Faculty Bibliography

OBJECTIVE:An important part of clinical training is learning how to identify and prevent hospital-acquired conditions or injuries. Despite this, there are few standardized methods in graduate medical education (GME) for teaching and assessing resident patient safety skills. Residents often do not report safety events, and increasing resident engagement can positively impact patient safety. In the current study, we sought to apply such a tool in gauging the capacity of orthopedic surgery interns at a large academic medical center to identify patient safety hazards and begin a discussion regarding the management of potential patient safety issues. METHODS:A total of 27 orthopedic surgery interns at a single large academic medical center participated in the current observational study divided into two distinct groups in the summers of 2016 and 2017. A patient room was simulated with a training mannequin lying supine in a hospital bed. A mock patient chart and handoff were created in the electronic medical record (EMR) on the bedside computer. Patient safety hazards and errors of care were placed around the room and in the EMR, including several derived from the Joint Commission's National Patient Safety Goals. Each intern was given a maximum of 20 minutes to identify as many of the simulated patient safety hazards as possible. A debrief was conducted at the end of the exercise to discuss their responsibility to speak up when hazards are identified in a non-simulated patient room. For analysis, the hazards were distributed into four categories: room organization, EMR, patient care, and white board. Each intern's individual score (number of complete identifications/total number of hazards) and the group's performance as a whole in each category were calculated. RESULTS:The mean individual score was 51.54% (26.67% to 70.00%) in group A and 40.41% (25.71% to 54.29%) in group B. In group A, room organization hazards were identified more than any other category (74.62%), followed by patient care errors (40.38%), EMR hazards (40.17%), and white board errors (38.46%). In group B, room organization was identified the most (57.74%), followed by EMR (50%), and patient care and white board hazards (28.57% each). Certain critical safety hazards were identified by a small number of interns. For example, the inadequate handoff was only identified by four interns in each group. CONCLUSIONS:Hazards related to room cleanliness were easier to identify than hazards related to specific errors in patient care. A wide variation in the identification of critical safety issues was observed among the trainees assessed. This type of simulated educational experience provides important opportunities for resident-specific education in the realm of patient safety and health care quality.

PURPOSE/OBJECTIVE:To determine if measurement of leg adipose tissue area by MRI is a better predictor of post-operative clinical outcome compared to body mass index (BMI) following arthroscopic meniscectomy. METHODS:Patients that underwent an arthroscopic partial meniscectomy between 2011 and 2016 were identified and a retrospective chart review was performed. Patients with additional knee pathology other than a meniscal tear with or without associated articular cartilage injury were excluded. Leg adipose tissue and muscle area measurements at the level of the knee joint were performed for patients on their preoperative axial magnetic resonance imaging (MRI) study and adipose-to-muscle area ratio (AMR) was calculated. Correlations among AMR, BMI, and post-operative clinical outcomes were compared. RESULTS:compared to those with no cartilage damage. AMR was also significantly correlated to age and BMI. CONCLUSIONS:The current study demonstrates that compared to BMI, leg adiposity as determined by the ratio of adipose tissue to muscle area on axial MRI (AMR), is a stronger predictor of functional outcome following meniscectomy. This suggests a role of obesity in the progression of OA beyond the increased joint forces associated with increased BMI. LEVEL OF EVIDENCE/METHODS:IV, retrospective case series.

