Faculty Bibliography

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).

OBJECTIVE:This study assesses the impact of a structured summer externship program (SEP) in orthopedic surgery on participants' career trajectories and diversity within the field. Specifically, we evaluated the proportion of SEP participants who chose a career in orthopedic surgery and analyzed trends in gender and racial/ethnic diversity among the cohort over a 20-year period. DESIGN/METHODS:A retrospective cohort analysis was conducted using data from participants in 1 academic department's SEP between 2004 and 2023. Participant demographic data, ultimate specialty match information, and residency outcomes were collected and statistically analyzed to assess trends in specialty selection, gender, and racial/ethnic diversity among the SEP alumni. SETTING/METHODS:This study took place in the Department of Orthopedic Surgery at a large academic tertiary medical center. PARTICIPANTS/METHODS:The study included 564 medical students who participated in the SEP between 2004 and 2023. Of these, 441 (78.2%) have graduated from medical school to date, 114 (20.2%) are still enrolled, and 5 (0.89%) have left medicine for careers in other sectors. Data for 9 participants (1.6%) was unavailable. RESULTS:Among the 436 graduates, 161 (36.9%) eventually matched into orthopedic surgery. An additional 13.5% entered internal medicine, 7.3% matched into radiology, 6.6% into emergency medicine, 5.5% into anesthesiology, and 30.3% into various other specialties. Female representation in the SEP increased from 16.6% in 2004 to 51.1% in 2023 (χ² = 4.95, p = 0.026), while non-white participant representation grew from 16.6% to 45% over the same period (χ² =3.18, p = 0.075). CONCLUSIONS:The SEP is one way of providing resources and opportunity for engagement for students interested in orthopedic surgery careers while promoting diversity within the field. This program serves as a valuable pathway, offering early exposure to orthopedic surgery, research opportunities, and professional networking, all of which may play an increasingly critical role as residency selection criteria evolve. The SEP's advantages to participants underscore the importance of targeted programs in fostering opportunity for previously underrepresented groups in the field of orthopedic surgery.

PURPOSE/OBJECTIVE:Meniscus repair is preferred over meniscectomy when possible due to its ability to preserve meniscal tissue and reduce long-term joint degeneration. However, meniscus repair has a risk of failure, resulting in an increasing number of patients presenting with symptoms following a failed repair. Revision meniscus repair remains an option for symptomatic patients, yet guidance on indications, surgical techniques, and expected outcomes is limited. The purpose of this review is to summarize indications, surgical approaches, and outcomes associated with revision meniscus repair. RECENT FINDINGS/RESULTS:Patient-specific factors such as age, activity level, and modifiable risk factors influence revision repair success. Younger, highly active individuals may be at higher risk of retear due to increased mechanical stress. Tissue quality and vascularity are critical, as degenerative changes and poor perfusion increase failure rates. The gold-standard inside-out technique is often favored for revision repairs due to its superior biomechanical stability. However, all-inside and outside-in techniques remain viable options in specific cases. Biological augmentation, including platelet-rich plasma (PRP) and marrow venting, may enhance healing potential but requires further investigation. Revision meniscus repair demonstrates comparable failure rates and functional outcomes to primary repair, with reported failure rates ranging from 21-33% at mid-term follow-up. Many patients successfully return to high levels of activity following revision repair. Although younger age and high activity levels may predispose to failure, revision meniscus repair remains a viable option for preserving meniscal integrity and optimizing long-term joint health.

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.

INTRODUCTION/BACKGROUND:Operative management of multi-ligament knee injuries (MLKI) is technically challenging, with high complication rates. However, the impact of surgeon experience on surgical outcomes remains underreported. This purpose of this study was to examine how surgeon experience impacts operative time and complication rates. It was hypothesized that increased surgeon experience in MLKI correlates with reduced surgical duration and postoperative complications. METHODS:A retrospective review of MLKI patients who underwent reconstruction from 2011 to 2024 by fellowship-trained sports medicine surgeons at two high-volume level 1 trauma centers was conducted. Patient demographics, surgical procedure characteristics, complications, and surgeon experience (defined by years in practice postfellowship) were analyzed. Correlations were examined using linear regression for continuous variables and binary logistic regression for binary variables. RESULTS:There were 191 MLKI patients meeting inclusion criteria, with a 25.7% overall complication rate. Arthrofibrosis (16.2%) was most common, followed by recurrent instability (3.7%), infection (3.7%), revision surgery (2.7%), and hardware removal (1.0%). Controlling for age, sex, BMI, and number of ligaments reconstructed, we found a significant negative correlation between surgeon experience and both surgical duration (ß =  - 0.28, p < .001) and complication risk (OR 0.92, p = 0.024). CONCLUSION/CONCLUSIONS:This study demonstrates that increased surgeon experience in operative management of MLKI is associated with decreased complication rates and shorter procedure duration. Additional risk factors for complications included the number of ligaments injured and concomitant knee dislocation.

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.

