Faculty Bibliography

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.

OBJECTIVES/OBJECTIVE:The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. METHODS:A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. RESULTS:Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p ​= ​0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p ​= ​0.47), return to sport (MQTFLR 50%, MPFLR 75%, p ​= ​0.61), return to work (MQTFLR 100%, MPFLR 88%, p ​= ​1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p ​= ​0.31). CONCLUSION/CONCLUSIONS:There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:To evaluate long-term outcomes of patients treated with posterior medial meniscal root tear (PMMRT) repair through assessment of functional outcome scores and to identify patient surgical and magnetic resonance imaging (MRI) characteristics associated with improved outcomes. METHODS:This was a single-centre, retrospective study evaluating patients who had undergone a PMMR repair using a transtibial suture pullout technique with two locking cinch sutures. This was performed as a follow-up to previously published 2-year and 5-year outcome studies, using the same cohort. All patients from the prior short-term and midterm studies were invited to participate. Patient-reported outcome (PROs) scores, including the International Knee Documentation Committee (IKDC) and Lysholm scores, were collected. Previously collected demographic data were updated based on review of the electronic medical record. Patient outcomes were assessed preoperatively, as well as at 2-year, 5-year and 8-year postoperatively. MRI outcome measurements were assessed at 2-year and 5-year follow-ups. All statistical analysis was performed using SPSS version 26. RESULTS:Seventeen patients of the original 18 patients (94.4%) were included in the final analysis. Additionally, three patients who had additional ipsilateral surgery were excluded from the analysis of PROs. The IKDC score significantly increased from 44.7 ± 11.6 at preoperative baseline to 71.2 ± 21.3 at 8-year post-operation (p = 0.001). There were no significant differences in IKDC score between 2-year and 8-year follow-ups (p = n.s.) or 5-year and 8-year follow-ups (p = n.s.). The Lysholm score significantly increased from 49.6 ± 7.3 at preoperative baseline to 76.4 ± 17.2 at 8-year follow-up (p < 0.001). There was no significant difference in Lysholm scores between 2-year and 8-year follow-ups (p = n.s.) or 5-year and 8-year follow-ups (p = n.s.). A linear regression analysis found that 5-year IKDC scores were significantly correlated with 8-year IKDC scores (β = 0.681, p = 0.038). At 8-year follow-up, four (23.5%) patients required additional procedures on their operative knee (one total knee arthroplasty conversion). CONCLUSION/CONCLUSIONS:Patients treated with repair of PMMRT had maintenance of clinical outcome improvements at long-term follow-up despite worsening MRI outcomes at short-term and medium-term follow-ups. While a high proportion of patients required additional procedures on their operative knee at 8-year follow-up, few of these patient's additional procedures were related to failure of their primary surgery. Providers and patients may expect durable clinical outcomes following the repair of PMMRT, irrespective of radiographic appearance. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND/UNASSIGNED:There has been a marked increase in the number of Schenck knee dislocation (KD) I injuries reported in the multiligament knee (MLK) injury (MLKI) and KD literature. PURPOSE/UNASSIGNED:To examine the heterogeneity of the Schenck KD I classification in the MLKI and KD literature. STUDY DESIGN/UNASSIGNED:Systematic review; Level of evidence, 4. METHODS/UNASSIGNED:A systematic literature search of PubMed, CINAHL, Scopus, Web of Science, EMBASE, and Cochrane Library was conducted for all studies that investigated KDs and/or MLKIs, utilized the Schenck or an MLKI classification system, and included patients with KD I or MLK 1 injuries. Pooled analysis determined the total number of KD I or MLK 1 injuries and the specific ligamentous tear patterns. Binary meta-analyses of the studies that reported neurovascular injury within each Schenck KD class compared the pooled odds ratio (OR) of vascular and neurological injury in unicruciate (KD I) and bicruciate (KD II-IV) injuries. RESULTS/UNASSIGNED:< .00001). CONCLUSION/UNASSIGNED:The number of true, clinically and/or radiographically confirmed unicruciate KDs was extremely rare, representing <1% of all reported Schenck KD I injuries. A misappropriation of these injury patterns as true KDs may be taking place, affecting outcome studies and potentially biasing published clinical results. An MLKI classification system must document whether a confirmed KD has occurred.

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.

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.

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.

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.

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:Open subpectoral biceps tenodesis (OSBT) with cortical button fixation has been shown to deliver acceptable results in the short and intermediate term for long head of the biceps (LHB) pathology with the benefit of smaller bone tunnel diameter and a reduced risk of postoperative humeral shaft fracture. The primary purpose of this study was to determine whether OSBT with cortical button fixation results in significant improvements in patient reported outcomes (PROs) from pre-operative to long-term final follow-up. METHODS:A retrospective analysis of patients who underwent OSBT with cortical button fixation at a single institution between the years of 2012 and 2014 was conducted and PROs were collected in the intermediate (> 2 years follow-up) and long term (> 9 years follow-up). PROs were measured pre-operatively, at intermediate follow-up, and at long-term follow-up using three validated questionnaires: American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Oxford Shoulder Score (OSS). Patients were additionally asked at final follow-up if they would undergo the same procedure again if they needed it. RESULTS:Twenty-nine (29) patients with a mean age of 51.16 ± 9.06 years at the time of surgery were included in the study at final follow-up. Mean final follow-up time was 10.2 ± 0.5 years (range: 9.2-11.1 years). All PROs (ASES, OSS, and DASH) demonstrated statistically significant improvements from pre-operative to final follow-up with p < 0.01 for each. The proportions of patients exceeding established values for minimum clinically important difference (MCID) were 96.55%, 93.10%, and 75.86% for ASES, OSS, and DASH respectively. Only one patient had required re-operation as of final follow-up. None experienced humeral fractures post-operatively. A significant majority (89.66%; p < 0.01) of patients reported that they would undergo the same procedure again if they needed it. Fifty-three (53) patients were included in the study at intermediate follow-up with a mean follow-up time of 3.5 ± 1.4 years (range: 2-5.3 years). There were no statistically significant differences in any of the PRO measures from intermediate to long-term follow-up. CONCLUSION/CONCLUSIONS:This study reported a minimum 9-year follow-up of patients undergoing OSBT with cortical button fixation for the management of LHBT pathology in the setting of concomitant shoulder procedures. All patients had significantly improved functional outcomes assessed with ASES, OSS, and DASH and no obvious differences in median group scores were found between patients assessed at intermediate (mean 3.5 years) and final (mean 10.2 years) follow-up. No infections, fractures, or fixation failures were reported.