BACKGROUND:/UNASSIGNED:Changes in the joint microenvironment after an injury to the articular surface of the knee have been implicated in the pathogenesis of osteoarthritis. While prior studies focused on changes in this microenvironment after anterior cruciate ligament ruptures, few have explored the biomarker changes that occur in the setting of meniscal injuries. PURPOSE:/UNASSIGNED:To determine whether meniscal injury results in significant alterations to synovial fluid biomarker concentrations as compared with noninjured contralateral knees. Additionally, to explore the relationship between synovial fluid biomarkers and the degree of cartilage injury seen in these patients. STUDY DESIGN:/UNASSIGNED:Cross-sectional study; Level of evidence, 3. METHODS:/UNASSIGNED:Patients undergoing surgery for unilateral meniscal injury were prospectively enrolled from October 2011 to December 2016, forming a cohort that had synovial fluid samples collected from both the injured knee and the contralateral uninjured knee at the time of meniscal surgery. Synovial fluid samples were collected just before incision, and the concentrations of 10 biomarkers of interest were determined with a multiplex magnetic bead immunoassay. The concentrations of synovial fluid biomarkers from the operative and contralateral knees were compared. Additionally, the synovial fluid biomarker concentrations of operative knees from patients with associated high-grade cartilage lesions were compared with those with low-grade lesions. RESULTS:/UNASSIGNED:The current analysis included synovial fluid samples from 82 knees (41 operative and 41 contralateral) from 41 patients undergoing arthroscopic surgery to treat a symptomatic meniscal injury. The mean ± SD age of patients was 49.86 ± 11.75 years. There were significantly greater concentrations of 4 of the 5 proinflammatory biomarkers (IL-6, MCP-1, MIP-1β, and MMP-3) in symptomatic knees as compared with asymptomatic knees when controlling for the duration of symptoms, body mass index, age, and the random effects of by-patient variability. In the injured knees, associated high-grade cartilage lesions were predictive of elevated MCP-1, MIP-1β, and VEGF levels. Low synovial fluid concentration of TIMP-1 or a greater ratio of MMP-3 to TIMP-1 was associated with the presence of synovitis. Increasing age was found to be an independent predictor of increased IL-6, MCP-1, and VEGF concentrations in the setting of symptomatic meniscal injury. CONCLUSION:/UNASSIGNED:The authors identified 4 proinflammatory synovial fluid biomarkers whose concentrations were significantly different after meniscal injury as compared with uninjured contralateral knees. Furthermore, they describe the effects of associated cartilage damage, synovitis, and patient age on biomarker concentrations.

With our aging population desiring to remain active, the incidence and costs associated with managing knee pain from both acute injury and symptomatic knee osteoarthritis continue to dramatically increase. Current treatment methods fall short with respect to their ability to improve the intra-articular environment and restore normal joint homeostasis. With increasing basic science and clinical evidence showing efficacy, cell-based therapies such as bone marrow concentrate (BMC) hold promise as a nonsurgical joint preserving treatment approach. BMC has inherent advantages over other treatments commonly used for various knee pathologies because it is a point-of-care orthobiologic product that uniquely and simultaneously delivers growth factors, anti-inflammatory proteins, and mesenchymal stem cells. There is increasing evidence for the use of BMC for repair of focal cartilage defects and for the treatment of generalized knee pain. However, continued high-quality studies are necessary for the clinical utility of BMC to be critically assessed with particular attention paid to appropriate patient selection, standardized aspiration, and processing and reporting of both functional and imaging-based outcomes.

PURPOSE/OBJECTIVE:To utilize MRI to assess the relationship between BMI, peripheral soft tissue composition about the knee, and surgical outcomes in patients undergoing primary ACL reconstruction. It was hypothesized that a fatty periarticular soft tissue composition may be better than BMI at predicting poor outcomes after ACL reconstruction. METHODS:Fifty-eight patients who underwent primary acute ACL reconstruction were identified from the surgical database and their data were retrospectively reviewed. Patients were selected based on availability of 2-year IKDC outcome scores, BMI data, and preoperative MRI studies. To approximate peripheral soft tissue composition, novel measurements of axial MRI images were employed using PACS ROI measurement tool. Relationships were assessed between IKDC outcome scores and measures of body habitus including BMI, total knee area, knee fatty-connective tissue area, and fatty-connective tissue to bone size ratio. RESULTS:(range 18.5-36.9). Median IKDC score was 81.0 (range 46-100). BMI was correlated with total knee area (R = 0.72) and periarticular fat (R = 0.53). Neither continuous BMI (n.s.) nor total knee area (n.s.) was predictor of IKDC outcomes scores. Periarticular fatty-connective tissue trended towards predicting negative outcomes (n.s.). Periarticular fatty-connective tissue to bone size ratio was a significant negative predictor of IKDC scores (p = 0.03). Patients with more fat than bone on axial MRI (ratio > 1, N = 34) reported a lower mean IKDC score compared to patients with a ratio < 1 (N = 24) (77.2 vs. 87.7, p = 0.0028). The top quartile (N = 14) of these ratios reported a mean IKDC score of 68.9, compared to 87.3 of the bottom quartile (p = 0.0001). CONCLUSIONS:Periarticular soft tissue composition, as approximated by the novel MRI analysis of this study, is a better predictor of outcomes following ACL reconstruction than is BMI. This information can be utilized in guiding surgeon and patient expectations following surgery, either via a direct application of these measurements or heightened awareness of the importance of peripheral body habitus. LEVEL OF EVIDENCE/METHODS:III.

