Faculty Bibliography

BACKGROUND:Inflammatory biomarkers in an injured knee have been shown to predict outcomes, yet the role of the subsequent systemic inflammatory response to injury remains poorly understood. PURPOSE/OBJECTIVE:To investigate whether synovial fluid (SF) biomarkers from the contralateral uninjured knee could predict long-term patient-reported outcomes (PROs) for the operative knee in patients undergoing arthroscopic knee surgery. STUDY DESIGN/METHODS:Case series; Level of evidence, 4. METHODS:This retrospective analysis included patients undergoing knee SF aspiration before arthroscopy with ≥8 years of follow-up. SF was aspirated from both the injured and healthy contralateral knees, and concentrations of 10 pro- and anti-inflammatory biomarkers were quantified. Patients completed visual analog scale (VAS) for pain score, Lysholm, Tegner, and Knee injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS) surveys preoperatively and at the final follow-up. Stepwise linear regression was performed to identify the most significant predictor(s) of PRO scores utilizing log-normalized contralateral biomarker concentration, age, body mass index, injury type, and Outerbridge grade as covariates. Concentrations from the contralateral knee were also compared with the injured knee to assess for correlations. RESULTS:= .006) score at the final follow-up. Contralateral concentrations of monocyte chemotactic protein 1, macrophage inflammatory protein 1β, vascular endothelial growth factor, and TIMP-1 were correlated with levels in the operative knee but at significantly lower concentrations. CONCLUSION/CONCLUSIONS:SF biomarker levels in the contralateral uninjured knee at the time of arthroscopy were predictive of long-term outcomes for the operative knee. Increased levels of pro-inflammatory biomarkers were predictive of worse outcomes, while anti-inflammatory cytokines predicted improved scores. These results suggest that unilateral knee injury can result in a broader systemic inflammatory response that influences long-term outcomes in patients.

High tibial osteotomy (HTO) is commonly used to correct excessive varus knee malalignment. Varus alignment places increased loads on the medial tibiofemoral joint, accelerating medical compartment degeneration. This article explores the benefits of HTO in correcting varus deformities and addresses concomitant procedures for managing medial compartment pathology, offering practical guidance for surgeons to optimize outcomes and restore knee function.

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.

The knee is a complex joint composed of a combination of osseous, musculotendinous, ligamentous, neurovascular, and intra-articular structures, which must be taken into consideration when performing surgical approaches, whether it be for trauma, replacement, or joint preservation surgery. A wide variety of surgical approaches exist for exposure of the lateral side of the knee, including approaches to the distal femur, knee joint, and proximal tibia. Care must be taken to choose the appropriate approach depending on the procedure being performed to best preserve and protect important neurovascular structures. This review thoroughly describes the most frequently used surgical approaches to the lateral knee. The common themes and anatomical considerations presented in this review, in combination with continued experience, can provide surgeons with familiarity with various ways of accessing the knee joint.

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 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.

BACKGROUND:The purpose was to investigate whether pain, function, satisfaction, or return to play (RTP) differs between sexes postoperatively in those undergoing medial patellofemoral ligament (MPFL) reconstruction for patellar instability. METHODS:A review of patients who underwent an MPFL reconstruction for patellar instability was performed. Kujala score, visual analogue scale (VAS), patient satisfaction, willingness to undergo surgery again, revisions, RTP, and MPFL-return to sport after injury (MPFL-RSI) score were evaluated. Clinical outcomes were compared between sexes. RESULTS:Our study included 141 knees that underwent MPFL reconstruction, and the population was 69.5% female. Postoperatively, the mean VAS score at rest was 1.0 ± 1.7 in male patients and 1.6 ± 2.1 in female patients (P = .0963). The mean Kujala score was 88.8 ± 13.3 and 83.5 ± 16.1 for male and female patients, respectively (P = .1062). Overall, there was a significant difference in RTP, with male patients returning at higher rates (58.1 vs. 33.3%, P = .0479). The mean VAS score during activity was significantly lower in male patients at 1.8 compared with female patients at 3 (P = .016). The MPFL-RSI score was also significantly worse in female patients (69.5 vs. 55.6, P = .0098). Although female patients had slightly higher rates of recurrent subjective instability (14.3 vs. 11.7%) and re-dislocation (2 vs. 0%), the difference was not statistically significant (P > .05). CONCLUSION/CONCLUSIONS:Female patients had worse clinical outcomes than male patients undergoing MPFL reconstruction for patellar instability, with significantly lower rates of RTP, VAS score during sport, and MPFL-RSI scores with a trend toward lower Kujala score and VAS score.

