Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose of this study was to compare the clinical outcomes of patients with patellofemoral osteoar-thritis (PFOA) treated non-operatively with those treated operatively with an unloading anteromedialization tibial tubercle osteotomy (TTO). METHODS:A retrospective chart review was performed to identify patients with isolated PFOA who were either managed non-operatively or surgically with a TTO and who had a minimum follow-up of 2 years. Patients were surveyed with the visual analog scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), Anterior Knee Pain scale (Kujala), and Tegner Activity scale. Statistical analysis included two-sample t-testing, one-way ANOVA, and bivariate analysis. RESULTS:The clinical outcomes of 49 non-operatively managed patients (mean age: 52.7 ± 11.3 years; mean follow-up: 1.7 ± 1.0 years) and 35 operatively managed patients (mean age: 31.8 ± 9.4 years; mean follow-up: 3.5 ± 1.7 years) were assessed. The mean VAS improved sig-nificantly in both groups [6.12 to 4.22 (non-operative), p < 0.0001; 6.94 to 2.45 (TTO); p < 0.0001], with operatively treated patients having significantly lower postoperative pain than non-operatively managed patients at the time of final follow-up [2.45 (TTO) vs. 4.22 (non-operative), p < 0.001]. The mean KOOS-JR score was significantly greater in the operative group at time of final follow-up [78.7 ± 11.6 (TTO) vs. 71.7 ± 17.8 (non-operative), p = 0.035]. There was no significant difference in Kujala or Tegner scores between the treatment groups. Additionally, there was no sig-nificant relationship between the number of intra-articular injections, duration of NSAID use, and number of physical therapy sessions on clinical outcomes in the non-operatively treated group (p > 0.05). CONCLUSIONS:An unloading anteromedialization TTO provides significantly better pain relief and restoration of function compared to non-operative management in the treatment of symptomatic PFOA.

BACKGROUND/UNASSIGNED:Elbow ulnar collateral ligament (UCL) reconstruction (UCLR) is the gold standard for operative treatment of UCL tears, with renewed interest in UCL repairs. PURPOSE/UNASSIGNED:To (1) assess trends in rates of UCLR and UCL repair and (2) identify predictors of complications by demographic, socioeconomic, or surgical center volume factors. STUDY DESIGN/UNASSIGNED:Descriptive epidemiology study. METHODS/UNASSIGNED:Patients who underwent UCLR or UCL repair at New York State health care facilities between 2010 and 2019 were retrospectively identified; concomitant ulnar nerve procedures among the cohort were also identified. Surgical center volumes were classified as low (<99th percentile) or high (≥99th percentile). Patient information, neighborhood socioeconomic status quantified using the Area Deprivation Index, and complications within 90 days were recorded. Poisson regression analysis was used to compare trends in UCLR versus UCL repair. Multivariable regression was used to determine whether center volume, demographic, or socioeconomic variables were independent predictors of complications. RESULTS/UNASSIGNED:= .011). CONCLUSION/UNASSIGNED:A rising incidence of UCL repair compared with UCLR was found in New York State, especially among female patients, older patients, and nonprivate payers. There were no differences in 3-month complication rates between high- and low-volume centers, and Medicaid insurance status was a predictor for overall complications within 90 days of operation.

BACKGROUND:Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). METHODS:Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. RESULTS:Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend. CONCLUSION/CONCLUSIONS:PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.

