Faculty Bibliography

PURPOSE/OBJECTIVE:To compare meniscus-specific reoperation rates among various meniscal allograft transplantation (MAT) fixation techniques including bone plug, bone bridge-in-slot, and suture-only fixation. METHODS:A retrospective review was conducted of patients who underwent MAT at a single academic institution between 2011 and 2023. Patients were included if they had documented fixation technique and a minimum of 1-year follow-up. Demographics, fixation techniques (bone plug, bone bridge-in-slot, and suture-only), and subsequent ipsilateral knee surgeries were recorded. Statistical analyses assessed the influence of fixation techniques and other factors on meniscus-specific reoperation rates defined as subsequent ipsilateral meniscectomy, meniscus repair, revision MAT, or knee arthroplasty. RESULTS:The study included 139 patients (54% male patients; mean age: 29.4 ± 10.0 years; body mass index: 27.3 ± 5.6) with a mean follow-up of 6.6 ± 3.1 years. Lateral compartment MAT was performed in 51.1% of cases. Patients undergoing suture-only fixation had significantly higher meniscus-specific reoperation rates (15/48, 31.3%) compared with bone bridge-in-slot (4/45, 8.9%) and bone plug (5/46, 10.9%) fixation (P = .006). Meniscectomy (15/35, 42.9%) and meniscal repair (7/35, 20.0%) were the most common reoperations. Other reoperations included 2 total knee arthroplasties within the suture-only cohort and a single MAT revision in the bone bridge-in-slot cohort. CONCLUSIONS:This study reveals that MAT using suture-only fixation exhibits significantly higher reoperation rates than bone plug and bone bridge-in-slot techniques, with meniscectomy and meniscal repair representing the predominant subsequent surgeries. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

BACKGROUND:Meniscus root repair has been shown to improve symptoms and protect against progressive knee arthritis by restoring more normal weightbearing force distribution. While advanced tibiofemoral chondrosis is known to negatively affect root repair outcomes, there is a paucity of literature describing the impact of concomitant patellofemoral chondrosis (PFC). PURPOSE/OBJECTIVE:To evaluate outcomes of meniscus root repair in patients with and without advanced PFC. STUDY DESIGN/METHODS:Cohort study; Level of evidence, 3. METHODS:This single-center retrospective study included patients who underwent isolated posterior medial meniscus root repair (PMMRR) between July 2013 and February 2023, with a minimum 2-year follow-up. Based on intraoperative arthroscopic findings, patients were stratified into 2 groups: those with PFC, defined as Outerbridge grade ≥3, and those without PFC (Outerbridge grade < 3). Clinical outcomes, including meniscal retear, conversion to unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA), and revision meniscal surgery, were obtained through chart review. Patient-reported outcomes (PROs) were collected from patients without retear or revision meniscal surgery and who did not convert to UKA or TKA and included the Knee injury and Osteoarthritis Outcome Score-12 (KOOS-12), International Knee Documentation Committee (IKDC) subjective score, and return-to-sport status. RESULTS:= .021). CONCLUSION/CONCLUSIONS:Patients with and without PFC at the time of PMMRR who did not experience a retear, undergo revision surgery, or convert to UKA or TKA had comparable PROs and clinically significant outcomes at the final follow-up. However, there was a significantly higher rate (almost 7-fold) of conversion to UKA or TKA in patients with PFC, suggesting that while short- to midterm functional outcomes may be preserved, advanced PFC may predispose patients to earlier progression of joint degeneration and need for arthroplasty.