PURPOSE/OBJECTIVE:The purpose of the current study was to define the incidence of minor and major complications following TTO at a tertiary-care institution, with determination of predictive factors related to the occurrence of a major complication. STUDY DESIGN/METHODS:Retrospective case series. METHODS:Patients who underwent TTO from 2011 to 2023 were retrospectively identified. Patients who did not have at least 30 days of follow-up and revision cases were excluded. Complications classified as "major" included intraoperative fracture, postoperative fracture, loss of fixation, delayed union, non-union, pulmonary embolism (PE), patella tendon rupture, deep infection, painful hardware requiring removal, arthrofibrosis requiring reoperation, recurrent patellar instability, reoperation for other indications, readmission, and revision. Complications classified as minor included superficial infection, deep venous thrombosis, wound dehiscence, and postoperative neuropraxia. Chi-square tests were used for categorical variables, t-tests for continuous variables. RESULTS:Four hundred and seventy-six TTOs in 436 patients were included in the final cohort with a mean follow-up of 1.9 years (range 1 month-10 years). Patients were 68.5% female with average age 28.3 years (range 13-57 years). The overall complication rate was 27.5 percent. Major complications were recorded in 23.7% of TTOs, and minor complications in 8.4% of TTOs. Reoperation was required in 16.6% of TTOs at a mean of 14 months following the index procedure. The most common complications were painful hardware requiring removal (6.5%), superficial infection (5.7%), and arthrofibrosis requiring return to the operating room (OR) (5.0%). Prior ipsilateral surgery was identified as a significant independent predictor of major complication by regression analysis. Hardware removal was more common with headed screws. Arthrofibrosis requiring reoperation was more common in patients who underwent a concomitant cartilage restoration/repair procedure. CONCLUSION/CONCLUSIONS:The overall complication rate following tibial tubercle osteotomy was 27.5%, with painful hardware requiring removal (6.5%) as the most common complication, and an overall reoperation rate of 16.6%. TTOs with major complications were performed at earlier years, in patients who were older, had a previous ipsilateral arthroscopic knee surgery, had an indication of cartilage lesion/arthritis, and had a steeper osteotomy cut angle. Hardware removal was found to be more common in patients with headed as compared to headless screws. Complications also varied based on timing after surgery.

PURPOSE/OBJECTIVE:To evaluate knee intra-articular cytokine concentrations in patients undergoing isolated meniscectomy and determine if these concentrations are associated with clinical outcomes. METHODS:Concentrations of ten biomarkers were quantified in synovial fluid aspirated from the operative knees of patients who underwent isolated meniscectomy from 10/2011-12/2019. Patients completed a survey at final follow-upincluding VAS, Lysholm, Tegner, and KOOS Physical Function Short Form (KOOS-PS). Failure was defined as subsequent TKA or non-achievement of the Patient Acceptable Symptom State (PASS) for knee pain defined as VAS > 27/100. Regression analysis investigating the relationship between cytokine concentrations and failure was performed. RESULTS:[25.5, 32.4], and a mean follow-up of 8.0 ± 2.2 years. There were no demographic or clinical differences between failures (n = 41) and non-failures (n = 59) at baseline. Monocyte Chemotactic Protein 1 (MCP-1) concentration was significantly higher in failures than in non-failures (344.3 pg/ml vs. 268.6 pg/ml, p = 0.016). In a regression analysis controlling for age, sex, BMI, symptom duration, length of follow-up, and ICRS grade, increased MCP-1 was associated with increased odds of failure (p = 0.002). CONCLUSIONS:The concentration of MCP-1 on the day of arthroscopic meniscectomy was predictive of failure as defined by an unacceptable pain level at intermediate- to long-term follow-up. This finding may help identify patients at high risk for poor postoperative outcomes following isolated meniscectomy and serve as a target for future postoperative immunomodulation research.

PURPOSE/OBJECTIVE:There is limited clinical outcome data comparing fixation methods for tenodesis of the long head of the biceps tendon (LHBT), particularly button fixation. The purpose of this study was to compare clinical outcomes, patient-reported outcomes, and return to sport (RTS) between patients undergoing LHBT with bicortical versus unicortical button technique. The authors hypothesized these fixation methods would be similar for all outcomes. METHODS:Patients who underwent LHBT using unicortical or bicortical button fixation with minimum 2-year follow-up were identified. Postoperative outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) questionnaire and visual analogue scale (VAS) pain score. A sports activity survey was collected to assess baseline sport participation and ability to return to pre-injury activities. Continuous variables were analyzed using the Mann-Whitney-U test. Categorical variables were analyzed using Chi-squared tests. Multivariable logistic and linear regression were performed to determine predictors of RTS and time to RTS. RESULTS:Sixty-four subjects (19 unicortical and 45 bicortical button fixation) were included (average follow-up 3.5 (range: 2.0-7.8) years). There were no significant differences found between button groups for VAS pain score (1.5 vs. 1.2; p = 0.876), VAS pain during sport score (1.6 vs. 1.1, p = 0.398), and ASES score (66 vs. 71; p = 0.294). There were no significant differences in rate of RTS (75.0 vs. 77.4%; p = 0.885) or average time to return to sport (11.7 ± 7.3 vs. 7.0 ± 4.0 months; p = 0.081) between groups. CONCLUSION/CONCLUSIONS:There were no significant differences in clinical outcomes, pain, or return to sport between patients who underwent LHBT with unicortical or bicortical button fixation.