Faculty Bibliography

PURPOSE:Though Femoroacetabular impingement (FAI) is thought of as primarily a hip condition an increasing body of evidence has demonstrated the existence of a relationship between the hip joint and lumbopelvic spine, termed the hip-spine syndrome (HSS). This review will provide an overview of the relevant pelvic parameters, proper HSS patient evaluation, describe how lumbar pathology may mechanistically affect the hip, provide a literature review of biomechanic and outcome papers exploring the subject, and finally investigate potential interventions that can be considered in these challenging patients. RECENT FINDINGS:Deviations from normal ranges in pelvic parameters have been shown in biomechanical studies to worsen FAI by decreasing the range of impingement free motion. The clinical relevance of this is still being determined. Patients with concomitant lumbar spine pathology may significantly improve after hip arthroscopy, though they may have a lower ceiling than comparable patients without lumbar spine pathology. SUMMARY:Surgeons and patients should be aware of the HSS. Alterations in pelvic parameters may affect outcomes, though this still has to be determined. Patients with lumbar spine pathology and FAI can still be treated successfully with hip arthroscopy, though should be counseled appropriately.

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.

PURPOSE/UNASSIGNED:To analyze patient sentiment, experience, and perception differences between anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon autograft (QTG) and ACLR with bone-tendon-bone autograft (BTB). METHODS/UNASSIGNED:and one-way analysis of variance tests were used to compare outcomes between the two graft types. RESULTS/UNASSIGNED:< .001). Thematic trends varied over time. Among QTG posts, discussion of recovery milestones increased from 34.9% in the early postoperative period (0-2 weeks) to 57.9% at more than 2 years. In contrast, this theme decreased among BTB posts over the same time frame (from 43.9% to 33.3%). Pain management themes declined over time for QTG posts (from 55.3% to 36.8%) but remained consistently high for BTB posts (from 54.4% to 47.7%). CONCLUSIONS/UNASSIGNED:Social media posts regarding QTG were more positive in nature when compared with posts on patellar tendon autograft. Common discussion topics within the publicly available, online orthopaedic patient community were also identified, including functional outcomes, pain management, and recovery milestones. CLINICAL RELEVANCE/UNASSIGNED:Social media can reflect patient sentiment regarding surgical options for ACLR. This study can therefore inform surgeons so that they can have more effective discussions with patients regarding autograft options.

PURPOSE/OBJECTIVE:To establish the minimum clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) for the Kujala score in patients that underwent isolated MPFLR for patellar instability with a minimum twenty-three month follow-up. METHODS:This retrospective cohort study used a prospectively maintained database of patients undergoing primary MPFLR between April 2016 and June 2021. Patients with concomitant procedures, such as osteotomy, trochleoplasty, meniscus repair, other ligamentous reconstruction, and cartilage transplantation were excluded. Kujala scores were recorded at baseline and minimum of twenty-three months postoperatively. Anchor-based and distribution-based methods were used to calculate the MCID, SCB, and PASS. RESULTS:, 68.2% female, 61.5% left side) with a minimum of twenty-three months follow-up patient reported outcome measures (PROMs) were included in the final analysis. The Kujala score threshold for achieving the MCID was defined as an increase of 10.0 based on the distribution-method calculations and 12.0 using anchor-based analysis. The SCB was defined as an increase of 25.5. The PASS was defined as achieving a minimum of twenty-three month Kujala score of 78.5. These results are comparable to scores seen at 6 months and 1-year. The MCID was calculated to be 86% sensitive and 64% specific; SCB was found to be 67% sensitive and 100% specific; and PASS was found to be 85% sensitive and 80% specific. The rates of achieving the MCID, SCB, and PASS at a minimum of twenty-three months were 89% (distribution)/84% (anchor), 58%, and 78%, respectively. CONCLUSION/CONCLUSIONS:This study established thresholds for the MCID, SCB, and PASS at minimum twenty three months following isolated MPFLR. The distribution-based MCID corresponded with an improvement in Kujala score or 10.0 as compared to the anchor-based method of 12.0. The value for achieving a SCB was 25.5. An absolute Kujala score of 78.5 was determined to be the threshold for patient satisfaction twenty three months postoperatively. LEVEL OF EVIDENCE/METHODS:IV; Retrospective case series.

