Faculty Bibliography

Orthopedic surgery is among the most physically demanding medical specialties, exposing surgeons to prolonged static postures, repetitive high-force movements, and heavy equipment that significantly increase the risk of musculoskeletal injury. Historical perspectives reveal that ergonomic principles have been recognized since antiquity, yet modern surgical practice continues to neglect them, resulting in high rates of pain, disability, and even premature retirement among orthopedic surgeons. Recent survey data demonstrate that musculoskeletal disorders affect surgeons across all subspecialties, with the lumbar spine, neck, and shoulders most frequently involved, and that these injuries directly influence surgical performance, career longevity, and workforce sustainability. Evidence-based strategies-including intraoperative postural awareness, optimized table and monitor positioning, ergonomic instrument design, microbreaks, targeted physical conditioning, and adoption of assistive technologies-have been shown to mitigate injury risk without compromising operative efficiency. Reframing ergonomics as a cornerstone of operative excellence is essential not only for surgeon well-being but also for ensuring high-quality, sustainable patient care in the future.

Osteotomies around the knee-including distal femoral osteotomies, high tibial osteotomies, and tibial tubercle osteotomies-are technically demanding procedures that are generally safe, with relatively low overall complication rates. However, complications do occur and can pose significant challenges, with substantial implications for patient outcomes. Awareness of potential complications and meticulous surgical technique are, therefore, essential to minimizing risk. This review highlights the most clinically relevant complications unique to knee osteotomies. These include vascular injury, hinge and shingle fractures, delayed union or nonunion, femur and tibia fractures, and infection. For each complication, contributing patient and surgical factors are examined, along with an emphasis on strategies for prevention and proposed treatment management algorithms. By combining preventive strategies with structured management guidance, this review aims to serve as a practical reference for optimizing outcomes and reducing the morbidity associated with knee osteotomies.

Among the strategies to improve outcomes of rotator cuff repair, proper surgical technique is quintessential. While the ideal goal of a rotator cuff repair is anatomic restoration of the native tendon footprint, this may not always be possible to accomplish without placing significant tension on the medial stump. Recent literature shows the importance of tension modulation in rotator cuff repair, showing better clinical outcomes and healing rates with tension-reducing techniques, compared with full footprint covering repair, with the difference notable in larger and more retracted tears. Simultaneously single- and double-row repairs showed similar outcomes, better results were achieved with rehabilitation that was conservative rather than accelerated, and no difference was shown between tendon remnant preservation and footprint medialization.

PURPOSE/OBJECTIVE:To systematically review and meta-analyze cadaveric studies quantifying the medial patellofemoral ligament (MPFL) femoral attachment site using radiopaque markers on radiographs to evaluate the accuracy of Schöttle's point as a radiographic landmark for MPFL attachment. METHODS:A systematic review and meta-analysis was performed of the PubMed, EMBASE, and Scopus databases to identify cadaveric studies reporting the radiographic position of the MPFL femoral attachment. Included studies reported attachment location relative to the posterior cortical extension line in the anterior-posterior direction and to either the posterior point of Blumensaat's line or another radiographic landmark in the proximal-distal direction. The distance between Schöttle's point and other mean radiographic locations were calculated; distances greater than 3 mm, the radius of a femoral surgical tunnel, represented substantial variation. RESULTS:Nine studies of 94 cadaveric knees were included in the final analysis with a mean age of 62.45 ± 11.64 years. The average distance from the posterior cortical extension line to the MPFL insertion was 1.04 ± 10.09 mm anterior [95% CI: 0.40, 2.28, range: 4.80 mm posterior to 8.80 mm anterior] (n = 94). The average distance from Blumensaat's line was 2.07 ± 5.06 mm proximal [95% CI: 1.12, 2.00, range: 0.90 mm distal to 4.70 mm proximal] (n = 77). Three studies reported mean distance from the condylar transition line, averaging 2.88 ± 6.02 mm distal [95% CI: -5.04, -0.54, range: 0.50-5.70 mm distal] (n = 25). CONCLUSIONS:There was substantial heterogeneity in the radiographic location of the MPFL attachment, which suggests that relying solely on Schöttle's point risks nonanatomic tunnel placement. CLINICAL RELEVANCE/CONCLUSIONS:Although Schöttle's point is commonly used as a radiographic landmark during MPFL reconstruction, its variability suggests that the utilization of additional methods of assessment such as clinical palpation and graft isometry evaluation may enhance surgical precision and outcomes.

