Faculty Bibliography

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.

OBJECTIVE:Concerns regarding patient safety and image quality have made the use of knee-spanning external fixators in MRI a challenging clinical scenario. The purpose of our study was to poll practicing musculoskeletal radiologists on their personal experiences regarding the use of knee-spanning external fixators in MRI in an effort to consolidate practice trends for the radiologists' benefit. METHODS:A 27-item survey was created to address the institutional use, safety, adverse events, quality, and perspectives of the radiologist related to MRI of an externally fixated knee. The survey was distributed to 1739 members of the Society of Skeletal Radiology. RESULTS:A total of 72 members of the Society of Skeletal Radiology completed the survey. Most notably, 40 of 72 (55.56%) respondents are permitted to place a knee-spanning external fixator inside the MR bore at their institution, while19 of 72 (26.39%) respondents are not permitted to do so. Fourteen of 32 (43.75%) respondents have institutional guidelines for safely performing an MRI of an externally fixated knee. Twenty-five of 32 (78.13%) respondents are comfortable permitting an MRI of an externally fixated knee. CONCLUSION/CONCLUSIONS:We found a general lack of consensus regarding the decision to scan a patient with a knee-spanning external fixator in MRI. Many institutions lack safety guidelines, and providers rely upon a heterogeneous breadth of resources for safety information. A re-examination of the FDA device labeling nomenclature and expectations of the individual manufacturers may be needed to bridge this gap and help direct management decisions placed upon the provider.

Osteochondral lesions (OCL) of the knee are a common pathology that can be challenging to address. Due to the innate characteristics of articular cartilage, OCLs generally do not heal in adults and often progress to involve the subchondral bone, ultimately resulting in the development of osteoarthritis. The goal of articular cartilage repair is to provide a long-lasting repair that replicates the biological and mechanical properties of articular cartilage, but there is no widely adopted technique that results in true pre-injury state hyaline cartilage. Current treatment modalities have seen reasonable clinical success, but significant limitations remain. Microfracture provides short-term benefit with a fibrocartilage-based repair. While osteochondral autograft or allograft and autologous chondrocyte implantation can be effective, each have their strengths and shortcomings. Emerging concepts in cartilage repair, including scaffold engineering and one stage cell-based options, are continually advancing. These have the benefits of reduced surgical morbidity and potentially improved integration with surrounding articular cartilage but have not yet reached widespread clinical application. Tissue engineering strategies and gene therapy have the potential to advance the field, however, they remain in the early stages. The current article reviews the structure and physiology of articular cartilage, the strengths and limitations of present treatment modalities, and the newer ongoing innovations that may change the way we approach osteochondral lesions and osteoarthritis.

Tibial-sided posterior cruciate ligament avulsion fractures are challenging injuries that often occur concomitantly in the setting of multiligament knee and other soft-tissue injuries. There is no consensus on the optimal surgical approach or timing of treatment for these injuries. This Technical Note describes the fixation of a displaced posterior cruciate ligament avulsion fracture with concomitant grade 3 medial collateral ligament injuries and bucket-handle lateral meniscus tears using open and arthroscopic techniques. This method allows the surgeon to address multiple pathologies in a single stage, although it requires strategic planning and rehabilitation considerations.

Posterior cruciate ligament (PCL) injuries are a rare form of knee injury often seen in the setting of high energy polytraumas; however, these injuries can occur in isolation as well. Often, the posterolateral corner (PLC) is involved, which imparts further posterior translational and rotational instability to these injuries. While non-operative management is certainly a reliable option for low grade isolated PCL tears, high grade injuries with concomitant PLC involvement, additional intra-articular pathologies requiring operative management, multiligamentous injuries, or patients who have failed non-operative management require PCL repair or reconstruction. The current review focuses on the many facets of PCL reconstruction, including single versus double bundle reconstruction, tibial slope implications, graft selection, multiligamentous injury considerations, tunnel management, and onlay versus inlay tibial footprint creation. We conclude with a proposed algorithm in the management of this injury.

