Faculty Bibliography

PURPOSE/OBJECTIVE:To determine the rate and characteristics of postoperative flares in rheumatic disease patients undergoing arthroscopic surgery, and the role of perioperative immunosuppression (IS) management in preventing or provoking these exacerbations. METHODS:We conducted a retrospective review of arthroscopic surgeries in patients with rheumatologic disease over 11 years. Patients taking IS at baseline and those without were matched 1:1 using propensity scores on age, sex, rheumatic disease type, and procedure complexity. Patients taking IS at baseline were sub-divided into those remaining on IS perioperatively versus those who held IS before surgery. Multivariable logistic regression identified risk factors for postoperative flares for the three IS groups, and survival analysis was used to compare the probability of remaining flare-free up to 12 weeks postoperatively. RESULTS:After matching, 428 patients (214 on various types of baseline IS, 214 not on baseline IS) were included, with 110 on baseline IS remaining on it perioperatively. Rates of postoperative flares were similar for those staying on vs holding their baseline IS (9.1% vs 9.6%) but flares were less frequent in patients not on baseline IS (1.9%). Patients who remained on perioperative IS did not have significantly less flares compared to patients taken off perioperative IS (OR 0.764 [0.267, 2.181]; p = 0.61). Patients not on baseline IS had a significantly higher probability ofremaining flare-free up to 12 weeks (p = 0.004). CONCLUSION/CONCLUSIONS:Rheumatic disease patients who hold IS medication before undergoing arthroscopy, out of concern for potential infection or complications, do not significantly increase their risk of flaring their autoimmune disease whether they had been taking csDMARDs or biologic agents. Those not taking any IS at baseline have a much lower risk of post-arthroscopic flaring, though as a group they likely harbor less of an autoimmune burden.

Introduction: While OCA has been shown to result in good long-term outcomes, there is still a considerable failure rate present with room for improvement. Objectives: The purpose of this study is to evaluate the impact that osteochondral allograft cartilage thickness has on contact pressures, and to simulate whether a mismatch of the subchondral bony interface relative to the host-recipient site results in altered biomechanics. Methods: Properties of articular cartilage and bone were incorporated into a finite element model to create a simulated osteochondral lesion (diameter: 10 mm, height: 10 mm, cartilage thickness: 2 mm, subchondral bone thickness: 8 mm). Five osteochondral plugs were constructed to fill the defect, with cartilage-to-bone ratios between 1:9 and 1:1. The plugs were inserted and given a static downward force of 5000 N. Resultant stresses and displacements were measured. Results: The 2:8 cartilage-to-bone ratio plug, matched with the recipient site, was deemed optimal based on its resultant stress and displacement. The 1:9 plug displaced less than the 2:8 match and endured greater stress per unit of cartilage volume, whereas the 3:7 plug also displayed similar displacement to the 1:9 plug but had greater cartilage volume and was able to distribute less stress per unit of cartilage volume. The 4:6 plug displaced to a similar extent as the 3:7 plug but displayed a unique pattern of strain. The 5:5 plug was considered nonfunctional, as the majority of displacement was seen in the cartilage of the recipient site rather than in the plug itself. Conclusions: The relationship between the cartilage-to-bone ratio in osteochondral allografts and that of their surroundings significantly impacts the distribution of stresses and predilection for micromotion at the repair site.