BACKGROUND:Genu valgum is a known risk factor for recurrent patellar instability, and surgical correction of deformity can be utilized as part of the management strategy to improve tracking and optimize outcomes. Tibial tuberosity-trochlear groove (TT-TG) distance is a widely used objective measurement of the lateral quadriceps force vector in patients with patellar instability. The evidence documenting the effect of lateral opening wedge distal femoral osteotomy (LOWDFO) and medial closing wedge high tibial osteotomy (MCWHTO) on TT-TG is limited, with minimal data directly comparing the biomechanical implications of one versus the other. PURPOSE/HYPOTHESIS/OBJECTIVE:The purpose of this study was to directly compare LOWDFO and MCWHTO using a computer model to determine the effect of each osteotomy on TT-TG distance. It was hypothesized that LOWDFO would have a greater effect on TT-TG distance, given the position farther away from the tibial tubercle. STUDY DESIGN/METHODS:Descriptive laboratory study. METHODS:A total of 22 knees from 21 patients with patellar instability and valgus malalignment were processed using 3D Slicer (Version 5.4.0) to convert their respective DICOM images into .stl mesh files to be used with Fusion (Autodesk; Version 2601.1.37) computer-aided design software. LOWDFOs and MCWHTOs were then simulated from 0° to 12° in 2° increments. TT-TG distance was then measured after each osteotomy. RESULTS:< .001). CONCLUSION/CONCLUSIONS:LOWDFO results in a significantly larger magnitude of change in the TT-TG compared with MCWHTO, with distal femoral osteotomy at almost a 1:1 change with TT-TG compared with the correction angle, and high tibial osteotomy about 1:4. CLINICAL RELEVANCE/CONCLUSIONS:The LOWDFO may be a more effective procedure in reducing the TT-TG distance, which is important when addressing patellar instability in patients with valgus malalignment.

Tibial tuberosity osteotomy (TTO) is a well-described treatment option for a broad range of patellofemoral joint disorders, including patellofemoral instability, focal chondral lesions of the patellofemoral joint, and patellofemoral arthritis. The purpose of this article is to review the indications and highlight the surgical technique for the more commonly performed TTO procedures and discuss outcomes, as well as surgical pearls for this technique.

Articular cartilage lesions of the knee, ranging from focal defects to tricompartmental osteoarthritis, present significant clinical challenges because of cartilage's limited regenerative capacity. It is important to highlight modern surgical advancements in the treatment of chondral pathology beyond injection therapy, traditional osteotomies, and arthroplasty options. Surface- and cell-based repair techniques, including matrix-induced autologous chondrocyte implantation, offer improved long-term outcomes, with emerging fourth-generation variants facilitating single-stage arthroscopic implantation. Off-the-shelf cartilage repair strategies, such as particulated juvenile cartilage, micronized allografts, and viable cartilage allografts, represent promising alternatives that bypass the need for two-stage procedures. For osteochondral defects, osteochondral autograft transfer and fresh allograft transplantation remain the gold standard, although decellularized and cryopreserved viable allografts are under investigation. Recently approved artificial osteochondral scaffolds, such as Agili-C, offer an FDA-cleared, acellular biphasic implant with promising midterm results. For patients with malalignment-associated osteoarthritis, patient-specific instrumentation in high tibial and distal femoral osteotomies enhances accuracy, particularly in biplanar corrections, and reduces intraoperative variability. Novel load-sharing implants, such as fiber-reinforced rafting nails and the MISHA knee system, provide less invasive alternatives to osteotomy, showing early success in reducing medial compartment load and improving functional outcomes. There is an expanding arsenal of biologically and biomechanically innovative treatments for articular cartilage restoration and osteoarthritis management.

