Faculty Bibliography

Deciding the appropriate procedure for an active patient with medial compartment knee osteoarthritis can be challenging, and both medial opening wedge high tibial osteotomy (HTO) and medial unicompartmental knee arthroplasty have great long-term outcomes. However, the literature suggests that HTO may be most appropriate in patients who want to maintain a very active lifestyle, specifically continuing high-impact activities. Unicompartmental knee arthroplasty may be more appropriate for patients who are seeking pain relief and are more accepting of only participating in lower impact activities.

BACKGROUND:The COVID-19 pandemic led to increased sedentary behavior and body mass index during 2020, which may decondition musculotendinous units and lead to increased risk for injury. As patients return to pre-COVID levels of activity, we hypothesize that there will be a resultant rebound increase in tendon ruptures. LEVEL OF EVIDENCE/METHODS:III, descriptive epidemiology study. METHODS:The electronic medical record was queried for current procedural terminology codes for tendon ruptures (Achilles, patella, quadriceps, hamstring, distal biceps, triceps, and pectoralis major) from January 2017 to December 2021 at a single academic urban center. Data were reviewed to ensure only acute tendon rupture repairs were included. The years 2017-2019 were used as a proxy for pre-COVID rates, 2020 as a proxy for the COVID quarantine, and 2021 as a proxy for "post-COVID" activity. Univariate analysis was performed for comparative data. RESULTS:A total of 1,879 patients (82.8% male, mean age 47.8 years) who sustained tendon injuries and underwent surgical repair were identified. There were 589 (31.3%) Achilles tendon repairs, 181 (9.6%) patella tendon repairs, 414 (22.0%) quadriceps tendon repairs, 100 (5.3%) hamstring tendon repairs, 397 (21.1%) distal biceps repairs, 105 (5.6%) triceps repairs, and 93 (4.9%) pectoralis tendon repairs. The total number of tendon injuries per year was 2017-357 (19.0%), 2018-380 (20.2%), 2019-380 (20.2%), 2020-308 (16.4%), and 2021-454 (24.2%). The rates in 2017, 2018, and 2019 were within 1% of each other, but there were a 3.8% decrease in rate of tendon injuries from 2019 to 2020 and a 7.8% increase in rate of tendon injuries from 2020 to 2021. When analyzed by quarter, a linear regression model demonstrated a statistically significant increase in case counts over the period from Q2 2020 to Q2 2021 (β = 21.20; 95% confidence interval = 13.62-28.78, P-value < .01). CONCLUSIONS:A "COVID rebound" of tendon rupture repairs in 2021 from a prolonged period of inactivity during 2020 occurred at a single academic center. As patients return to pre-COVID levels of activity that may be unsuitable to their deconditioned state, healthcare providers should counsel patients appropriately on return to activity or sport following long periods of induced inactivity.

BACKGROUND:Nordic combined (NC) and ski jumping (SJ) athletes have a high prevalence of chronic hip pathology, which may lead to altered knee and ankle biomechanics. PURPOSE/OBJECTIVE:The purpose of this study was to determine the relationship among athlete-reported lower extremity outcomes in a proximal-to-distal sequence. STUDY DESIGN/LEVEL OF EVIDENCE/UNASSIGNED:cross-sectional study, Level IV. METHODS:Elite SJ and NC athletes who competed at the national and international levels were prospectively recruited to complete a survey eliciting information about their Hip Disability and Osteoarthritis Outcome Score (HOOS), International Knee Demographic Committee (IKDC) score, and Foot and Ankle Outcome Score (FAOS). Univariate linear regressions modeling IKDC scores and FAOS subscores were performed for each of the following independent variables: age, sex, body mass index, Nordic event (NC or SJ), HOOS subscore, and FAOS subscore or IKDC score, respectively. RESULTS:A total of 22 athletes were included in the study. HOOS symptoms subscores were significantly lower (worse) among SJ athletes compared with NC athletes (P = .002). HOOS quality of life subscores were lower for female athletes compared with male athletes (54 ± 21, 73 ± 4.0; P = .029) in the entire cohort. An increase in the HOOS pain subscore (0.54 ± 0.20, P = .016) and HOOS sports subscore (0.40 ± 0.17, P = .042) was associated with a significant increase in the IKDC score. An increase in the HOOS symptoms subscore (0.63 ± 0.21, P = .011) was associated with a significant increase in the FAOS symptoms subscore. CONCLUSION/CONCLUSIONS:Elite NC and SJ athletes are at high risk of hip pain, which increases their risk of developing knee and ankle pain as well. These findings strongly suggest that training targeted at hip strength and conditioning may optimize knee and ankle outcomes in elite NC and SJ athletes. CLINICAL RELEVANCE/CONCLUSIONS:The results of this study may help guide physicians, allied health personnel, and coaches to alter lower extremity training regimens to decrease the risk of injury.