BACKGROUND:The knee's inflammatory response to ligamentous, meniscal, and cartilage injuries is complex and incompletely understood, particularly in the setting of concomitant injuries. Recent research has highlighted the potential utility of synovial fluid biomarker analysis in identifying factors involved in the progression of posttraumatic osteoarthritis. PURPOSE/OBJECTIVE:To investigate if unique patterns of knee injury are associated with distinct synovial fluid biomarker profiles at the time of surgical intervention. STUDY DESIGN/METHODS:Cross-sectional study; Level of evidence, 3. METHODS:Patients undergoing arthroscopic knee surgery were prospectively enrolled and asked to complete the Lysholm Knee Scoring Scale and visual analog scale for pain preoperatively. Synovial fluid was aspirated from the operative knee before surgical incision, and the concentrations of 10 biomarkers of interest were quantified. Patients with intraoperative evidence of articular cartilage, meniscal, and/or anterior cruciate ligament (ACL) injury were identified and included for subsequent analysis. Biomarker concentrations were log-normalized and standardized. Principal component analysis (PCA) was performed using biomarker variables to reduce dimensionality and extract key patterns. Multivariable linear regression for each retained principal component (PC) was performed with the predictors of age, sex, body mass index, symptom duration, ACL injury, meniscal injury, and Outerbridge grade. A separate regression analysis was performed to assess relationships between PCs and patient-reported outcomes controlling for the same variables. RESULTS:= .001; β = -.199). CONCLUSION/CONCLUSIONS:Cartilage lesions exhibited a synovial fluid inflammatory profile distinct from ACL and meniscal injury at the time of knee arthroscopy. While ACL and meniscal injuries displayed a pro-inflammatory phenotype, more severe cartilage lesions were associated with a reduced presence of anti-inflammatory markers. The pro-inflammatory phenotype also independently correlated with worse baseline knee function. These findings contribute to the understanding of the pathophysiology of ligamentous, meniscal, and cartilage injuries and may aid in the identification of pathology-specific treatments to help alter the natural history of disease.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate patient-reported outcomes (PROs) and survivorship in obese patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at 10-year follow-up. METHODS:A retrospective review was conducted of patients who underwent arthroscopy for FAIS from 2010-2013. Patients were assessed at baseline, 1 month, 6 months, 1-, 2-, 5-, and 10 years using the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS). Patients were categorized based on BMI into normal, overweight, and obese cohorts. Minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) were calculated for both PROs. Improvements from baseline were analyzed and differences between groups were evaluated while controlling for age. Survival to revision surgery was assessed with Kaplan-Meier survival curves. RESULTS:144 patients (65.2% female) with a mean age of 38.8 ± 13.0 years and an average follow-up of 11.6 (range 10.0-13.8) years were included, and categorized into normal weight (59.7%), overweight (26.4%), and obese (13.9%). All groups showed significant improvement in PROs at 10 years compared to baseline (p=0.007). Obese patients had lower postoperative scores (mHHS: 72.8 vs. 90.1, p=0.009; NAHS: 68.4 vs.. 88.6, p=0.003) and improvement in scores from baseline (mHHS: 23.4 vs. 37.7, p=0.013; NAHS: 18.4 vs. 40.0, p=0.004) at 10-year follow-up, as well as lower achievement of mHHS PASS (60.0% vs 87.2%, p=0.015), NAHS PASS (50.0% vs. 89.5%, p<.001) and NAHS MCID (70.0% vs. 93.0%, p=0.008). Obese patients also had a higher rate of conversion to THA (17.4% vs 3.3%, p=0.012). The overall complication rate was 4.2% compared to 10% in the obese group, with obese patients experiencing a superficial infection more frequently (p=0.002). CONCLUSION/CONCLUSIONS:Although obese patients still have significantly improved outcomes compared to baseline, at 10-year follow-up they have inferior outcomes compared to nonobese patients and higher rates of conversion to THA. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