MRI is central to evaluation of the post-operative knee, providing a comprehensive assessment of reconstructions, repairs, and cartilage restoration procedures. Accurate interpretation requires familiarity with operative techniques, graft biology, and the expected temporal evolution of post-operative imaging findings. This review presents a practical, imaging-based approach to contemporary knee surgery. Emphasis is placed on anterior cruciate ligament reconstruction, the renewed interest in primary repair, and common mechanisms of failure. Meniscal surgery, including repair, root repair, centralization, and transplantation, is discussed with attention to expected post-operative MRI appearances and findings suggestive of recurrent or failed repair. Finally, cartilage resurfacing and restoration techniques are reviewed using a systematic framework to assess graft infill, integration, surface congruity, and subchondral bone response. By integrating surgical context with time-dependent MRI findings, this review aims to provide radiologists with a practical framework to distinguish expected post-operative changes from complications, improving diagnostic confidence and clinical relevance of post-operative knee MRI interpretation.

PURPOSE/OBJECTIVE:Knee dislocations (KDs) can be limb-threatening injuries that may require a temporising knee-spanning external fixator (KSEF) for stabilisation. Precise indications for this commonly utilised invasive immobilisation technique remain controversial and poorly defined. The purpose of this study was to establish consensus-driven indications for temporising KSEF use in the initial management of KDs. METHODS:A working group of fellowship-trained orthopaedic surgeons generated clinical scenarios reflecting commonly debated indications for temporising KSEF application. Utilising a modified Delphi technique, 23 surgeons from the International Knee Dislocation Study Group completed two anonymous online survey rounds. Consensus was defined a priori as ≥70% agreement or disagreement. RESULTS:Response rates were 100% for Round 1 and 96% for Round 2. Four scenarios achieved unanimous consensus: (1) KD without post-reduction instability (100% disagreement), (2) inability to maintain tibiofemoral reduction in the sagittal/coronal plane with non-invasive knee immobilisation (NIKI) after initial reduction (i.e., redislocation/subluxation) (100% agreement), (3) tibial plateau fracture-dislocation with post-reduction subluxation (100% agreement), and (4) in bilateral closed KDs where one limb is indicated and the other is NOT, span ONLY the indicated limb (100% agreement). Two scenarios achieved strong positive consensus (90%-99.9% agreement): (1) morbid obesity (BMI ≥ 40) without NIKI of sufficient size (91.3% agreement), and (2) extensor mechanism injury with post-reduction subluxation (91.3% agreement). Four and one additional scenarios achieved positive and negative consensus, respectively. CONCLUSIONS:This modified Delphi study established consensus-driven indications for temporising KSEF application in the initial management of KDs, which advocate for more selective use than what is demonstrated in the literature. LEVEL OF EVIDENCE/METHODS:Level V.

PURPOSE/OBJECTIVE:Although bone-patellar tendon-bone autograft is widely used for anterior cruciate ligament reconstruction, it is often associated with anterior knee pain resulting from the residual patellar bone defect. Various materials have been proposed to fill this void, yet no consensus exists regarding the optimal choice. This study compared three commonly used patellar harvest site bone void fillers and assessed their impact on the frequency and severity of anterior knee pain. We hypothesised that calcium phosphate cement would result in lower postoperative anterior knee pain compared with autologous bone graft and demineralised bone matrix (DBM) due to its compressive modulus approximating cancellous bone. METHODS:Skeletally mature patients undergoing primary anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft were enrolled. Exclusion criteria included age under 18, prior anterior cruciate ligament reconstruction, multiligament knee injury, coronal malalignment exceeding three degrees of varus or valgus, or less than 1 year of follow-up. Participants were randomly assigned to one of three groups: (1) autologous bone graft, (2) calcium phosphate cement or (3) DBM. Patient-reported outcomes were collected preoperatively and at 1 week, 6 weeks, 3 months, 6 months, 9 months and 12 months postoperatively. Analysis of variance and chi-square tests were used for statistical analysis. RESULTS:After applying exclusion criteria, 148 patients were included in the final analysis. No significant differences in visual analog scale pain scores were observed between cohorts at any postoperative interval (12-month, p = 0.598). Similarly, Kujala and Knee injury and Osteoarthritis Outcome scores did not differ significantly among the three cohorts at any time point (12-month, p = 0.878, p = 0.366). CONCLUSIONS:Filling the patellar harvest site defect with autologous bone graft, calcium phosphate cement, or DBM resulted in similar postoperative anterior knee pain following anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft. LEVEL OF EVIDENCE/METHODS:Level I.