BACKGROUND:To compare clinical outcomes, return to activities, and rates of revision surgery following arthroscopic glenoid labral repair in patients who were prescribed NSAIDs as part of their postoperative pain management regimen versus those who were not. METHODS:Patients aged 18-55 who underwent primary arthroscopic labral repair at a single academic institution from the years 2016-2020 were retrospectively reviewed. Patients who underwent concomitant rotator cuff repair, remplissage, or did not have minimum 2-year postoperative follow-up were excluded. Patients who were prescribed postoperative NSAIDs were matched 1:1 to those who were not based on age, sex, BMI, and number of suture anchors. Outcomes were assessed using the Visual Analog Scale (VAS) for pain, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Simple Shoulder Test (SST), Single Assessment Numeric Evaluation rating (SANE), and satisfaction. Pre-injury sport and work activity information were recorded. RESULTS:Of 269 eligible patients, 224 patients were included. Patients prescribed NSAIDs postoperatively had similar levels of pain (1.2 vs 1.0, p=0.527) and function (ASES: 90.8 vs 89.9, p=0.824; SST: 91.9 vs 90.6, p=0.646; SANE: 83.8 vs 85.3, p=0.550) compared to those who were not. Rates of revision surgery (2.7% vs 0.9%, p=0.622) and recurrent instability (5.4% vs 8.0%, p=0.594) were similar between NSAID and non-NSAID groups. Rates of return to sport (83.5% vs 77.8%, p=0.318) and return to pre-injury level (59.3% vs 61.6%, p=0.177) were similar between NSAID and non-NSAID groups. Prescription of postoperative NSAIDs was not associated with delayed return to sport (OR:1.47, 95%CI [0.68,3.18], p=0.327) or return to work (OR:0.56, 95%CI [0.14,2.28], p=0.416). CONCLUSIONS:Patients who were prescribed NSAIDs as a part of a postoperative pain management regimen following primary arthroscopic labral repair for glenohumeral instability had similar patient-reported outcomes, revision rates, and rates of return to pre-injury activities compared to those who were not prescribed NSAIDs.

BACKGROUND:Risks associated with graft transplantation due to donor-recipient sex differences have been reported in whole organ transplantation literature but are not well-described in meniscal allograft transplantation (MAT). This study assessed the effect of donor-recipient sex mismatch on patient-reported outcomes (PROs) following MAT. METHODS:A retrospective review of patients <50 years of age that underwent unicompartmental MAT from 2010 to 2023 at a single institution with minimum 2-year follow up was conducted. Exclusion criteria were revision procedures or insufficient donor information. PROs collected included: Knee Injury and Osteoarthritis and Outcome Score (KOOS), Visual Analog scale (VAS) for pain and satisfaction, and return to sport (RTS). PROs were compared between donor-recipient graft matching groups (same-sex (SS) or different-sex (DS)) and by donor sex. RESULTS:, and follow up of 73.4 ± 29.2 months. Donors were mostly male (77.2 %). Thirty-six patients (63.3 %) received SS grafts and 21 (36.8 %) received DS grafts. There were no significant differences between groups in KOOS subscores, VAS pain, satisfaction scores, or RTS rates (P > 0.05). Donor sex also showed no association with PROs. Linear and logistic regression models controlling for age, BMI, and average follow up demonstrated that graft mismatch was not associated with KOOS scores, RTS, or graft failure. Decreasing patient age was associated with improved KOOS-pain (β: -0.376; 95 % CI (-1.892, -0.155); P = 0.022). CONCLUSIONS:Patients that undergo MAT with grafts from a different sex had similar outcomes to patients receiving grafts from a donor of the same sex. Sex-mismatch was not associated with functional outcomes or RTS. The results of this paper support the use of geometrically matched donor grafts, independent of donor sex, which should expand available graft options when matching a patient for MAT.

PURPOSE/OBJECTIVE:To determine whether chondroplasty for isolated medial patellar facet lesions produces similar clinical outcomes compared to patients without patellofemoral cartilage lesions in the setting of medial patellofemoral ligament (MPFL) reconstruction for patellar instability. METHODS:We retrospectively identified patients who underwent MPFL reconstruction with or without tibial tubercle osteotomy (TTO) from 2015 to 2020 with minimum 2-year follow-up. Operative reports detailed patellofemoral articular surfaces and Outerbridge grade. Exclusion criteria were: prior knee surgery, multiple lesions, concomitant cartilage repair, trochleoplasty, or meniscus repair. Patients with isolated medial facet lesions (case) were propensity matched to patients without patellofemoral cartilage injury (control) by age, sex, BMI, and concomitant TTO. Clinical outcomes were evaluated using the Kujala score, Tegner activity scale, and the Visual Analog Score (VAS) for pain. RESULTS:Of 79 eligible patients, 59 (74.7%) completed all surveys, and 40 patients (8 M and 32 F) were matched 1:1 with mean 4.1-year (range: 2.1-8.5) follow-up, including 20 patients with medial facet lesions (5 grade II, 6 grade III, and 9 grade IV). There were no significant differences between groups with respect to Kujala score (85.2 vs 84.6, p = 0.906), Tegner (5.7 ± 2.6 vs 4.9 ± 3.0, p = 0.924), or VAS pain score (12.4 ± 20.1 vs 16.5 ± 23.9, p = 0.718). Chondral lesion size at the index procedure was not significantly correlated with pain (R = - 0.06, p = 0.816) or Kujala score (R = - 0.67, p = 0.779). CONCLUSION/CONCLUSIONS:Chondroplasty for isolated medial patellar facet lesions led to similar clinical outcomes to patients with intact patellofemoral articular cartilage at a minimum of 2 years following MPFL reconstruction. These findings support conservative management of isolated medial facet lesions without need for cartilage restoration procedures. LEVEL OF EVIDENCE III/METHODS:Retrospective comparative cohort study.