Faculty Bibliography

BACKGROUND:This study aims to investigate the effect of donor-recipient sex-mismatch on graft survival, patient-reported outcomes (PROs), and return to sport (RTS) following knee osteochondral allograft (OCA) transplantation. METHODS:Patients who underwent knee OCA transplantation between 2011 and 2022 with minimum 2-year clinical follow-up were divided into two cohorts (same-sex (SS) and different-sex (DS) donor). Cumulative survival was compared via multivariable Cox regression analyses controlling for age, graft size, and body mass index (BMI). A sub-analysis comparing PROs between groups was performed, including the Visual Analog Scale (VAS) for pain and satisfaction, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and RTS rates. RESULTS:285 patients were included (189 SS, 96 DS) with mean follow-up of 4.8 ± 2.0 years. There was a graft failure rate of 6.0% with no significant difference in graft survival rate between DS and SS groups (p = 0.70). Sub-analyses between the four donor-recipient groups (male-male, female-male, male-female, and female-female) and between female and male donor groups demonstrated no significant differences in graft survival. Among patients who failed the procedure, time to failure was significantly shorter for those with sex-mismatched grafts (353 days vs. 864 days, p = 0.002). Sub-analysis of a 71-patient cohort with two-year PROs demonstrated no differences between SS and DS groups with respect to satisfaction, pain, or KOOS scores after controlling for sex (p > 0.05). CONCLUSION/CONCLUSIONS:Patients undergoing knee OCA transplantation demonstrated no observable differences in graft survivorship based on donor-recipient graft sex-matching, suggesting that surgeons can use sex-mismatched grafts and expect limited effect on graft survivorship. LEVEL OF EVIDENCE/METHODS:IV.

BACKGROUND:Efforts to decrease pain, improve early rehabilitation, and reduce opioid consumption have prompted a focus on peripheral nerve blocks for pain management after anterior cruciate ligament reconstruction (ACLR). The commonly used adductor canal block (ACB) might not provide sufficient postoperative pain control because of its lack of coverage of the posterior aspect of the knee. The addition of the IPACK (interspace between the popliteal artery and the capsule of the posterior knee) block, which targets this area, to the standard ACB could potentially provide better pain control after ACLR over the current standard of care. PURPOSE/HYPOTHESIS/OBJECTIVE:The purpose of this study was to compare and analyze postoperative pain, satisfaction, and opioid demand between the standard ACB and a combination of an ACB and IPACK block in patients undergoing ACLR with a bone-patellar tendon-bone (BTB) autograft. It was hypothesized was that the addition of the IPACK block would substantially improve early postoperative pain control and minimize opioid use. STUDY DESIGN/METHODS:Randomized controlled trial; Level of evidence, 2. METHODS:test or nonparametric test for continuous variables and the chi-square test for categorical variables. Opioid usage was reported as morphine milligram equivalents (MME). RESULTS:< .001). CONCLUSION/CONCLUSIONS:The results of this study suggest that the addition of an IPACK block to an ACB leads to reduced opioid consumption, improved pain control, and higher satisfaction with pain control acutely after ACLR with a BTB autograft. REGISTRATION/BACKGROUND:NCT05286307 (ClinicalTrials.gov).

BACKGROUND:To compare clinical outcomes, return to activities, and rates of revision surgery following arthroscopic glenoid labral repair in patients who were prescribed NSAIDs as part of their postoperative pain management regimen versus those who were not. METHODS:Patients aged 18-55 who underwent primary arthroscopic labral repair at a single academic institution from the years 2016-2020 were retrospectively reviewed. Patients who underwent concomitant rotator cuff repair, remplissage, or did not have minimum 2-year postoperative follow-up were excluded. Patients who were prescribed postoperative NSAIDs were matched 1:1 to those who were not based on age, sex, BMI, and number of suture anchors. Outcomes were assessed using the Visual Analog Scale (VAS) for pain, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Simple Shoulder Test (SST), Single Assessment Numeric Evaluation rating (SANE), and satisfaction. Pre-injury sport and work activity information were recorded. RESULTS:Of 269 eligible patients, 224 patients were included. Patients prescribed NSAIDs postoperatively had similar levels of pain (1.2 vs 1.0, p=0.527) and function (ASES: 90.8 vs 89.9, p=0.824; SST: 91.9 vs 90.6, p=0.646; SANE: 83.8 vs 85.3, p=0.550) compared to those who were not. Rates of revision surgery (2.7% vs 0.9%, p=0.622) and recurrent instability (5.4% vs 8.0%, p=0.594) were similar between NSAID and non-NSAID groups. Rates of return to sport (83.5% vs 77.8%, p=0.318) and return to pre-injury level (59.3% vs 61.6%, p=0.177) were similar between NSAID and non-NSAID groups. Prescription of postoperative NSAIDs was not associated with delayed return to sport (OR:1.47, 95%CI [0.68,3.18], p=0.327) or return to work (OR:0.56, 95%CI [0.14,2.28], p=0.416). CONCLUSIONS:Patients who were prescribed NSAIDs as a part of a postoperative pain management regimen following primary arthroscopic labral repair for glenohumeral instability had similar patient-reported outcomes, revision rates, and rates of return to pre-injury activities compared to those who were not prescribed NSAIDs.