PURPOSE/OBJECTIVE:Multi-ligamentous knee injuries (MLKIs) are high-energy injuries that may infrequently present with concomitant patellar tendon rupture. There is limited information in the literature regarding these rare presentations, with even less information regarding clinical outcomes. Using propensity-score matching, the purpose of this study was to compare the outcomes of MLKIs with and without patellar tendon ruptures and to investigate the overall predictors of these outcomes. METHODS:Twelve patients who underwent surgical repair for combined MLKI and patellar tendon rupture from 2011 to 2020 with minimum 1-year follow-up data were identified from two separate institutions. Patients were propensity-score matched with a 1:1 ratio with controls based on age, body mass index (BMI), gender, and time from surgery. Patient-reported outcomes included International Knee Documentation Committee (IKDC) Subjective Knee Form, Lysholm and Tegner scores. RESULTS:Twelve MLKIs with concomitant patellar tendon injuries were identified out of a multicenter cohort of 237 (5%) patients sustaining MLKI and were case matched 1:1 with 12 MLKIs without extensor mechanism injuries. The average follow-up was 5.5 ± 2.6 years. There were no differences in Schenck Classification injury patterns. There were significant differences found across IKDC (Patellar Tendon mean: 53.1 ± 24.3, MLKI mean 79.3 ± 19.6, P < 0.001) and Lysholm scores (Patellar Tendon mean: 63.6 ± 22.3, MLKI mean 86.3 ± 10.7, P < 0.001) between the two, illustrating poorer outcomes for patients with concomitant patellar tendon ruptures. CONCLUSION/CONCLUSIONS:In the setting of MLKI, patients who have a concomitant patellar tendon rupture have worse functional outcomes compared to those without. This information will be important for patient counseling and might be considered to be added to Schenck classification, reflecting its prognostic value. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND:Recent interest has surged in the anterolateral ligament (ALL) and complex (ALC) of the knee. Its existence and role in rotary stability of the knee, particularly in the setting of anterior cruciate ligament (ACL) reconstruction, remains a contentious and controversial topic. UNDERSTANDING THE ALC/UNASSIGNED:We must review our history and recognize the pioneers who pushed our understanding of the ALL forward before it was popularly recognized as a discrete structure. Additionally, given that many eponyms remain in common use related to the ALC, we must standardize our nomenclature to prevent misuse or misunderstanding of terms in the literature. In this review, modern understanding of the anterolateral ligament complex (ALC) is traced to 1829 by exploring eponymous terms first in anatomy and then in surgical technique. Understanding our history and terminology will allow us to better understand the ALC itself. CONCLUSION/CONCLUSIONS:This review aims to provide historical context, define terminology, and provide insight into the clinical relevance of the ALC.

PURPOSE/UNASSIGNED:To compare satisfaction and return to play (RTP) rates between patients undergoing primary biceps tenodesis for a symptomatic SLAP tear and patients undergoing secondary biceps tenodesis following a failed SLAP repair. METHODS/UNASSIGNED:value of <.05 was considered to be statistically significant. RESULTS/UNASSIGNED: = .9529) between patient groups. Patients reported playing tennis, swimming, golf, rock climbing, and basketball. No patients required a further shoulder surgery after undergoing biceps tenodesis. CONCLUSIONS/UNASSIGNED:In this study, patients undergoing primary biceps tenodesis had significantly better functional outcomes compared with secondary biceps tenodesis following a failed SLAP repair. LEVEL OF EVIDENCE/UNASSIGNED:III, retrospective comparative study.

PURPOSE/OBJECTIVE:The purpose of this study was to examine the relationship between obesity and post-operative stiffness following surgical management of MLKIs using a large two-center cohort, by both (1) using binary cutoffs at various body mass indexes (BMI) and (2) a linear regression model. METHODS:190 consecutive patients who underwent surgical management of MLKIs between January 2001 and March 2020 were reviewed at two level 1 academic trauma centers. Patient demographics, surgical characteristics, and MUA/lysis of adhesions (LOA) were reviewed. Patients were stratified by obesity grades: grade 1 (BMI 30 to < 35) grade 2 (BMI 35 to < 40); grade 3 (BMI > 40), and compared with a non-obese comparison group with BMI < 30. Multivariate logistic regressions were performed including the covariates of age, gender, BMI, acute versus chronic injury, external fixator, vascular injury, knee dislocation, and Schenck Classification. Fisher's Exact Test was used to compare rate of MUA between grades of obesity. Analyses were performed with R. Statistical significance was set at p < 0.05. RESULTS:. The mean overall follow up was 27.2 ± 7.2 months (range 14 - 142 months). There were 55 (29.1%) MUA procedures observed at a mean 3.77 ± 2.18 months (range 1.8 - 9.7 months) after final MLKI surgery. No significant difference was found in BMI of patients who underwent a MUA compared to patients who did not (30.2 vs. 28.8; p = 0.67). There was no significant difference in rate or time to MUA following MLKI surgery between groups, with logistic regression demonstrating no significance (p=0.144). Use of external fixation at the index surgery (OR = 3.3 (95% CI: 2.2, 4.7, p < 0.0001)) and vascular injury (OR = 6.2 ((95% CI: 1.8, 24.5, p = 0.005)) were found to be independent predictors for need for MUA. CONCLUSION/CONCLUSIONS:No difference in risk for post-operative stiffness requiring MUA following surgery for MLKI was found based on BMI. At all BMI levels, there were no significant increase in need for post-operative MUA, suggesting at minimum a neutralizing effect of obesity on post-operative stiffness. In addition, patients with external fixator use and vascular injury at index surgery were found to be at significantly higher risk for post-operative stiffness requiring MUA following surgery for MLKI. Surgeons should be aware of the risk factors for arthrofibrosis when proceeding with surgical repair or reconstruction of two or more ligaments of the knee.