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.

BACKGROUND/UNASSIGNED:The patient-specific instrumentation (PSI) used during corrective high tibial osteotomies and distal femoral osteotomies is based on 3-dimensional computed tomography (3D CT). Plain radiographs are typically used preoperatively to determine the need for an osteotomy; however, it is unclear how well measurements on plain radiographs correlate with 3D CT. PURPOSE/HYPOTHESIS/UNASSIGNED:The purpose of this study was to evaluate the correlation between coronal and sagittal alignment measurements on plain radiographs and 3D CT. It was hypothesized that there would be high agreement in the measurement of the mechanical medial tibial width ratio (mMTWr) and the medial posterior tibial slope (PTS) between both modalities. STUDY DESIGN/UNASSIGNED:Cohort study (diagnosis); Level of evidence, 3. METHODS/UNASSIGNED:Patients who underwent hip-to-ankle CT as part of the preoperative workup before a corrective osteotomy from October 2020 to November 2023 were reviewed. Coronal (mMTWr) and sagittal alignment (medial PTS) were evaluated preoperatively by 2 raters on standing whole-leg radiographs and a lateral radiograph of the knee, respectively, and by semi-automated PSI software on 3D CT. Intraclass correlation coefficients (ICC) were calculated to assess interrater reliability for each measurement and to evaluate agreement between raters and the PSI software. RESULTS/UNASSIGNED:Complete data sets were obtained for 91 cases. The ICC between raters for preoperative mMTWR was 0.99. The ICC between the raters' measurements and the PSI software measurements of mMTWr was 0.99. The ICC between raters for preoperative PTS was 0.82. The ICC between the raters' measurements and the PSI software's PTS measurements was 0.63. CONCLUSION/UNASSIGNED:This study found that coronal measurements performed on whole-leg radiographs and 3D CT were highly correlated, with near-perfect agreement, and that medial PTS measurements showed moderate agreement between modalities. These data suggest that measurements on plain radiographs are reproducible and accurate for evaluating coronal alignment and PTS preoperatively. Surgeons can confidently use plain radiographs to assess whether or not a patient is a candidate for a knee osteotomy.