OBJECTIVES/OBJECTIVE:What patient characteristics and injury factors predict decreased knee range of motion (ROM) following operative management of tibial plateau fractures? DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over 11 years, tibial plateau fractures at a single academic institution were prospectively followed. A total of 266 patients were included in this study. INTERVENTION/METHODS:Surgical repair of tibial plateau fractures and secondary interventions due to arthrofibrosis. MAIN OUTCOME MEASURE/METHODS:Clinical outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA) and range of motion (ROM) at 3-month, 6-month and long-term follow-up. Secondary outcomes were considered as the need for a subsequent procedure due to arthrofibrosis. RESULTS:At 3-month follow-up, the mean ROM was 113°. By long-term follow-up (mean=17 months), the mean ROM improved to 125°. Independent predictors of decreased knee ROM were the following: At 3-month follow-up, open fractures (P=0.047), application of a knee spanning external fixator (P=0.026), orthopaedic poly trauma (P=0.003), and tibial spine involvement (P=0.043). At long-term follow-up, non-Caucasian ethnicity (P=0.003), increasing age (P=0.003), and a deep infection (P=0.002). Ten patients (3.7%required a secondary procedure for arthrofibrosis. There was a significant improvement in the knee ROM (P<0.001) and functional outcomes (P=0.004) following the intervention. CONCLUSIONS:At long-term follow-up, independent predictors of decreased knee ROM were non-Caucasian ethnicity, increasing age, and sustaining a post-operative complication of a deep infection. Secondary interventions were reliable treatments for arthrofibrosis. LEVEL OF EVIDENCE/METHODS:Prognostic level III.

CASE/METHODS:A 37-year-old woman presented with repetitive catching of the right knee 4 weeks after implantation of a 2-plug osteochondral autograft into the medial femoral condyle. The workup indicated that the symptoms were secondary to patellar engagement with the donor sites of the lateral aspect of the trochlea. She subsequently underwent osteochondral allograft implantation, resulting in painless, full range of motion with complete resolution of the mechanical symptoms. CONCLUSION/CONCLUSIONS:It is important to consider donor-site morbidity following osteochondral autograft implantation, especially in patients with a relatively narrow distal aspect of the femur. Implantation of osteochondral allograft plugs in the symptomatic donor site is a feasible management option for this rarely reported complication.

PURPOSE: The purpose of the current study was to evaluate the short-term results of meniscal root repair surgery, assessing clinical and radiographic outcomes, utilizing MRI to assess root healing and extent of post-operative extrusion. METHODS: This was a single-center, retrospective study evaluating patients who had undergone a medial meniscus posterior root repair using a transtibial pullout technique with two locking cinch sutures. Demographic data were collected from patient charts. Clinical outcomes were assessed with pre- and post-operative IKDC and Lysholm scores. Pre-op scores were taken at the patients' initial clinical visit, mean 1.55 months prior to surgery (+/- 1.8 months, min 0.3, max 7.3). Radiographic outcomes were assessed with MRI evaluation of root healing, meniscal extrusion, and cartilage degeneration using ICRS criteria. Tunnel placement was evaluated and compared to the anatomic footprint. RESULTS: Eighteen patients (47.2 years +/- 11.9) were evaluated at mean follow-up of 24.9 months (+/- 7.2, min 18.4, max 35.6). The IKDC score significantly increased from 45.9 (+/- 12.6) pre-operatively to 76.8 (+/- 14.7) post-operatively (p < 0.001). Lysholm scores also increased from 50.9 (+/- 7.11) to 87.1 (+/- 9.8) (p < 0.001). Mean tunnel placement was 5.3 mm (+/- 3.5, range 0-11.8) away from the anatomic footprint. Mean extrusion increased from 4.74 mm (+/- 1.7) pre-operatively to 5.98 (+/- 2.8) post-operatively (p < 0.02). No patients with > 3 mm of extrusion on pre-operative MRI had < 3 mm of extrusion on post-operative MRI. Both medial femoral condyle and medial tibial plateau ICRS grades worsened significantly (p < 0.02 and p < 0.01, respectively). On MRI, one root appeared completely healed, 16 partially healed, and one not healed. CONCLUSION: Patients treated with the transtibial suture pull-out technique with two locking cinch sutures had improved clinical outcomes, but only partial healing in the majority of cases, increased extrusion, and progression of medial compartment cartilage defect grade on follow-up MRI. Patients should be counseled that although clinical outcomes in the short term may be optimistic, long-term outcomes regarding progression to degenerative arthritis may not be as predictable. CLINICAL LEVEL OF EVIDENCE: III.