Faculty Bibliography

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: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.

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/UNASSIGNED:The utility and safety of patient-specific cutting guides (PSCGs) in osteotomies about the knee is uncertain. PURPOSE/UNASSIGNED:To compare the cost, accuracy of radiographic correction, and safety of PSCG versus standard cutting guide (SCG) corrective osteotomies about the knee. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:Patients undergoing high tibial osteotomy (HTO) or distal femoral osteotomy (DFO) were retrospectively reviewed from 2017 to 2022. Those who underwent 3-dimensional PSCG osteotomy were propensity matched to patients undergoing traditional osteotomies. Procedure time and fluoroscopic details were extracted from operative notes. Hip-knee-ankle (HKA) angle, posterior tibial slope (PTS), and mechanical axis deviation were measured on pre- and postoperative radiographs. Intraclass correlation coefficients were calculated to determine the reliability between the intended and resultant correction of HKA. Time-driven activity-based costing (TDABC) analysis was performed to compare procedure costs. RESULTS/UNASSIGNED:= .01) were lower in the PSCG group. TDABC analysis demonstrated a total cost of $27,026 for PSCG and $27,100 for SCG. The rate of hinge fractures (9.5% vs 33.3%) and return to the operating room (4.8% vs 19.0%) were lower in the PSCG group, although these differences were nonsignificant. CONCLUSION/UNASSIGNED:Both traditionally guided osteotomies and PSCG-guided osteotomies accurately corrected lower extremity malalignment. Utilization of PSCG resulted in similar procedure times and cost, as well as less fluoroscopy and lower tourniquet time, compared with conventional osteotomy. PSCG trended toward a decreased rate of postoperative complications.

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.

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/UNASSIGNED:Patellofemoral instability is a relatively common condition and is multifactorial in its cause, with both soft tissue and bony components. Trochleoplasty is a newly described surgical procedure to help improve outcomes following patellar restabilization. INDICATIONS/UNASSIGNED:Trochleoplasty is an emerging surgical technique during patellar stabilization surgery in those patients with underlying trochlear dysplasia. TECHNIQUE DESCRIPTION/UNASSIGNED:Trochleoplasty was performed via an open medial parapatellar arthrotomy. Using a combination of osteotome and guided bur, the subchondral surface was undermined to produce a deeper sulcus. The cartilage surface was then plastically deformed into the newly developed trochlea. Trochleoplasty was then secured with a central triple-loaded interference screw and 3 peripheral interference screws. Medial patellofemoral ligament reconstruction was then performed in standard fashion. RESULTS/UNASSIGNED:Postoperative course was complicated by arthrofibrosis, which required manipulation at 4 weeks. Following manipulation, the patient recovered uneventfully and had returned to full activities at 6 months with full strength, range of motion, and minimal pain. DISCUSSION/CONCLUSION/UNASSIGNED:Trochleoplasty with combined soft tissue reconstruction is a viable treatment option in those patients with recurrent patellar instability and underlying trochlear dysplasia. While not without complications, this surgical technique remains a powerful tool in the correctly indicated patient. Appropriate patient selection and adherence to postoperative rehabilitation are crucial for optimal outcomes. 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.

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.