PURPOSE/OBJECTIVE:To compare clinical outcomes, rate of return to sports, and psychological readiness among patients undergoing anterior cruciate ligament reconstruction (ACLR) with and without concomitant Segond fracture. METHODS:We retrospectively identified patients who underwent primary ACLR from January 2012 to December 2020 with minimum 2-year follow-up. Exclusion criteria were additional ligamentous injury, age <16 years, or a concomitant lateral augmentation procedure. Preoperative knee radiographs were reviewed to identify Segond fractures. Identified patients were matched 1:2 to controls by age/sex/body mass index/graft type. Charts were reviewed for pre- and postoperative knee stability. Surveys administered included preinjury sport participation and return status, Lysholm score, Tegner activity scale, and ACL-Return to Sport Index (ACL-RSI), a metric of psychological sport readiness. Multivariable logistic regression was conducted to identify predictors of return to sport. RESULTS:There were 120 patients who were included in the final analysis (40 Segond, 80 controls) at a mean follow-up of 5.7 ± 2.4 years. A total of 52.5% of patients received bone-patellar tendon-bone autograft. The overall rate of return to sport was 79.5% in the Segond group compared with an 83.8% rate of return in the control group (P = .569). In total, 48.7% of the Segond group and 56.8% of the control group returned to their preinjury level of sport (P = .415). Lysholm (89.6 ± 10.3 vs 85.4 ± 16.7, P = .296), Tegner (5.7 ± 1.8 vs 6.1 ± 2.2, P = .723), and ACL-RSI (62.2 ± 25.4 vs 56.6 ± 25.4, P = .578) scores were similar between Segond and control groups. There was a single graft failure in the Segond group 5 years' postoperatively. Increasing ACL-RSI score was significantly predictive of return to sport (P < .001). CONCLUSIONS:Patients who had an ACL tear and a concomitant Segond fracture who underwent isolated ACLR without lateral augmentation procedures had similar clinical outcomes and rates of return sport compared with a matched isolated ACLR control group at minimum 2-year follow-up. There was no significant difference in psychological readiness between groups as measured by the ACL-RSI. LEVEL OF EVIDENCE/METHODS:Level III, retrospective cohort study.

Recurrent patellar instability can significantly impact patients' quality of life and function. A large amount of research on patellar instability has been conducted in the past two decades, and a number of traditionally held principles of treatment have been challenged. This review addresses three current concepts and controversies in the treatment of patellar instability, specifically what factors lead to an increased tibial tubercle-trochlear groove distance and how to address them, when to add a tibial tubercle osteotomy to a medial patellofemoral ligament (MPFL) reconstruction, and which medial patellar stabilizers should be reconstructed. Based on current evidence, there are a few recommendations that can be made at this time. While trochleoplasty does have concerns with regard to reproducibility and complication risk, surgeons should consider this technique especially in cases with Dejour D trochlear dysplasia given high failure rates with other techniques. When evaluating whether to concomitantly perform a tibial tubercle osteotomy (TTO) with a MPFL, a TTO does appear to improve outcomes in the presence of maltracking or a positive J sign even with a tibial tuberosity-trochlear grove distance (TT-TG) of 18 to 20 mm, whereas patients without maltracking with a TT-TG of up to 25 mm may do well with an isolated MPFL reconstruction. Lastly, while MPFL reconstruction continues to have the most robust data supporting favorable outcomes, a number of biomechanical studies and short-term clinical studies have suggested promising results with medial quadriceps tendon femoral ligament and hybrid techniques.

This review highlights the expanding use of knee-based osteotomies in the treatment of knee joint malalignment and joint preservation. Planning and outcomes of traditional high tibial osteotomies and distal femoral osteotomies are discussed in addition to some of the challenges encountered with these procedures. Lastly, the role of patient-specific instrumentation and three-dimensional guided templating in performing osteotomies is discussed with respect to procedures that involve biplanar corrections and those performed in combination with other joint preservation procedures.

