damage was measured intraoperatively. Clinical items were assessed preoperatively and at the last follow-up. Patients’ satisfaction with the surgery and changes in postoperative sports ability in those who had previously been active in sports were assessed at the last follow-up. The Tönnis grade was assessed preoperatively and at the last follow-up for radiologic evaluation. Chondral damage to the acetabular and femoral head detected intraoperatively was significantly different between the groups (P = 0.005 and P < 0.001). At the last follow-up, Group A patients experienced more difficulty performing sports activities than Group B patients (P = 0.056), and significantly, more Group A patients had stopped exercising despite their active participation in sports preoperatively (P = 0.002). Regarding the Tönnis grade, significant differences were found only at the final follow-up (P = 0.020). Patients with partial LT tear showed a higher grade of chondral damage, experienced decreased exercise capacity and had significantly worsened Tönnis grades, suggesting hip osteoarthritis progression compared to those with an intact LT.

Nonarthritic Hip Pathology Patterns According to Sex, Femoroacetabular Impingement Morphology, and Generalized Ligamentous Laxity

Background: Sex differences are frequently encountered when diagnosing orthopaedic problems. Current literature suggests specific sex differences, such as a higher prevalence of cam-type femoroacetabular impingement syndrome in male patients and features of hip instability in female patients. Purpose: To identify hip pathology patterns according to sex, alpha angle deformity, and generalized ligamentous laxity (GLL) in a nonarthritic patient population that underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome and labral tears. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients who underwent primary hip arthroscopy between February 2008 and February 2017 were included and separated into male and female groups for initial analysis. Patients were excluded if they had Tönnis osteoarthritis grade >1, previous ipsilateral hip surgery, or previous hip conditions. The demographics, radiographic findings, intraoperative findings, and surgical procedures were then analyzed and compared. Subanalyses were performed for both groups. A threshold of 1 SD above the mean alpha angle in the male group was used to create 2 subgroups. For female patients, GLL based on a Beighton score ≥4 was used to divide the group. Intraoperative findings were compared for both subanalyses. Results: A total of 2701 hips met all inclusion and exclusion criteria. Of those, 994 hips were in the male group and 1707 in the female group. The mean ± SD age was 36.6 ± 13.8 and 37.1 ± 15.0 years for the male and female groups, respectively( P = .6288). The average body mass index was significantly higher in the male group ( P < .0001). GLL was more common in women (38.6%) than men (13.6%) ( P < .001). The male group had a higher proportion of acetabular Outerbridge grade 3 (21.8%) and 4 (19.2%) lesions when compared with the female group (9.3% and 6.3%, respectively) ( P < .0001). Men in the subgroup with an alpha angle ≥78° reported higher rates of acetabular Outerbridge grade 4 damage than men with an alpha angle <78° ( P < .001). Mean lateral center-edge angle was lower in the female subgroup with Beighton score ≥4 vs <4 (23.7°± 4.2° vs 31.3°± 5.8°; P < .0001). Conclusion: In this analysis of a large cohort of patients who underwent hip arthroscopy, 2 patterns of hip pathologies were related to sex. On average, male patients had larger alpha angles and increased acetabular chondral damage when compared with their female counterparts. Furthermore, a larger cam-type anatomy was associated with more severe acetabular chondral damage in men. In the female group, the incidence of features of hip instability such as GLL were significantly higher than in the male group.