PURPOSE/OBJECTIVE:To systematically review existing literature to define the rate and types of complications of anterior closing wedge osteotomy (ACWO) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR). METHODS:A systematic query of PubMed, Embase and Scopus databases was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2025. Studies were included if they reported complications in patients undergoing ACWO with concurrent ACLR. Data on demographics, surgical technique, fixation method, graft type, posterior tibial slope (PTS) correction and complications were extracted. Data were described narratively and presented as frequencies with ranges in order to avoid potential bias and misleading conclusions from pooling heterogeneous data. RESULTS:Twelve retrospective case series comprising 505 patients undergoing combined ACLR with ACWO were included. The overall complication rate was 9.7% (range: 0%-82.8%). The most common complication was symptomatic hardware (6.1%), accounting for nearly half of all reported complications. The overall rate of postoperative ACL graft rupture was 1.7%. Other reported complications included arthrofibrosis (0.4%), infection (0.2%) and malunion (0.2%). No reported cases of nonunion, hinge fracture, neurovascular injury or loss of sagittal plane correction were reported. CONCLUSION/CONCLUSIONS:ACWO performed during ACLR demonstrates a clinically relevant complication rate, with hardware-related symptoms constituting the most frequent adverse event. Severe complications were rare. ACWO may reduce but does not eliminate the risk of ACL graft failure in patients with elevated PTS and appears to be a safe and effective option when PTS correction is indicated. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND:The indications for temporizing knee-spanning external fixation (KSEF) in the setting of knee dislocation (KD) are poorly defined, leading to significant uncertainty and inconsistency in clinical practice. This study aimed to analyze and describe the documented indications for temporizing KSEF in a series of patients with KDs. METHODS:A retrospective, multi-center review was conducted at two level I trauma centers from January 2001 to May 2024, identifying patients with documented KD treated with KSEF. Data were extracted from operative records, imaging, and clinical notes, and reviewed for demographics, injury characteristics, and documented indications for KSEF. A set of KSEF indications derived from the literature was developed a priori to individually assess the appropriateness of each KSEF application. Knees were classified as 'did not meet criteria' for KSEF only when both of the following conditions were true: (1) no predefined indication was met; and (2) there was no radiographic, clinical, or documented evidence of persistent post-reduction instability. RESULTS:A total of 33 patients with 36 documented KDs treated with KSEF were identified from a cohort of 289 multiple ligament injured knees (12.5 %). Of the 36 KDs, 28 (77.8 %) met the selected criteria for KSEF. The most common primary indications for KSEF were vascular injury, tibial plateau fracture-dislocation, inability to maintain tibiofemoral reduction via non-invasive means, and morbid obesity. The remaining eight KDs (22.2 %) did not meet criteria for KSEF either as isolated injuries or in the setting of "polytrauma." The rationale for KSEF application was cited as "polytrauma" in 6/8 (75.0 %) of these cases. CONCLUSION/CONCLUSIONS:Eight of the 36 (22.2 %) KSEF applications did not meet the predefined criteria for KSEF in the setting of KD, nor showed evidence of an inability to maintain tibiofemoral reduction via non-invasive means. Polytrauma is frequently cited in the literature as a primary indication for temporizing KSEF in the setting of KD without a clear definition. Further investigation into the role of temporizing KSEF is needed, particularly in the polytraumatized patient, to determine its specific role in the management of KDs.

BACKGROUND AND OBJECTIVE/UNASSIGNED:High tibial osteotomy (HTO), particularly through a medial opening-wedge technique [medial opening-wedge high tibial osteotomy (MOWHTO)], is a well-established surgical intervention for correcting varus malalignment and unloading the medial compartment in younger patients with early osteoarthritis or secondary ligamentous or chondral deficiency. However, conventional methods pose high technical demands for accurate alignment, often requiring repeat intraoperative fluoroscopy. Patient-specific instrumentation (PSI), developed through three-dimensional (3D) imaging and printing technologies, offers a promising solution by enabling precise preoperative planning and intraoperative execution via customized cutting guides. This narrative review aims to explore the inception and current data surrounding PSI in HTO, specifically in regards to radiation, cost effectiveness, hinge fractures, surgical accuracy, and multiplanar osteotomies. METHODS/UNASSIGNED:A comprehensive literature review was conducted using PubMed, incorporating studies related to "high tibial osteotomy", "virtual planning", "patient-specific instrumentation", and "3D planning" published up to March 1st, 2025. Relevant English-language studies were included to summarize the use and outcomes associated with PSI in HTO. KEY CONTENT AND FINDINGS/UNASSIGNED:traditional osteotomy are nearly identical, with potential for even further monetary savings in revision rates, survivorship, and downstream healthcare utilization. Current evidence on hinge fracture prevention remains inconclusive, but PSI offers theoretical benefits through controlled cutting depths, hinge-pin technology, and anatomically tailored guides. Studies report alignment deviations typically within 2° of the preoperative plan in both coronal and sagittal planes, surpassing traditional and navigation-assisted techniques. CONCLUSIONS/UNASSIGNED:PSI represents a significant advancement in the execution of high tibial osteotomies, offering increased surgical accuracy, reduced radiation exposure, and enhanced procedural efficiency. It holds particular value in complex or multiplanar deformities where traditional techniques are limited. Although cost and hinge fracture data remain areas for further investigation, the growing body of evidence supports PSI's clinical utility and reproducibility. As 3D planning technologies and guided manufacturing become more accessible, PSI is well-positioned to become a standard adjunct in knee realignment procedures.