Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose was to evaluate long-term functional outcomes, including patient-reported outcomes (PROs), strength recovery and complications, following surgical repair of complete proximal hamstring avulsions at a minimum 5-year follow-up. We hypothesised that patients would demonstrate sustained functional outcomes with minimal long-term strength deficits. METHODS:Patients undergoing surgical repair of complete proximal hamstring tendon avulsions at a single institution with ≥5-year follow-up were included. Bilateral injuries were excluded. Data collected included demographics, perioperative characteristics, PROs, isokinetic hamstring strength testing, hip range of motion (ROM), thigh circumference and any postoperative posterior thigh dysesthesia. RESULTS:The cohort included 35 patients who completed PRO surveys, and 17 who underwent physical exams at a 7.6-year follow-up ± 1.8. Mean age at surgery was 51.3 years ± 9.9, with a 54% male predominance. All tears were complete with a mean tendon retraction of 4.5 cm ± 3.6. Regarding chronicity, 22 patients (63.0%) had acute injuries (<6 weeks from injury to operation) and 12 (34%) had chronic injuries (>6 weeks from injury to operation); one was unreported. The mean duration of symptoms prior to surgery was 111 days ± 219. The mean isokinetic knee flexion torque deficit was 9.5% ± 23.1. The thigh circumference deficit was <1.0% ± 2.1. Mean hip extension asymmetry was 3.5% ± 42.3, and hip flexion asymmetry was <1.0% ± 6.4. There were two reoperations (11.1%). The mean international hip outcome tool (iHOT-12) was 83.3 ± 16.5, lower extremity functional scale (LEFS) 73.8 ± 10.6 (range 32-80), Marx Activity Scales 6.1 ± 5.5, visual analogue scale (VAS) pain 1.4 ± 2.5. The return to sport (RTS) rate was 78%, with mean satisfaction 4.3 ± 1.5. CONCLUSION/CONCLUSIONS:Surgical repair of proximal hamstring tendon avulsions demonstrates long-term durability, with minimal strength or circumference deficits, low complication rates and high RTS and satisfaction maintained at mean 7.6- year follow-up. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND/UNASSIGNED:Social determinants of health disparities (SDHD), encompassing environmental, health care, social, educational, and economic factors, are known to increase the risk of complications after various orthopaedic procedures. However, their impact on tibial tubercle osteotomy (TTO) outcomes remains undefined. HYPOTHESIS/PURPOSE/UNASSIGNED:This study aimed to compare complication risks and health care utilization within 90 days and 1 year of primary TTO in patients with versus without SDHD. It was hypothesized that SDHD patients would show higher odds of health care utilization and complications. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:Adult (>17 years) patients who underwent primary TTO from January 2010 to April 2023 were identified using the PearlDiver M170 database. The exclusion criteria included inactivity within 90 days after TTO or a history of neoplasm or infection within 90 days before the procedure. The overall cohort was divided into SDHD and non-SDHD groups. Patient characteristics-including age, sex, Elixhauser Comorbidity Index, obesity, type 2 diabetes mellitus, tobacco or nicotine use, and substance use disorder-were abstracted. Patients without versus with SDHD were matched (2:1) based on all demographic variables. Moreover, 90-day and 1-year complications were identified and compared using the Pearson chi-square test and multivariable logistic regression, adjusted for demographic variables. RESULTS/UNASSIGNED:< 0.05). CONCLUSION/UNASSIGNED:The present study found that SDHD patients were associated with increased odds of ED visits, readmissions, VTE, and UTI after primary TTO. Additionally, SDHD patients demonstrated higher odds of revision TTO and nonunion. Further research is needed to identify the root causes of these differences, enabling targeted strategies to reduce future outcome inequities associated with SDHD.

PURPOSE/OBJECTIVE:Evaluate the association between posterior tibial slope and survivorship following meniscal allograft transplantation and to determine whether a slope threshold is associated with increased risk of graft failure at short-term follow-up. METHODS:A retrospective cohort study was performed of patients who underwent meniscal allograft transplantation from 2011 to 2024 with postoperative lateral radiographs and a minimum 1-year follow-up. Posterior tibial slope was measured using the circle-of-best-fit method. Graft failure was defined as revision surgery, conversion to arthroplasty and meniscal repair and/or meniscectomy of the allograft. Multivariable logistic regression and Cox proportional hazards modelling were used to evaluate the association between slope and failure. Receiver operating characteristic analysis with Youden's index was used to identify an optimal posterior tibial slope threshold, and Kaplan-Meier analysis assessed graft survivorship. RESULTS:Eighty-three meniscal allograft transplantations were included (age 30.7 ± 8.6 years, 55.4% male) with a mean follow-up of 4.4 ± 3.1 years. Twenty-four clinical graft failures (28.9%) occurred at a mean time of 2.3 ± 1.9 years postoperatively. Mean posterior tibial slope was 11.3° ± 3.0° and was not significantly associated with failure when analyzed as a continuous variable (OR 1.1, 95% CI 1.0-1.4, p = 0.174). Receiver operating characteristic analysis identified a threshold of 11.9°, above which survivorship was reduced. Kaplan-Meier analysis demonstrated decreased survival for slope ≥11.9° (log-rank p < 0.001). Compartment-specific analyses demonstrated similar patterns. CONCLUSIONS:Although posterior tibial slope was not independently associated with graft failure when modelled continuously, a threshold of approximately 11.9° was associated with reduced meniscal allograft transplantation survivorship. These findings suggest a potential threshold-dependent relationship between sagittal alignment and graft survival. LEVEL OF EVIDENCE/METHODS:Level III.

