Faculty Bibliography

Osteotomies around the knee are an effective procedure that shifts the weight-bearing axis from the pathologic side to the uninvolved side to alleviate pain, unload cartilage transplantations, slow down the progression of arthritis, and protect ligament reconstructions. The advancement in plates from nonlocking to locking have increased the stability of constructs to allow for early mobilization and maintained corrections. Further developments with patient-specific instrumentation have made these techniques more reproducible and accurate. Bone grafting and biologics remain a topic of debate but likely a helpful adjuvant in the context of larger corrections or joint preservation surgeries.

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:The coronavirus disease (COVID)-19 pandemic led to shutdowns of organized sporting activity. Prolonged periods of inactivity lead to deconditioning and may increase one's risk for injury. The purpose of this study was to quantify the incidence of anterior cruciate ligament (ACL) injuries requiring reconstruction during the peripandemic period. METHODS:The electronic medical record of a single university teaching hospital was queried for current procedural terminology codes for ACL reconstructions (ACLR; 29,888) from January 2017 to December 2022. Date of injury was collected from clinic notes if it could be estimated within 2 weeks. The years 2017-2019 were used as a proxy for "pre-COVID," the year 2020 for "COVID," and the years 2021-2022 for "post-COVID." RESULTS:In total, 2178 patients had an ACL injury and underwent reconstruction from 2017 to 2022. Date of injury could be estimated for 1,617 patients (51.3% male, average age 30.9 ± 11.0 years). There was a decrease in the number of ACL surgeries observed during the COVID era, followed by a post-COVID rebound. The proportion of female patients who underwent ACLR increased from the pre-COVID to the post-COVID period (42.7% vs. 49.4%, P < .001). The proportion of patients with American Society of Anesthesiologists (ASA) score 2 increased from the COVID to the post-COVID period in relation to the proportion of patients with ASA score 1 (P = .007). CONCLUSION/CONCLUSIONS:ACLRs decreased at our institution during the COVID-19 pandemic, followed by an increase in ACLRs from 2021 to 2022. The proportion of female patients and patients with higher ASA scores increased in the post-COVID era.

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.

The need to perform revision anterior cruciate ligament reconstruction (ACLR) has several etiologies such as infection, arthrofibrosis, cyclops lesions, and graft failure, which should be distinguished before revision ACLR. Even the definition of graft failure varies within the literature. ACLR graft failure falls into modifiable, surgeon-controlled factors, such as tunnel position, graft choice, and alignment, and nonmodifiable factors, such as patient age, tissue quality, or secondary traumatic reruptures. In this review, we describe a facile framework for the workup of modifiable ACLR graft failure.

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.

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/OBJECTIVE:To determine whether chondroplasty for isolated medial patellar facet lesions produces similar clinical outcomes compared to patients without patellofemoral cartilage lesions in the setting of medial patellofemoral ligament (MPFL) reconstruction for patellar instability. METHODS:We retrospectively identified patients who underwent MPFL reconstruction with or without tibial tubercle osteotomy (TTO) from 2015 to 2020 with minimum 2-year follow-up. Operative reports detailed patellofemoral articular surfaces and Outerbridge grade. Exclusion criteria were: prior knee surgery, multiple lesions, concomitant cartilage repair, trochleoplasty, or meniscus repair. Patients with isolated medial facet lesions (case) were propensity matched to patients without patellofemoral cartilage injury (control) by age, sex, BMI, and concomitant TTO. Clinical outcomes were evaluated using the Kujala score, Tegner activity scale, and the Visual Analog Score (VAS) for pain. RESULTS:Of 79 eligible patients, 59 (74.7%) completed all surveys, and 40 patients (8 M and 32 F) were matched 1:1 with mean 4.1-year (range: 2.1-8.5) follow-up, including 20 patients with medial facet lesions (5 grade II, 6 grade III, and 9 grade IV). There were no significant differences between groups with respect to Kujala score (85.2 vs 84.6, p = 0.906), Tegner (5.7 ± 2.6 vs 4.9 ± 3.0, p = 0.924), or VAS pain score (12.4 ± 20.1 vs 16.5 ± 23.9, p = 0.718). Chondral lesion size at the index procedure was not significantly correlated with pain (R = - 0.06, p = 0.816) or Kujala score (R = - 0.67, p = 0.779). CONCLUSION/CONCLUSIONS:Chondroplasty for isolated medial patellar facet lesions led to similar clinical outcomes to patients with intact patellofemoral articular cartilage at a minimum of 2 years following MPFL reconstruction. These findings support conservative management of isolated medial facet lesions without need for cartilage restoration procedures. LEVEL OF EVIDENCE III/METHODS:Retrospective comparative cohort study.

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.

PURPOSE/OBJECTIVE:ACL tears are among the most common injuries in active individuals, with Bone-Patellar Tendon-Bone (BTB) autograft being the gold-standard treatment for reconstruction. Despite excellent outcomes, complications such as patella fractures, reported as high as 1.8%, remain a concern. This study aimed to update the incidence of patella fractures after BTB ACL reconstruction at a high-volume center and compare patient outcomes with isolated ACL rupture or patella fracture. We hypothesized a lower incidence than previously reported and comparable post-operative outcomes across groups. METHODS:We retrospectively reviewed patients undergoing BTB ACL reconstruction (2012-2022) who sustained harvest site patella fractures. Cases were 2:1 propensity score-matched with patients having isolated ACL rupture or patella fracture. Inclusion criteria were age > 18, ≥ 1-year follow-up, and post-op patella fracture diagnosis. Data collected included demographics, surgical details, bone plug dimensions, and patient-reported outcomes (Lysholm, IKDC, Tegner Activity Scale). Treatment strategies and healing outcomes for patella fractures were also recorded. RESULTS:Among 5770 BTB ACL reconstructions, 12 patients (0.21%) sustained post-op patella fractures. They were matched to 24 with isolated ACL rupture and 24 with patella fracture. Average follow-up was 6.4 years. Pre-op scores demonstrated significant differences: ACL + patella fracture group had lower Lysholm (62.8), IKDC (48.1), and Tegner scores (7.1) compared to isolated ACLR and patella fracture groups. Post-op scores in the ACL + patella fracture group improved significantly (Lysholm 84.4, IKDC 72.0). CONCLUSIONS:Patella fracture incidence after BTB ACL reconstruction is lower than previously reported (0.21%). Patients with this complication still achieve excellent outcomes comparable to those with isolated ACL or patella injuries.