PURPOSE/OBJECTIVE:This study aims to evaluate patient-reported outcomes (PROs) and reoperation rates in patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) over a minimum 10-year follow-up stratified by sex, age, and body mass index (BMI). METHODS:Primary hip arthroscopies performed for FAIS between 2010 and 2013, with a minimum 10-year follow-up, were reviewed. Procedures consisting of microfracture, or labral debridement without repair, were excluded. Ten-year PROs were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were categorized into three groups by age (<30, 30-44, >45 years) and BMI (<25.0, 25.0-29.9, ≥30). Minimum clinically important difference (MCID) was set to half the preoperative standard deviation of the cohort. Reoperation rates and PROs were compared, and regression analysis identified independent predictors of PROs. RESULTS:At minimum 10-year follow-up (mean: 11.6 [10.0-13.9] years), 59.2% follow-up was achieved, representing 154 hips (141 patients). The cohort had a mean age of 38.5 years, BMI of 24.4, and was 68.2% female. At follow-up, 91.6% of the cohort achieved MCID with a 9.7% re-operation rate. In the middle-aged group, males had higher mHHS (mean, 92.8 vs. 85.2, P = 0.015) and NAHS (mean, 91.6 vs. 83.4, P = 0.008) scores compared to females. In the BMI ≥30 group, males had higher mHHS (mean, 83.3 vs. 66.4, P = 0.030) and NAHS scores (mean, 83.0 vs. 58.5, P = 0.035). Only 72.7% of females with BMI ≥30 achieved MCID for mHHS and NAHS, compared to BMI < 25 (96.6% and 94.9%, respectively) and 25-29.9 (87.5% and 83.3%) (mHHS: P = 0.016; NAHS: P = 0.038). Similarly, 78.8% of females aged ≥ 45 achieved MCID for NAHS, compared to 92.9% of those aged < 30 and 97.1% of those 30-44 (P = 0.040). Multivariable regression identified older age (mHHS: P=0.019; NAHS: P=0.042) and higher BMI (mHHS: P=0.007; NAHS: P<0.001) as independently predictive of worse 10-year PROs. CONCLUSION/CONCLUSIONS:Older age and greater BMI independently predicted poorer long-term functional outcomes after hip arthroscopy for FAIS. Female sex, while not independently predictive, may make patients more susceptible to the negative effects of older age and BMI. No significant association was observed for reoperation rates. LEVEL OF EVIDENCE/METHODS: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:The minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) are valuable clinical thresholds used to provide clinical relevance to patient outcome scores. In hip arthroscopy (HA) for femoroacetabular impingement (FAI) syndrome, these values have been defined for the short- and midterm postoperative period, but meaningful long-term thresholds have not been established. PURPOSE/OBJECTIVE:To define the MCID, PASS, and SCB for the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) at a minimum follow-up of 10 years for patients who underwent HA for FAI syndrome. STUDY DESIGN/METHODS:Case series; Level of evidence, 4. METHODS:A retrospective cohort study including all patients who underwent primary HA for FAI with a single surgeon from February 2010 to December 2013 was performed. Patient outcomes were assessed with an anchor question, mHHS, and NAHS at baseline and at 1, 5, and 10 years of follow-up. MCID was calculated using the distribution-based method at all time points, using 0.5 standard deviations as the threshold. The anchor-based MCID, PASS, and SCB were calculated at 10 years using thresholds representing the optimal cutoff on a receiver operating characteristic curve. Correlations between baseline characteristics and achievement of the MCID, PASS, and SCB were assessed with binomial logistic regressions. RESULTS:= .01). CONCLUSION/CONCLUSIONS:The establishment of the MCID, SCB, and PASS for the NAHS and mHHS provides a valuable clinical context for improvements in outcome scores after HA. Anchor-based calculations were consistently higher than distribution-based calculations.

BACKGROUND:Synovial fluid (SF) biomarkers demonstrate time-dependent variation after acute knee injury, and it is postulated that persistently elevated inflammatory markers may mediate worse long-term outcomes. PURPOSE/OBJECTIVE:This study investigated the relationship between biomarkers in SF at the time of meniscectomy and long-term patient-reported outcomes in patients with acute versus chronic meniscal injuries. STUDY DESIGN/METHODS:Cohort study; Level of evidence, 3. METHODS:This retrospective analysis included patients who underwent knee SF aspiration on the day of arthroscopic meniscectomy between October 2011 and October 2020 with minimum 4-year follow-up. SF aspirated from the operative knee was analyzed for 10 pro- and anti-inflammatory biomarkers. Patients completed the visual analog scale for pain, Lysholm Knee Questionnaire, Tegner Activity Scale, and Knee injury and Osteoarthritis Outcome Score-Physical Function Short-form (KOOS-PS) before surgery and at follow-up. Patients were categorized as having acute (<6 weeks) or chronic (>1 year) symptoms. K-means clustering analysis was performed using biomarker levels to group patients into distinct cohorts. RESULTS:= .020) than the low-inflammation cohort. CONCLUSION/CONCLUSIONS:In patients with chronic meniscal injury, those with a more proinflammatory SF biomarker profile at the time of meniscectomy had worse outcomes than those who had a low inflammatory profile. In acute meniscal injuries, most patients demonstrate a high inflammatory profile, which was not associated with a difference in long-term outcomes.