PURPOSE/OBJECTIVE:Although bone-patellar tendon-bone autograft is widely used for anterior cruciate ligament reconstruction, it is often associated with anterior knee pain resulting from the residual patellar bone defect. Various materials have been proposed to fill this void, yet no consensus exists regarding the optimal choice. This study compared three commonly used patellar harvest site bone void fillers and assessed their impact on the frequency and severity of anterior knee pain. We hypothesised that calcium phosphate cement would result in lower postoperative anterior knee pain compared with autologous bone graft and demineralised bone matrix (DBM) due to its compressive modulus approximating cancellous bone. METHODS:Skeletally mature patients undergoing primary anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft were enrolled. Exclusion criteria included age under 18, prior anterior cruciate ligament reconstruction, multiligament knee injury, coronal malalignment exceeding three degrees of varus or valgus, or less than 1 year of follow-up. Participants were randomly assigned to one of three groups: (1) autologous bone graft, (2) calcium phosphate cement or (3) DBM. Patient-reported outcomes were collected preoperatively and at 1 week, 6 weeks, 3 months, 6 months, 9 months and 12 months postoperatively. Analysis of variance and chi-square tests were used for statistical analysis. RESULTS:After applying exclusion criteria, 148 patients were included in the final analysis. No significant differences in visual analog scale pain scores were observed between cohorts at any postoperative interval (12-month, p = 0.598). Similarly, Kujala and Knee injury and Osteoarthritis Outcome scores did not differ significantly among the three cohorts at any time point (12-month, p = 0.878, p = 0.366). CONCLUSIONS:Filling the patellar harvest site defect with autologous bone graft, calcium phosphate cement, or DBM resulted in similar postoperative anterior knee pain following anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft. LEVEL OF EVIDENCE/METHODS:Level I.

Osteotomies around the knee-including distal femoral osteotomies, high tibial osteotomies, and tibial tubercle osteotomies-are technically demanding procedures that are generally safe, with relatively low overall complication rates. However, complications do occur and can pose significant challenges, with substantial implications for patient outcomes. Awareness of potential complications and meticulous surgical technique are, therefore, essential to minimizing risk. This review highlights the most clinically relevant complications unique to knee osteotomies. These include vascular injury, hinge and shingle fractures, delayed union or nonunion, femur and tibia fractures, and infection. For each complication, contributing patient and surgical factors are examined, along with an emphasis on strategies for prevention and proposed treatment management algorithms. By combining preventive strategies with structured management guidance, this review aims to serve as a practical reference for optimizing outcomes and reducing the morbidity associated with knee osteotomies.

Articular cartilage lesions of the knee, ranging from focal defects to tricompartmental osteoarthritis, present significant clinical challenges because of cartilage's limited regenerative capacity. It is important to highlight modern surgical advancements in the treatment of chondral pathology beyond injection therapy, traditional osteotomies, and arthroplasty options. Surface- and cell-based repair techniques, including matrix-induced autologous chondrocyte implantation, offer improved long-term outcomes, with emerging fourth-generation variants facilitating single-stage arthroscopic implantation. Off-the-shelf cartilage repair strategies, such as particulated juvenile cartilage, micronized allografts, and viable cartilage allografts, represent promising alternatives that bypass the need for two-stage procedures. For osteochondral defects, osteochondral autograft transfer and fresh allograft transplantation remain the gold standard, although decellularized and cryopreserved viable allografts are under investigation. Recently approved artificial osteochondral scaffolds, such as Agili-C, offer an FDA-cleared, acellular biphasic implant with promising midterm results. For patients with malalignment-associated osteoarthritis, patient-specific instrumentation in high tibial and distal femoral osteotomies enhances accuracy, particularly in biplanar corrections, and reduces intraoperative variability. Novel load-sharing implants, such as fiber-reinforced rafting nails and the MISHA knee system, provide less invasive alternatives to osteotomy, showing early success in reducing medial compartment load and improving functional outcomes. There is an expanding arsenal of biologically and biomechanically innovative treatments for articular cartilage restoration and osteoarthritis management.

