Faculty Bibliography

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the literature for tibial tubercle osteotomy (TTO) studies and systematically reviewed them for indications, clinical outcomes, complications, and reoperations. Therapeutic clinical studies that reported TTO indications, operative findings, and outcomes were included. Quality of each study was assessed with the modified Coleman methodology score (MCMS). Twenty-one studies (976 patients, 1055 knees) were included in the analysis. Better quality studies had a mean (SD) MCMS of 19.8 (8.2), well under the 55-point cutoff. TTO was most commonly performed for isolated patellar instability in the presence of knee pain. The other pathologies addressed were patellofemoral osteoarthritis, patella alta, and patella baja with or without knee pain. TTO significantly improved knee pain and clinical outcome scores, though 21% of patients (>1 in 5) required reoperation for hardware removal. Young women with prior surgery on the affected knee were the primary patient population.

Matrix-induced autologous chondrocyte implantation (MACI) is a viable procedure that can be used as both a primary or revision cartilage regenerative procedure in high-functioning individuals without tibiotalar arthritis. Both short-term and midterm follow-up results demonstrate clinical, radiographic, and functional improvements with high rates of return to full activities. Cost remains a chief concern with the use of this technique, but theoretical improvements in the durability of repair with type II cartilage replacement may offer long-term benefits.

BACKGROUND:Excellent outcomes have been reported for anterior cruciate ligament (ACL) reconstruction (ACLR) in professional athletes in a number of different sports. However, no study has directly compared these outcomes between sports. PURPOSE/OBJECTIVE:To determine if differences in performance-based outcomes exist after ACLR between professional athletes of each sport. STUDY DESIGN/METHODS:Cohort study; Level of evidence, 3. METHODS:National Football League (NFL), National Basketball Association (NBA), National Hockey League (NHL), and Major League Baseball (MLB) athletes undergoing primary ACLR for an acute rupture were identified through an established protocol of injury reports and public archives. Sport-specific performance statistics were collected before and after surgery for each athlete. Return to play (RTP) was defined as a successful return to the active roster for at least 1 regular-season game after ACLR. RESULTS:Of 344 professional athletes who met the inclusion criteria, a total of 298 (86.6%) returned to play. NHL players had a significantly higher rate of RTP (95.8% vs 83.4%, respectively; P = .04) and a shorter recovery time (258 ± 110 days vs 367 ± 268 days, respectively; P < .001) than athletes in all the other sports. NFL athletes experienced significantly shorter careers postoperatively than players in all the other sports (2.1 vs 3.2 years, respectively; P < .001). All athletes played fewer games ( P ≤ .02) 1 season postoperatively, while those in the NFL had the lowest rate of active players 2 and 3 seasons postoperatively (60%; P = .002). NBA and NFL players showed decreased performance at season 1 after ACLR ( P ≤ .001). NFL players continued to have lower performance at seasons 2 and 3 ( P = .002), while NBA players recovered to baseline performance. CONCLUSION/CONCLUSIONS:The data indicate that NFL athletes fare the worst after ACLR with the lowest survival rate, shortest postoperative career length, and sustained decreases in performance. NHL athletes fare the best with the highest rates of RTP, highest survival rates, longest postoperative career lengths, and no significant changes in performance. The unique physical demand that each sport requires is likely one of the explanations for these differences in outcomes.

BACKGROUND:Tears of the anterior cruciate ligament (ACL) are common in the National Football League (NFL). The impact of these injuries on the careers of NFL linemen is unknown. PURPOSE/OBJECTIVE:To define the percentage of NFL linemen who return to sport (RTS) after ACL reconstruction, the mean time to RTS, and the impact on performance compared with matched controls. STUDY DESIGN/METHODS:Cohort study; Level of evidence, 3. METHODS:Data on NFL offensive and defensive linemen who sustained an ACL tear and underwent ACL reconstruction between 1980 and 2015 were analyzed. Players were identified through NFL team websites, publicly available injury reports, player profiles, and press releases. Demographics and mean in-game performance data preinjury and post-ACL reconstruction were recorded. A player was deemed to have returned to sport if he played in at least 1 NFL game after his ACL reconstruction. A healthy control group was selected to compare in-game performance data and was matched with the study group on several parameters. RESULTS:= .020). CONCLUSION/CONCLUSIONS:Overall, 64.3% of NFL offensive and defensive linemen who undergo ACL reconstruction returned to play. Linemen who RTS do so at a high level, with no difference in in-game performance or career duration when compared with matched controls.

BACKGROUND:The medial collateral ligament (MCL) is the most frequently injured ligament of the knee, but it infrequently requires surgical treatment. Current literature on MCL reconstructions is sparse and offers mixed outcome measures. PURPOSE/HYPOTHESIS/UNASSIGNED:The purpose of this study was to compare the outcomes of isolated MCL reconstruction and multiligamentous MCL reconstruction. Our hypothesis was that in selective patients, MCL reconstruction would significantly improve objective and subjective patient knee performance measures, those being baseline valgus laxity, range of motion, objective and subjective International Knee Documentation Committee (IKDC) scores, Tegner score, and Lysholm knee activity scores. STUDY DESIGN/METHODS:Systematic review; Level of evidence, 4. METHODS:tests. RESULTS:< .001). Normal or nearly normal range of motion was obtained by 88% of all patients. CONCLUSION/CONCLUSIONS:The systematic review of 10 studies and 275 knees found that the reported patient outcomes after MCL reconstruction were significantly improved across all measures studied, with no significant difference in outcomes between concomitant reconstructions.