BACKGROUND:Tibial tubercle anteromedialization (AMZ) is a commonly performed procedure for patients with patellofemoral instability or patellofemoral osteochondral disease. While prior studies have demonstrated that this form of osteotomy produces generally good outcomes, the time needed for return to work and return to sport remains unclear. This study aimed to determine the mean length of time before return to work and the rate of return to sport following AMZ. PATIENTS AND METHODS/METHODS:Patients who had undergone AMZ for either patellofemoral instability or isolated osteochon- dral defect with a minimum follow-up time of 1 year were identified. Patients less than 18 years of age were excluded. Patients were asked to complete a series of patient reported outcomes surveys including specific queries regarding their return to work and return to athletic activity. RESULTS:A total of 109 patients were included in this study. The majority were female (79 patients, 72.3%). The mean age was 30.74 ± 9.90 years at the time of surgery. The mean follow-up duration was 3.40 ± 1.97 years. Of the 109 patients, 104 (95.4%) had returned to work at the time of follow-up. Mean time to return to work was 2.96 ± 3.33 months (range: 0.25 to 24 months). Of the 90 patients who were involved in a sport or physical activity prior to injury, 64 patients (71.1%) had returned to sport at some level at the time of most recent follow-up. Of those who had returned to sport, mean time to return to sport was 9.21 ± 5.46 months (range: 1 to 24 months). CONCLUSIONS:At a minimum follow-up time of 1 year, patients who underwent AMZ were found to have a return to sport rate of 71% with a mean time of 9.21 months to return to athletic activity. Over 95% of AMZ patients had returned to work by 1 year after the procedure. Patients required an average of 3 months to return to work, although those with physically demanding jobs required slightly more time. Data from the current study is useful in setting expectations for patients undergoing tibial tubercle anteromedialization for patellofemoral instability or patellofemoral osteochondral disease.

UNLABELLED:Bulletin of the Hospital for Joint Diseases 2022;80(4):252-6252 Bloom DA, Gonzalez M, Hurley ET, Kingery MT, Carter CW, Jazrawi LM, Strauss EJ. Sex-based differences in outcomes of tibial tubercle anteromedi- alization. Bull Hosp Jt Dis. 2022;80(4):252-6. Abstract Background: Previous research has demonstrated sex- based differences in patient-reported outcomes of orthopedic surgical procedures. The hypothesis of the current study was that females would have inferior patient-reported outcomes to their male peers following a tibial tubercle anteromedial- ization (AMZ) procedure for both patellofemoral instability and cartilage defects. METHODS:Patients who had undergone AMZ for isolated osteochondral defect or patellofemoral instability with a minimum follow-up time of 1 year were identified. They were then asked to complete several patient-reported outcome questionnaires that were then statistically analyzed. RESULTS:Overall, 109 patients were included in this study. Seventy-nine patients (72.5%) were female with a mean follow-up duration of 3.4 ± 2.0 years. Forty-seven females had AMZ for patellar instability while 32 females had AMZ for osteochondral defects. There were no statistically signifi- cant differences between sexes with respect to concomitant procedures performed, visual analog scale (VAS) pain score, or patient reported outcome (PRO) scores at follow-up (p > 0.05). There was no statistically significant difference with respect to outcomes between the sexes for AMZ overall and when isolating the sexes based on indication. CONCLUSION/CONCLUSIONS:This study demonstrates that female patients undergoing AMZ have short-term clinical and functional outcomes that are not significantly different to those reported in males.