PURPOSE/OBJECTIVE:To assess clinical outcomes and return to sport (RTS) rates among patients that undergo osteochondral allograft (OCA) transplantation and autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI), for patellofemoral articular cartilage defects. METHODS:A retrospective review of patients who underwent an OCA or ACI/MACI from 2010-2020 was conducted. Patient-reported outcomes (PROs) collected included: Visual Analog Scale for pain/satisfaction, Knee Injury and Osteoarthritis Outcome Score (KOOS), and RTS. The percentage of patients that met the Patient Acceptable Symptom State (PASS) for KOOS was recorded. Logistic regression was used to identify predictors of worse outcomes. RESULTS:A total of 95 patients were included (78% follow-up) with ACI or MACI performed in 55 cases (57.9%) and OCA in 40 (42.1%). A tibial tubercle osteotomy was the most common concomitant procedure for OCA (66%) and ACI/MACI (98%). Overall, KOOS pain was significantly poorer in OCA than ACI/MACI (74.7, 95% CI [68.1, 81.1] vs 83.6, 95% CI [81.3, 88.4], p= 0.012), while the remaining KOOS subscores were non-significantly different (all p>0.05). Overall, RTS rate was 54%, with no significant difference in return between OCA or ACI/MACI (52% vs 58%, p= 0.738). There were 26 (27%) reoperations and 5 (5%) graft failures in the entire group. Increasing age was associated with lower satisfaction in OCA and poorer outcomes in ACI/MACI, while larger lesion area was associated with lower satisfaction and poorer outcomes in ACI/MACI. CONCLUSION/CONCLUSIONS:Clinical and functional outcomes were similar in patients that underwent OCA or ACI/MACI for patellofemoral articular cartilage defects at a mean follow-up of 5 years. Patients who received OCA had a higher proportion of degenerative cartilage lesions and, among those with trochlear lesions, reported higher pain at final follow-up than their ACI/MACI counterparts. Overall, increasing age and a larger lesion size were associated with worse patient-reported outcomes.

PURPOSE/OBJECTIVE:There is limited clinical outcome data comparing fixation methods for tenodesis of the long head of the biceps tendon (LHBT), particularly button fixation. The purpose of this study was to compare clinical outcomes, patient-reported outcomes, and return to sport (RTS) between patients undergoing LHBT with bicortical versus unicortical button technique. The authors hypothesized these fixation methods would be similar for all outcomes. METHODS:Patients who underwent LHBT using unicortical or bicortical button fixation with minimum 2-year follow-up were identified. Postoperative outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) questionnaire and visual analogue scale (VAS) pain score. A sports activity survey was collected to assess baseline sport participation and ability to return to pre-injury activities. Continuous variables were analyzed using the Mann-Whitney-U test. Categorical variables were analyzed using Chi-squared tests. Multivariable logistic and linear regression were performed to determine predictors of RTS and time to RTS. RESULTS:Sixty-four subjects (19 unicortical and 45 bicortical button fixation) were included (average follow-up 3.5 (range: 2.0-7.8) years). There were no significant differences found between button groups for VAS pain score (1.5 vs. 1.2; p = 0.876), VAS pain during sport score (1.6 vs. 1.1, p = 0.398), and ASES score (66 vs. 71; p = 0.294). There were no significant differences in rate of RTS (75.0 vs. 77.4%; p = 0.885) or average time to return to sport (11.7 ± 7.3 vs. 7.0 ± 4.0 months; p = 0.081) between groups. CONCLUSION/CONCLUSIONS:There were no significant differences in clinical outcomes, pain, or return to sport between patients who underwent LHBT with unicortical or bicortical button fixation.