BACKGROUND/UNASSIGNED:Isolated medial compartment knee osteoarthritis (OA) presents a challenging problem to treat for knee surgeons, with a multitude of options from conservative management, including injections and unloader braces, meniscal procedures, osteotomies, and unicompartmental knee arthroplasty (UKA). A new medial implantable shock absorber (MISHA) allows for offloading 142 N of the medial compartment during stance phase of gait. INDICATIONS/UNASSIGNED:US Food and Drug Administration approval was obtained on April 10, 2023, with the following indications: isolated medial knee OA (Kellgren-Lawrence grades I-IV) that failed 6 months of conservative management, ages 25 to 65 years, body mass index <35 or body weight <300 lbs, <15° of varus, no flexion contracture >10°, and no significant medial osteophytes or medial meniscal extrusion. TECHNIQUE DESCRIPTION/UNASSIGNED:A longitudinal medial knee incision is made 1 cm proximal to the medial epicondyle to the pes insertion, around 3 cm medial to the tibial tubercle, exposing the superficial medial collateral ligament, and medial joint line. The establishment of the femoral anisometric point is critical to provide a 4-mm posterior condylar offset in 90° of flexion compared to full extension. A trial implant can be placed to confirm appropriate anisometry, implant loading in extension, and relaxation in flexion. The final implant is placed and the titanium femoral and tibial baseplates are fixed with 3 unicortical titanium locking screws each. RESULTS/UNASSIGNED:Expected results per recommended postoperative protocol are immediate weightbearing without range of motion restrictions. From author experience, patients typically feel improvement and return to sport more rapidly than with anterior cruciate ligament reconstructions. Recovery and return to work are faster than osteotomies or UKAs based on comparative short-term studies. While long-term results are lacking given the novelty of the procedure, prospective studies have demonstrated 100% arthroplasty-free survival at 2 years and 85% survival at 5 years. DISCUSSION/CONCLUSION/UNASSIGNED:The MISHA is a viable option for isolated medial compartment knee OA that provides a joint-preserving alternative to arthroplasty and a less morbid alternative to osteotomy. This treatment can be technically difficult to perform, but several pearls and techniques can offer a reproducible, minimally invasive surgery and good functional results. PATIENT CONSENT DISCLOSURE STATEMENT/UNASSIGNED:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

PURPOSE/OBJECTIVE:The purpose of the current study was to define the incidence of minor and major complications following TTO at a tertiary-care institution, with determination of predictive factors related to the occurrence of a major complication. STUDY DESIGN/METHODS:Retrospective case series. METHODS:Patients who underwent TTO from 2011 to 2023 were retrospectively identified. Patients who did not have at least 30 days of follow-up and revision cases were excluded. Complications classified as "major" included intraoperative fracture, postoperative fracture, loss of fixation, delayed union, non-union, pulmonary embolism (PE), patella tendon rupture, deep infection, painful hardware requiring removal, arthrofibrosis requiring reoperation, recurrent patellar instability, reoperation for other indications, readmission, and revision. Complications classified as minor included superficial infection, deep venous thrombosis, wound dehiscence, and postoperative neuropraxia. Chi-square tests were used for categorical variables, t-tests for continuous variables. RESULTS:Four hundred and seventy-six TTOs in 436 patients were included in the final cohort with a mean follow-up of 1.9 years (range 1 month-10 years). Patients were 68.5% female with average age 28.3 years (range 13-57 years). The overall complication rate was 27.5 percent. Major complications were recorded in 23.7% of TTOs, and minor complications in 8.4% of TTOs. Reoperation was required in 16.6% of TTOs at a mean of 14 months following the index procedure. The most common complications were painful hardware requiring removal (6.5%), superficial infection (5.7%), and arthrofibrosis requiring return to the operating room (OR) (5.0%). Prior ipsilateral surgery was identified as a significant independent predictor of major complication by regression analysis. Hardware removal was more common with headed screws. Arthrofibrosis requiring reoperation was more common in patients who underwent a concomitant cartilage restoration/repair procedure. CONCLUSION/CONCLUSIONS:The overall complication rate following tibial tubercle osteotomy was 27.5%, with painful hardware requiring removal (6.5%) as the most common complication, and an overall reoperation rate of 16.6%. TTOs with major complications were performed at earlier years, in patients who were older, had a previous ipsilateral arthroscopic knee surgery, had an indication of cartilage lesion/arthritis, and had a steeper osteotomy cut angle. Hardware removal was found to be more common in patients with headed as compared to headless screws. Complications also varied based on timing after surgery.