INTRODUCTION/BACKGROUND:Peroneal nerve injuries are rare injuries and usually associated with multiligamentous knee injuries (MLKIs) involving one or both cruciate ligaments. The purpose of our study was to perform a multicenter retrospective cohort analysis to examine the rates of peroneal nerve injuries and to see whether a peroneal nerve injury was suggestive of a particular injury pattern. METHODS:A retrospective chart review was conducted in patients who were diagnosed with MLKI at two level I trauma centers from January 2001 to March 2021. MLKIs were defined as complete injuries to two or more knee ligaments that required surgical reconstruction or repair. Peroneal nerve injury was clinically diagnosed in these patients by the attending orthopaedic surgeon. Radiographs, advanced imaging, and surgical characteristics were obtained through a chart review. RESULTS:Overall, 221 patients were included in this study. The mean age was 35.9 years, and 72.9% of the population was male. Overall, the incidence of clinical peroneal nerve injury was 19.5% (43 patients). One hundred percent of the patients with peroneal nerve injury had a posterolateral corner injury. Among patients with peroneal nerve injury, 95.3% had a complete anterior cruciate ligament (ACL) rupture as compared with 4.7% of the patients who presented with an intact ACL. There was 4.4 times of greater relative risk of peroneal nerve injury in the MLKI with ACL tear group compared with the MLKI without an ACL tear group. No statistical difference was observed in age, sex, or body mass index between patients experiencing peroneal nerve injuries and those who did not. CONCLUSION/CONCLUSIONS:The rate of ACL involvement in patients presenting with a traumatic peroneal nerve palsy is exceptionally high, whereas the chance of having a spared ACL is exceptionally low. More than 90% of the patients presenting with a nerve palsy will have sustained, at the least, an ACL and posterolateral corner injury. LEVEL OF EVIDENCE/METHODS:IV, Case Series.

BACKGROUND/UNASSIGNED:Patients undergoing anterior cruciate ligament (ACL) reconstruction have been shown to be at risk for postoperative arthrofibrosis. Diagnostic biomarkers associated with the development of postoperative stiffness are unknown. HYPOTHESIS/UNASSIGNED:Biomarkers found in the synovial fluid at the time of surgery are associated with the development of postoperative arthrofibrosis in a cohort of patients undergoing ACL reconstruction. STUDY DESIGN/UNASSIGNED:Case-control study; Level of evidence, 3. METHODS/UNASSIGNED:Patients undergoing ACL reconstruction were prospectively enrolled. Synovial fluid was collected before surgical incision. A cohort of patients with postoperative stiffness requiring manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) was retrospectively identified. Matching of cases to controls was performed using a 1:2 pair matching algorithm. Risk factor-adjusted single-biomarker and multivariable models were used to assess the association of synovial fluid biomarkers with postoperative stiffness requiring MUA/LOA. Stepwise logistic regression controlling for clinical risk factors was used to identify biomarkers that are possible predictors of postoperative stiffness. RESULTS/UNASSIGNED:= .046). CONCLUSION/UNASSIGNED:Higher concentrations of synovial fluid biomarkers bFGF and RANTES were associated with increased risk for stiffness requiring intervention after ACL reconstruction. Interleukin 6 (IL-6), vascular endothelial growth factor A (VEGF-A), tissue inhibitor of metalloproteinases 1 (TIMP-1), interleukin 1 receptor antagonist (IL-1RA), matrix metalloproteinase 3 (MMP-3), monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein 1B (MIP-1B) were not associated with the development of postoperative arthrofibrosis.