OBJECTIVE:To determine the cost-effectiveness of rotator cuff hydroxyapatite deposition disease (HADD) treatments. METHOD/METHODS:A 1-year time horizon decision analytic model was created from the US healthcare system perspective for a 52-year-old female with shoulder HADD failing conservative management. The model evaluated the incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) of standard strategies, including conservative management, ultrasound-guided barbotage (UGB), high- and low-energy extracorporeal shock wave therapy (ECSW), and surgery. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2022 US dollars. The willingness-to-pay (WTP) threshold was $100,000. RESULTS:For the base case, UGB was the preferred strategy (0.9725 QALY, total cost, $2199.35, NMB, $95,048.45, and ICER, $33,992.99), with conservative management (0.9670 QALY, NMB $94,688.83) a reasonable alternative. High-energy ECSW (0.9837 QALY, NMB $94,805.72), though most effective, had an ICER of $121, 558.90, surpassing the WTP threshold. Surgery (0.9532 QALY, NMB $92,092.46) and low-energy ECSW (0.9287 QALY, NMB $87,881.20) were each dominated. Sensitivity analysis demonstrated that high-energy ECSW would become the favored strategy when its cost was < $2905.66, and conservative management was favored when the cost was < $990.34. Probabilistic sensitivity analysis supported the base case results, with UGB preferred in 43% of simulations, high-energy ECSW in 36%, conservative management in 20%, and low-energy ECSW and surgery in < 1%. CONCLUSION/CONCLUSIONS:UGB appears to be the most cost-effective strategy for patients with HADD, while surgery and low-energy ECSW are the least cost-effective. Conservative management may be considered a reasonable alternative treatment strategy in the appropriate clinical setting.

OBJECTIVE:Marrow stimulation is used to address knee cartilage defects. In this study, we used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to evaluate statistical fragility of outcomes reported in randomized controlled trials (RCTs) evaluating marrow stimulation. DESIGN/METHODS:PubMed, Embase, and MEDLINE were queried for recent RCTs (January 1, 2010-September 5, 2023) assessing marrow stimulation for cartilage defects of the knee. The FI and rFI were calculated as the number of outcome event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI by the study sample size. RESULTS:Across 155 total outcomes from 21 RCTs, the median FI was 3 (interquartile range [IQR], 2-5), with an associated median FQ of 0.067 (IQR, 0.033-0.010). Thirty-two outcomes were statistically significant, with a median FI of 2 (IQR, 1-3.25) and FQ of 0.050 (IQR, 0.025-0.069). Ten of the 32 (31.3%) outcomes reported as statistically significant had an FI of 1. In total, 123 outcomes were nonsignificant, with a median rFI of 3 (IQR, 2-5). Studies assessing stem cell augments were the most fragile, with a median FI of 2. In 55.5% of outcomes, the number of patients lost to follow-up was greater than or equal to the FI. CONCLUSION/CONCLUSIONS:-values with FI and FQ metrics to aid in the interpretation of clinical findings in comparative trials assessing cartilage restoration.

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:Several randomized controlled trials (RCTs) have been conducted to assess the use of tranexamic acid (TXA) in the setting of arthroscopic rotator cuff repair (ARCR). However, these studies have shown mixed results, with some showing improved intraoperative visualization, subsequent operative times, and pain levels, and others finding no difference. PURPOSE/UNASSIGNED:To perform a systematic review of the RCTs in the literature to evaluate the use of TXA on ARCR. STUDY DESIGN/UNASSIGNED:Meta-analysis; Level of evidence, 1. METHODS/UNASSIGNED:value < .05 was deemed statistically significant. RESULTS/UNASSIGNED:= .001). No study found any difference in intraoperative pump pressures or swelling. CONCLUSION/UNASSIGNED:TXA improved visualization, operative time, and subsequent postoperative pain levels in patients undergoing ARCR.

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.