BACKGROUND:The purpose of our study was to identify force plate-derived balance metrics that were predictive of multimodal return-to-sport test findings in a sample of anterior cruciate ligament reconstruction patients. METHODS:We conducted a cross-sectional study of anterior cruciate ligament reconstruction patients who were at least 6 months postoperative. Subjects completed our multimodal Institutional RTS testing battery which included testing of hip and knee range of motion (ROM), isokinetic quadriceps strength, and core trunk muscle strength (Bunkie test), as well as balance testing on a force plate. Balance metrics predictive of Institutional RTS test findings for the involved leg were identified using multivariable regression with stepwise selection. Model significance was assessed at α = 0.002. RESULTS:Sixteen subjects (7M, 9F) were enrolled in our study with a median age of 29 years (range 20-47). Multivariate multiscale entropy (MMSExyz) of the involved leg was predictive of knee flexion active ROM (P = .02) and Bunkie stabilizing test score (P = .03), MMSExyz of the uninvolved leg was predictive of Bunkie lateral and medial test scores (P = .02 and P = .02), and interlimb symmetry of MMSExyz was predictive of triple jump test score (P = .007). Interlimb symmetry of the COPx shift balance metric was predictive of hip internal rotation active and passive ROM (P = .008 and P = .03) and step-down test score (P = .004). CONCLUSION/CONCLUSIONS:Force plate-based balance testing metrics are predictive of some return-to-sport test findings including knee flexion ROM and Bunkie test scores, but further analysis is needed to identify balance metrics predictive of quadriceps isokinetic testing and muscle flexibility testing results.

BACKGROUND:Risks associated with graft transplantation due to donor-recipient sex differences have been reported in whole organ transplantation literature but are not well-described in meniscal allograft transplantation (MAT). This study assessed the effect of donor-recipient sex mismatch on patient-reported outcomes (PROs) following MAT. METHODS:A retrospective review of patients <50 years of age that underwent unicompartmental MAT from 2010 to 2023 at a single institution with minimum 2-year follow up was conducted. Exclusion criteria were revision procedures or insufficient donor information. PROs collected included: Knee Injury and Osteoarthritis and Outcome Score (KOOS), Visual Analog scale (VAS) for pain and satisfaction, and return to sport (RTS). PROs were compared between donor-recipient graft matching groups (same-sex (SS) or different-sex (DS)) and by donor sex. RESULTS:, and follow up of 73.4 ± 29.2 months. Donors were mostly male (77.2 %). Thirty-six patients (63.3 %) received SS grafts and 21 (36.8 %) received DS grafts. There were no significant differences between groups in KOOS subscores, VAS pain, satisfaction scores, or RTS rates (P > 0.05). Donor sex also showed no association with PROs. Linear and logistic regression models controlling for age, BMI, and average follow up demonstrated that graft mismatch was not associated with KOOS scores, RTS, or graft failure. Decreasing patient age was associated with improved KOOS-pain (β: -0.376; 95 % CI (-1.892, -0.155); P = 0.022). CONCLUSIONS:Patients that undergo MAT with grafts from a different sex had similar outcomes to patients receiving grafts from a donor of the same sex. Sex-mismatch was not associated with functional outcomes or RTS. The results of this paper support the use of geometrically matched donor grafts, independent of donor sex, which should expand available graft options when matching a patient for MAT.