PURPOSE/OBJECTIVE:The purpose of this study is to assess the association between sagittal tibial tuberosity-trochlear groove (sTT-TG) distance and patellofemoral chondral lesion size in patients undergoing cartilage restoration procedures. METHODS:A retrospective cohort analysis of patients who underwent an osteochondral allograft transplantation or matrix-induced autologous chondrocyte implantation in the patellofemoral compartment, from 2010 to 2020, were included if they had patellofemoral high-grade lesions, magnetic resonance imaging (MRI) and minimum 2-year follow-up. The preoperative sTT-TG distance was measured independently on axial T2-weighted MRI sequences by two authors, each at least two weeks apart. Intraoperative lesion size was reported according to operative report measurements by the attending surgeon. An interclass correlation coefficient (ICC) was calculated to assess intra- and inter-rater reliability, and categorical data analysis and linear regression models were used to assess the relationship between sTT-TG and lesion size. RESULTS:. Intra- (ICC: 0.99,0.98) and inter-rater reliability (ICC: 0.96) were excellent for both MRI defect size and sTT-TG measurements. The mean sTT-TG was -4.8 ± 4.9 mm and was significantly inversely related to MRI defect size (-0.45, p < 0.01), intraoperative patellar lesion size (-0.32, p = 0.01), total lesion area (-0.22, p = 0.04), but not trochlear lesion size (-0.09, p = 0.56). Multivariable regression demonstrated a more negative sTT-TG remained an independent variable correlated with larger MRI-measured patellofemoral defect sizes and intraoperative patellar lesions. CONCLUSION/CONCLUSIONS:A more negative sTT-TG was an independent variable correlated with larger patellofemoral lesions in patients undergoing patellofemoral cartilage restoration. LEVEL OF EVIDENCE/METHODS:Level III, Diagnostic.

PURPOSE/OBJECTIVE:The purpose of this study was to determine whether significant differences exist when comparing posterior tibial slope (PTS) measured using increasing lengths of the tibia to determine the anatomical axis. METHODS:Patients with full-length weight-bearing tibial radiographs were retrospectively identified from 2014 to 2022 at a single institution. Patients were excluded if there was any previous history of lower extremity fracture or osteotomy. The anatomical axis of the tibia was determined using the full length of tibial radiographs, and the "reference PTS" was measured using this axis. Using the same radiograph, the PTS was measured using four different anatomical axes at standardized tibial lengths. While the center of the proximal circle remained constant at 5-cm below the tibial plateau, the center of the distal circle was drawn at four points: a) overlapping circles; b) 10-cm distal to the tibial plateau; c) 15-cm distal to the tibial plateau; d) half the length of the tibia, measured from the tibial plateau to the tibial plafond. Bivariate correlation and frequency distribution analysis (measurements >2-degrees from reference PTS) were performed between the reference PTS and PTS measured at each of the four other lengths. RESULTS:A total of 154 patients (39.8 ± 17.4 years old, 44.2% male) were included in the final analysis. Measurements at each of the four tibial lengths were all significantly different from the reference PTS (p < 0.001). The correlation strength improved with increasing tibial length (overlapping: R = 0.681, 10-cm: R = 0.821, 15-cm: R = 0.937, and half-tibia: R = 0.963). The number of PTS measurements >2-degree absolute difference from the reference PTS decreased with increasing tibial length (overlapping: 40.3%, 10-cm: 24.0%, 15-cm: 26.0%, and half-tibia: 18.8%). CONCLUSION/CONCLUSIONS:Assessment of PTS is dependent on the length of the tibia utilized to obtain the anatomical axis. Accuracy and precision of PTS measurements improved with increasing length of tibia used to determine the anatomical axis. STUDY DESIGN/METHODS:Case series.

OBJECTIVES/OBJECTIVE:The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. METHODS:A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. RESULTS:Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p ​= ​0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p ​= ​0.47), return to sport (MQTFLR 50%, MPFLR 75%, p ​= ​0.61), return to work (MQTFLR 100%, MPFLR 88%, p ​= ​1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p ​= ​0.31). CONCLUSION/CONCLUSIONS:There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/UNASSIGNED:To analyze the effects of 1 or more patient-reported allergies on clinical outcomes, in particular graft failure rate, and patient-reported outcomes (PROs) following osteochondral allograft transplantation (OCA) of the knee. METHODS/UNASSIGNED:Retrospective review of patients who underwent knee OCA from August 2010 to May 2021 with a minimum of 2-year follow-up. Patients were initially divided into 2 cohorts: those with at least 1 allergy and those without any allergies. Clinical outcomes assessed included graft failure, reoperation rates, deep vein thrombosis/pulmonary embolism, and manipulation under anesthesia/lysis of adhesions (MUA/LOA). PROs assessed, including the visual analog scale (VAS) for pain and satisfaction, the Knee injury and Osteoarthritis Outcome Score (KOOS), and return to sport rates, were compared. RESULTS/UNASSIGNED: = .022). There was no difference in rate of reoperation, complications, infection, and MUA/LOA. Of the 100 patients who completed PROs, there was no difference in VAS satisfaction, pain, and any of the KOOS outcome scores or return to sport. CONCLUSIONS/UNASSIGNED:The presence of 1 or more patient-reported allergies was shown to be significantly associated with OCA graft failure. Furthermore, an increasing number of patient-reported allergies were associated with a higher rate of graft failure. However, there were no significant differences in VAS satisfaction or pain, KOOS symptom, quality of life, pain, or return to sport in patients with at least 1 patient-reported allergy and those without allergies. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.

BACKGROUND:Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). METHODS:Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. RESULTS:Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend. CONCLUSION/CONCLUSIONS:PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.