Assessment of acetabular chondral damage and labral pathologies via direct MR arthrography: specialization matters

Aims To compare the diagnostic accuracy of investigators from different specialities (radiologists and orthopaedic surgeons) with varying levels of experience of 1.5 T direct magnetic resonance arthrography (dMRA) against intraoperative findings in patients with femoroacetabular impingement syndrome (FAIS). Methods A total of 272 patients were evaluated with dMRA and subsequent hip arthroscopy. The dMRA images were evaluated independently by two non-hip-arthroscopy-trained orthopaedic surgeons, two fellowship-trained musculoskeletal radiologists, and two hip-arthroscopy-trained orthopaedic surgeons. The radiological diagnoses were compared with the intraoperative findings. Results Hip arthroscopy revealed labral pathologies in 218 (79%) and acetabular chondral lesions in 190 (69%) hips. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for evaluating the acetabular labral pathologies were 79%, 18%, 79%, 18%, and 66% (non-hip-arthroscopy trained orthopaedic surgeons), 83%, 36%, 83%, 36%, and 74% (fellowship-trained musculoskeletal radiologists), and 88%, 53%, 88%, 54% and 81% (hip-arthroscopy trained orthopaedic surgeons). The sensitivity, specificity, PPV, NPV and accuracy of dMRA for assessing the acetabular chondral damage were 81%, 36%, 71%, 50%, and 66% (non-hip-arthroscopy trained orthopaedic surgeons), 84%, 38%, 75%, 52%, and 70% (fellowship-trained musculoskeletal radiologists), and 91%, 51%, 81%, 73%, and 79% (hip-arthroscopy trained orthopaedic surgeons). The hip-arthroscopy trained orthopaedic surgeons displayed the highest percentage of correctly diagnosed labral pathologies and acetabular chondral lesions, which is significantly higher than the other two investigator groups (p < 0.05). Conclusion The accuracy of dMRA on detecting labral pathologies or acetabular chondral lesions depends on the examiner and its level of experience in hip arthroscopy. The highest values are found for the hip-arthroscopy-trained orthopaedic surgeons. Level of evidence Retrospective cohort study; III.

Chondral Damage After Arthroscopic Repair Techniques for Acute Bony Bankart Lesions: A Biomechanical Study

Background: Bony Bankart lesions can be encountered during treatment of shoulder instability. Current arthroscopic bony Bankart repair techniques involve intra-articular suture placement, but the effect of these repair techniques on the integrity of the humeral head articular surface warrants further investigation. Purpose: To quantify the degree of humeral head articular cartilage damage secondary to current arthroscopic bony Bankart repair techniques in a cadaveric model. Study Design: Controlled laboratory study. Methods: Testing was performed in 13 matched pairs of cadaveric glenoids with simulated bony Bankart fractures, with a defect width of 25% of the glenoid diameter. Half of the fractures were repaired with a double-row technique, while the contralateral glenoids were repaired with a single-row technique. Samples were subjected to 20,000 cycles of internal-external rotation across a 90° arc at 2 Hz after a compressive load of 750 N, or 90% body weight (whichever was less) was applied to simulate wear. Cartilage defects on the humeral head were quantified through a custom MATLAB script. Mean cartilage cutout differences were analyzed by the Wilcoxon rank-sum test. Results: Both single- and double-row repairs showed macroscopic damage. The histomorphometric analysis demonstrated that the double-row technique resulted in a significantly ( P = .036) more chondral damage (mean, 57,489.1 µm2; SD, 61,262.2 µm2) than the single-row repair (mean, 28,763.5 µm2; SD, 24,4990.2 µm2). Conclusion: Both single-row and double-row arthroscopic bony Bankart fixation techniques resulted in damage to the humeral head articular cartilage in the concavity-compression model utilized in this study. The double-row fixation technique resulted in a significantly increased cutout to the humeral head cartilage after simulated wear in this cadaveric model. Clinical Relevance: This study provides data demonstrating that placement of intra-articular suture during arthroscopic bony Bankart repair techniques may harm the humeral head cartilage. While the double-row repair of bony Bankart lesions is more stable, it results in increased cartilage damage. These findings suggest that alternative, cartilage-sparing arthroscopic techniques for bony Bankart repair should be investigated.