We conducted a study to determine the rates of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) after high tibial osteotomy (HTO), distal femoral osteotomy (DFO), or tibial tubercle osteotomy (TTO) in patients who did not receive postoperative chemical prophylaxis. All patients who had HTO, DFO, or TTO performed by a single surgeon between 2009 and 2014 were identified. Charts were reviewed to determine presence or absence of DVT or PE. Patient age, smoking status, oral contraceptive (OC) use, and body mass index (BMI) were recorded. Patients received no chemical or mechanical prophylaxis after surgery. We identified 141 patients (44% male, 56% female) who underwent HTO, DFO, or TTO. Mean (SD) age was 34.28 (9.86) years, mean (SD) follow-up was 17.1 (4.1) months, and mean (SD) BMI was 26.88 (5.11) kg/m2. Overall, 36.7% of female patients used OCs, and 13.48% of all patients were smokers. After surgery, 2 patients (1.42%) developed below-knee DVT (unilateral in 1 case, bilateral in the other). The bilateral DVT case progressed to PE. Neither patient smoked, but the bilateral DVT/PE patient was using OCs. DVT patients' mean (SD) age was 48.16 (8.24) years, and their mean (SD) BMI was 23.18 (0.18) kg/m2. HTO, DFO, and TTO patients who did not receive chemical prophylaxis had low rates of DVT (1.42%) and PE (0.71%). Administration of DVT/PE prophylaxis after these osteotomies may not be warranted.

BACKGROUND:Meniscal tears are common in the young, active population. In this group of patients, repair is advised when possible. While inside-out repair remains the standard technique, recent advances in all-inside repair devices have led to a growth in their popularity. Previous reviews on the topic have focused on outdated implants of limited clinical relevance. PURPOSE:To determine the difference in failure rates, functional outcomes, and complications between inside-out and modern all-inside repairs. STUDY DESIGN:Systematic review. METHODS:A systematic review was registered with PROSPERO and performed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using the MEDLINE, EMBASE, and Cochrane databases. Inclusion criteria were (1) clinical study reporting on all-inside or inside-out repair, (2) evidence levels 1 to 4, and (3) use of modern all-inside implants for all-inside repairs. Exclusion criteria were (1) use of meniscal arrows or screws and (2) concomitant surgical procedures. Study characteristics, subjects, surgical technique, clinical outcomes, and complications were collected and analyzed. RESULTS:A total of 481 studies were screened and assessed for eligibility, which identified 27 studies for review. Studies defined clinical failure as persistent mechanical symptoms, effusion, or joint line tenderness, while anatomic failure was incomplete or no healing on MRI or second-look arthroscopy. There were no significant differences in clinical or anatomic failure rates between inside-out and all-inside repairs (clinical failure: 11% vs 10%, respectively, P = .58; anatomic failure: 13% vs 16%, respectively, P = .63). Mean ± SD Lysholm and Tegner scores for inside-out repair were 88.0 ± 3.5 and 5.3 ± 1.2, while the respective scores for all-inside repair were 90.4 ± 3.7 and 6.3 ± 1.3. Complications occurred at a rate of 5.1% for inside-out repairs and 4.6% for all-inside repairs. CONCLUSION:The quality of the evidence comparing inside-out and all-inside meniscal repair remains low, with a majority of the literature being evidence level 4 studies. In this review comparing modern all-inside devices with inside-out repair, no differences were seen in failure rates, functional outcome scores, or complication rates.

BACKGROUND:Total knee arthroplasty is a successful operation for treatment of arthritis. However, devastating wound complications and infections can compromise the knee joint, particularly in revision situations. METHODS:Soft tissue loss associated with poor wound healing and multiple operations can necessitate the need for reconstruction for wound closure and protection of the prosthesis. RESULTS:Coverage options range from simple closure methods to complex reconstruction, including delayed primary closure, healing by secondary intention, vacuum-assisted closure, skin grafting, local flap coverage, and distant microsurgical tissue transfer. CONCLUSION:Understanding the advantages and pitfalls of each reconstructive option helps to guide treatment and avoid repeated operations and potentially devastating consequences such as knee arthrodesis or amputation.

Coracoid transfer procedures are highly effective at improving glenohumeral stability in patients with recurrent shoulder instability; complication rates from this procedure are generally low. We present the first case in the literature of a Propionibacterium acnes (P. acnes) infection following a coracoid transfer. The case stresses the importance of proper antibiotic prophylaxis for patients undergoing Latarjet procedures, as well as the workup for a painful postoperative shoulder, and the need to maintain cultures from the shoulder for up to 21 days to isolate P. acnes.