Osteotomies around the knee are an effective procedure that shifts the weight-bearing axis from the pathologic side to the uninvolved side to alleviate pain, unload cartilage transplantations, slow down the progression of arthritis, and protect ligament reconstructions. The advancement in plates from nonlocking to locking have increased the stability of constructs to allow for early mobilization and maintained corrections. Further developments with patient-specific instrumentation have made these techniques more reproducible and accurate. Bone grafting and biologics remain a topic of debate but likely a helpful adjuvant in the context of larger corrections or joint preservation surgeries.

The need to perform revision anterior cruciate ligament reconstruction (ACLR) has several etiologies such as infection, arthrofibrosis, cyclops lesions, and graft failure, which should be distinguished before revision ACLR. Even the definition of graft failure varies within the literature. ACLR graft failure falls into modifiable, surgeon-controlled factors, such as tunnel position, graft choice, and alignment, and nonmodifiable factors, such as patient age, tissue quality, or secondary traumatic reruptures. In this review, we describe a facile framework for the workup of modifiable ACLR graft failure.

BACKGROUND:The coronavirus disease (COVID)-19 pandemic led to shutdowns of organized sporting activity. Prolonged periods of inactivity lead to deconditioning and may increase one's risk for injury. The purpose of this study was to quantify the incidence of anterior cruciate ligament (ACL) injuries requiring reconstruction during the peripandemic period. METHODS:The electronic medical record of a single university teaching hospital was queried for current procedural terminology codes for ACL reconstructions (ACLR; 29,888) from January 2017 to December 2022. Date of injury was collected from clinic notes if it could be estimated within 2 weeks. The years 2017-2019 were used as a proxy for "pre-COVID," the year 2020 for "COVID," and the years 2021-2022 for "post-COVID." RESULTS:In total, 2178 patients had an ACL injury and underwent reconstruction from 2017 to 2022. Date of injury could be estimated for 1,617 patients (51.3% male, average age 30.9 ± 11.0 years). There was a decrease in the number of ACL surgeries observed during the COVID era, followed by a post-COVID rebound. The proportion of female patients who underwent ACLR increased from the pre-COVID to the post-COVID period (42.7% vs. 49.4%, P < .001). The proportion of patients with American Society of Anesthesiologists (ASA) score 2 increased from the COVID to the post-COVID period in relation to the proportion of patients with ASA score 1 (P = .007). CONCLUSION/CONCLUSIONS:ACLRs decreased at our institution during the COVID-19 pandemic, followed by an increase in ACLRs from 2021 to 2022. The proportion of female patients and patients with higher ASA scores increased in the post-COVID era.

BACKGROUND:The COVID-19 pandemic led to increased sedentary behavior and body mass index during 2020, which may decondition musculotendinous units and lead to increased risk for injury. As patients return to pre-COVID levels of activity, we hypothesize that there will be a resultant rebound increase in tendon ruptures. LEVEL OF EVIDENCE/METHODS:III, descriptive epidemiology study. METHODS:The electronic medical record was queried for current procedural terminology codes for tendon ruptures (Achilles, patella, quadriceps, hamstring, distal biceps, triceps, and pectoralis major) from January 2017 to December 2021 at a single academic urban center. Data were reviewed to ensure only acute tendon rupture repairs were included. The years 2017-2019 were used as a proxy for pre-COVID rates, 2020 as a proxy for the COVID quarantine, and 2021 as a proxy for "post-COVID" activity. Univariate analysis was performed for comparative data. RESULTS:A total of 1,879 patients (82.8% male, mean age 47.8 years) who sustained tendon injuries and underwent surgical repair were identified. There were 589 (31.3%) Achilles tendon repairs, 181 (9.6%) patella tendon repairs, 414 (22.0%) quadriceps tendon repairs, 100 (5.3%) hamstring tendon repairs, 397 (21.1%) distal biceps repairs, 105 (5.6%) triceps repairs, and 93 (4.9%) pectoralis tendon repairs. The total number of tendon injuries per year was 2017-357 (19.0%), 2018-380 (20.2%), 2019-380 (20.2%), 2020-308 (16.4%), and 2021-454 (24.2%). The rates in 2017, 2018, and 2019 were within 1% of each other, but there were a 3.8% decrease in rate of tendon injuries from 2019 to 2020 and a 7.8% increase in rate of tendon injuries from 2020 to 2021. When analyzed by quarter, a linear regression model demonstrated a statistically significant increase in case counts over the period from Q2 2020 to Q2 2021 (β = 21.20; 95% confidence interval = 13.62-28.78, P-value < .01). CONCLUSIONS:A "COVID rebound" of tendon rupture repairs in 2021 from a prolonged period of inactivity during 2020 occurred at a single academic center. As patients return to pre-COVID levels of activity that may be unsuitable to their deconditioned state, healthcare providers should counsel patients appropriately on return to activity or sport following long periods of induced inactivity.