BACKGROUND/UNASSIGNED:Previous research has found that the incidence of neurovascular injury is greatest among multiligamentous knee injuries (MLKIs) with documented knee dislocation (KD). However, it is unknown whether there is a comparative difference in functional recovery based on evidence of a true dislocation. PURPOSE/UNASSIGNED:To determine whether the knee dislocation-3 (KD3) injury pattern of MLKI with documented tibiofemoral dislocation represents a more severe injury than KD3 MLKI without documented dislocation, as manifested by poorer clinical outcomes at long-term follow-up. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:A multicenter retrospective cohort study was performed of patients who underwent surgical treatment for KD3 MLKI between May 2012 and February 2021. Outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, and visual analog scale (VAS) for pain. Documented dislocation was defined as a radiographically confirmed tibiofemoral disarticulation, the equivalent radiology report from outside transfer, or emergency department documentation of a knee reduction maneuver. Subgroup analysis was performed comparing lateral (KD3-L) versus medial (KD3-M) injuries. Multivariable linear regression was conducted to determine whether documented dislocation was predictive of outcomes. RESULTS/UNASSIGNED:= .007) scores. CONCLUSION/UNASSIGNED:Patients undergoing surgical management of KD3 injuries with true, documented KD had significantly worse clinical and functional outcomes than those with nondislocated joints at a mean 6.5-year follow-up. The current MLKI classification based solely on ligament involvement may be obscuring outcome research by not accounting for true dislocation.

BACKGROUND/UNASSIGNED:Bone marrow stimulation (BMS) has been proposed to augment healing at the time of arthroscopic rotator cuff repair (ARCR) by creating several bone marrow vents in the footprint of the rotator cuff, allowing mesenchymal stem cells, platelets, and growth factors to cover the area as a "crimson duvet." PURPOSE/UNASSIGNED:To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes after BMS and a control for those undergoing ARCR. STUDY DESIGN/UNASSIGNED:Meta-analysis; Level of evidence, 1. METHODS/UNASSIGNED:value <.05 was considered to be statistically significant. RESULTS/UNASSIGNED: CONCLUSION/UNASSIGNED:The level 1 evidence in the literature did not support BMS as a modality to improve retear rates or clinical outcomes after ARCR.

An important domain of artificial intelligence is deep learning, which comprises computed vision tasks used for recognizing complex patterns in orthopaedic imaging, thus automating the identification of pathology. Purported benefits include an expedited clinical workflow; improved performance and consistency in diagnostic tasks; decreased time allocation burden; augmentation of diagnostic performance, decreased inter-reader discrepancies in measurements and diagnosis as a function of reducing subjectivity in the setting of differences in imaging quality, resolution, penetrance, or orientation; and the ability to function autonomously without rest (unlike human observers). Detection may include the presence or absence of an entity or identification of a specific landmark. Within the field of musculoskeletal health, such capabilities have been shown across a wide range of tasks such as detecting the presence or absence of a rotator cuff tear or automatically identifying the center of the hip joint. The clinical relevance and success of these research endeavors have led to a plethora of novel algorithms. However, few of these algorithms have been externally validated, and evidence remains inconclusive as to whether they provide a diagnostic benefit when compared with the current, human gold standard.

PURPOSE/UNASSIGNED:To compare psychological readiness to return to sport (RTS), RTS rate, level of return, and time to return between patients who underwent bilateral anterior cruciate ligament reconstruction (ACLR) and those who underwent unilateral ACLR. METHODS/UNASSIGNED:The electronic medical record at a single academic medical center was queried for patients who underwent ACLR from January 2012 to May 2020. The inclusion criteria were skeletally mature patients who underwent either single or sequential bilateral ACLR and who had undergone either the primary ACLR or second contralateral ACLR at least 2 years earlier. Bilateral ACLRs were matched 1:3 to unilateral reconstructions based on age, sex, and body mass index. Psychological readiness to RTS was assessed using the validated ACL Return to Sport After Injury (ACL-RSI) scale. This, along with time to return and level of RTS, was compared between the 2 cohorts. RESULTS/UNASSIGNED: = .31) between the 2 cohorts. CONCLUSIONS/UNASSIGNED:Compared with patients who undergo unilateral ACLR, patients who undergo bilateral ACLR are equally as psychologically ready to RTS, showing equal rates of RTS, time to return, and level of return. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.