PURPOSE/UNASSIGNED:To evaluate short-term clinical and patient reported outcomes after gluteus maximus/tensor fascia lata (GM/TFL) transfer for abductor insufficiency. METHODS/UNASSIGNED:This was a retrospective case series. Inclusion criteria were patients who underwent GM/TFL for chronic abductor insufficiency from 2017 to 2024 at a single institution with a minimum follow-up of 6 months and at least 1 recorded postoperative visit. Demographic, clinical, and outcome data were collected, including hip range of motion, abduction strength, presence of Trendelenburg gait, postoperative rehabilitation details, complications, and patient-reported outcomes. Statistical comparisons of pre- and postoperative objective measures were performed using the Wilcoxon signed-rank test. RESULTS/UNASSIGNED:> .05), and Trendelenburg gait persisted in 80% of patients. However, patient-reported outcome scores were strong, with a mean postoperative modified Harris Hip Score of 76.5 ± 22.4 and Non-Arthritic Hip Score of 74.1 ± 21.7. Patient satisfaction was high, with 100% of patients indicating they would undergo the procedure again. Three patients experienced complications (30%), including 2 patients who had persistent pain and seroma formation, and a patient who had a recurrent hematoma. CONCLUSIONS/UNASSIGNED:GM/TFL transfer does not consistently improve hip strength or gait mechanics; however, it provides pain relief and improved quality of life, as evidenced by high patient satisfaction and favorable modified Harris Hip Score outcomes. Three patients experienced complications (30%), including two patients who had persistent pain and seroma formation, and a patient who had a recurrent hematoma. LEVEL OF EVIDENCE/UNASSIGNED:Level IV, retrospective therapeutic case series.

PURPOSE/OBJECTIVE:To identify demographic or radiographic predictors of sagittal tibial tuberosity-trochlear groove (sTT-TG) distance utilizing a cohort of patellofemoral surgical patients. METHODS:Patients who underwent an osteochondral allograft (OCA) transplantation or autologous chondrocyte implantation (ACI) from 2010 to 2020 were included if they had patellofemoral high-grade lesions and preoperative magnetic resonance imaging (MRI). Patient demographics, radiographic measurements such as coronal TT-TG, Caton-Deschamps index (CDI), and trochlear dysplasia were recorded. The preoperative sTT-TG distance was measured independently on axial T2-weighted MRI sequences by two authors at least two weeks apart. An interclass correlation coefficient (ICC) was calculated to assess intra- and inter-rater reliability of sTT-TG measurements, and univariate and multivariable linear regression models were used to assess the relationship between sTT-TG and any demographic or radiographic predictors. RESULTS:Seventy-three knees composed of 44 females and 29 males with a mean age of 31.0 ± 10.1 years, a mean BMI of 26.8 ± 6.1, and a mean follow-up of 60.4 ± 21.0 months were included. Thirty-four of these (46.6 %) underwent OCA transplantations and 39 (53.4 %) underwent ACI/MACIs. Thirty-one (42.4 %) knees were determined to have evidence of trochlear dysplasia. Twenty-four patients were found to have high grade trochlear dysplasia (grades B, C and D) and 7 patients were found to have low grade trochlear dysplasia (grade A). The mean sTT-TG of the entire cohort was -5.3 ± 4.9 mm. Interobserver reliability for sTT-TG measurements was excellent with an ICC of 0.95 (0.927-0.969, p < 0.001). There was a significant difference in sTT-TG between patients who had no trochlear dysplasia, low-grade trochlear dysplasia and high grade trochlear dysplasia (-3.51 ± 3.96 vs. -6.17 ± 4.29 vs. -9.25 ± 5.32, p < 0.001). On multivariate regression, trochlear dysplasia remained the only significant predictor of sTT-TG (β = -2.25, p = 0.005). Post-hoc analysis showed that both low- and high-grade dysplasia were associated with significantly more negative sTT-TG values compared to patients without dysplasia, though no significant difference was observed between the low- and high-grade groups. CONCLUSION/CONCLUSIONS:Trochlear dysplasia was associated with a more negative sagittal tibial tuberosity-trochlear groove (sTT-TG) distance, with increasing severity of trochlear dysplasia correlated with a relatively more posterior tibial tuberosity. LEVEL OF EVIDENCE/METHODS:Level III; diagnostic cross-sectional study.

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.

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: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.