242 Maintaining Surgical Training During the Covid-19 Pandemic; A Novel Use of Surgical Simulators

Introduction During Covid-19 pandemic, operation theatres limit the number of staff during each session, which causes a decrease in training opportunity. To counteract this lapse, the Orthopaedic Research Institute (ORI) designs an innovative training session. During the nationwide lockdown, the closure of the Institute allowed for the transfer of the VirtaMed ArthrosTM (VA), to our NHS facility. VA is a surgical simulator which enables the participant to practise knee arthroscopy. Method Participants with little arthroscopic experience were included in the study. Three fellowship-trained surgeons conducted daily teaching sessions. Participants were taught necessary arthroscopic skills before undertaking training modules on diagnostic arthroscopy. 90% of the participants attended the session at least three times. At the end of every module, VA generates a score based on parameters which include procedure duration, visualisation of key structures and iatrogenic chondral damage. Structure questionnaires were also used to analyse feedback. Results The overall confidence and module scores progress with each subsequent session. A keystone of success is the location and ease of access to the simulator. Conclusions Surgical simulators are a useful tool for surgical education and training. We should encourage their use in the future, especially in the UK surgical training programme.

There is an Association of Synovial Interleukin-6 Levels With Chondral Damage in Anterior Cruciate Ligament–Deficient Knees

Background: Osteoarthritis (OA) in the anterior cruciate ligament (ACL)–deficient knee is seen in approximately 50% of affected patients. Possible causes include biochemical or biomechanical changes. Purpose: We sought to study the correlation between inflammatory cytokines and chondral damage in ACL-deficient knees. Methods: Seventy-six male patients who underwent ACL reconstruction were enrolled in a cross-sectional study. Synovial fluid was aspirated before surgery and analyzed for levels of the inflammatory cytokines tumor necrosis factor-α, interleukin-1 (IL-1), and interleukin-6 (IL-6). At the time of ACL reconstruction, the severity of chondral damage was documented as described by the Outerbridge classification. Results: Patients with grade 2 or higher chondral damage were observed to have elevated IL-6 levels when compared to patients who had no chondral damage. Interleukin-6 levels had no correlation with the duration of injury. Conclusion: Elevated levels of IL-6 in synovial fluid were associated with chondral damage in ACL-deficient knees. Further study is warranted to determine whether inflammatory cytokines contribute to the development of OA of the knee after ACL injury.

Hip arthroscopy following slipped capital femoral epiphysis fixation: chondral damage and labral tears findings

Purpose This study investigated the association between chondrolabral damage and time to arthroscopic surgery for slipped capital femoral epiphysis (SCFE). Methods This was a descriptive retrospective study that enrolled patients with SCFE who underwent hip arthroscopy for femoral osteochondroplasty after SCFE fixation. SCFE type, time from SCFE symptom onset or slip fixation surgery to hip arthroscopy and intraarticular arthroscopic findings were recorded. Acetabular chondrolabral damage was evaluated according to the Konan and Outerbridge classification systems. Nested analysis of variance and the chi-squared test were used for statistical analyses. Results We analyzed 22 cases of SCFE in 17 patients (five bilateral). The mean age at the time of hip arthroscopy was 13.6 years-old (8–20), and mean time from SCFE fixation to arthroscopy was 25.1 months (3 weeks to 8 years). Labral frying was present in 20 cases, labral tears in 16 and acetabular chondral damage in 17. The most frequent lesion was type 3 (41%) (Konan classification). Two cases had a grade III and 1 had a grade II acetabular chondral lesion (Outerbridge classification). Positive associations were observed between time from SCFE to hip arthroscopy and hip intraarticular lesions evaluated using Konan (p = 0.004) and Outerbridge (p = 0.000) classification systems. There was no association between SCFE severity (chi-squared = 0.315), stability (chi-squared = 0.558) or temporality (chi-squared = 0.145) type and hip intraarticular lesions. Conclusion A longer time from SCFE symptom onset and fixation to hip arthroscopy is associated with greater acetabular chondrolabral damage. Level of evidence IV