Faculty Bibliography

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.

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.

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.

Sharps-related injuries represent a significant occupational hazard to orthopedic surgeons. Despite increased attention and targeted interventions, evidence suggests that the majority of incidents continue to go unreported. The purpose of this study was to examine the incidence, attitudes, and factors that affect the reporting of sharps injuries among orthopedic surgery residents at a large academic teaching hospital in an effort to increase reporting rates and design effective interventions. This study administered an anonymous cross-sectional survey regarding intraoperative sharps exposures to current orthopedic house staff, with an 87% (54/62) response rate. Overall, 76% of surveyed residents (41/54) had at least one sharps exposure during residency. The majority of these incidents (55%) were never reported. The most common reason cited for not reporting was a "perception of low risk." Residents whose exposures were witnessed by others on the surgical team were more likely to report the incident (57% vs. 23%, p = 0.043), suggesting that peer pressure acts to improve reporting rates. While the implementation of a "needlestick hotline" and increased education has led to improved reporting rates at our institution, further improvements aimed at reducing unwitnessed incidents, and therefore unreported incidents, could comprise an increased emphasis on surgical team vigilance, positive peer pressure, the incorporation of sharps-specific surgical debriefing statements and anonymous tip lines.

PURPOSE OF REVIEW/OBJECTIVE:The purposes of this review are to (1) discuss the epidemiology and workup of the rare posterior cruciate ligament (PCL) avulsion fracture, (2) review the indications for nonoperative and operative management of patients with PCL avulsion fractures, (3) examine surgical outcomes in this patient population, and (4) discuss the authors' preferred management algorithm and surgical approach. RECENT FINDINGS/RESULTS:In accordance with the rarity of these injuries, the literature is sparse regarding surgical outcomes. Many of these injuries are in the setting of a multi-ligamentous injury. Most authors suggest that displaced PCL avulsion fractures should undergo operative fixation and current data suggests excellent outcomes when treating these patients with either open or arthroscopic fixation, with a low complication rate. PCL avulsion fractures, although rare, should undergo fixation when displacement is present. Current studies report successful outcomes and a low complication rate.

Tibial spine fractures are uncommon injuries affecting the insertion of the anterior cruciate ligament on the tibia. They typically occur in skeletally immature patients aged 8 to 14 years and result from hyperextension of the knee with a valgus or rotational force. Diagnosis is based on history, physical examination, and standard radiographs. The use of MRI can identify entrapped soft tissue that may prevent reduction. Open or arthroscopic repair is indicated in patients with partially displaced fractures (>5 mm) with one third to one half of the avulsed fragment elevated, in patients who have undergone unsuccessful nonsurgical reduction and long leg casting or bracing, and in patients with completely displaced fractures. Arthroscopy offers reduced invasiveness and decreased morbidity. Suture fixation and screw fixation have produced successful results. Suture fixation can eliminate the risk of fracture fragment comminution during screw insertion, the risk of neurovascular injury, and the need for hardware removal. Suture fixation is ideal in cases in which existing comminution prevents screw fixation.

The management of meniscal root injuries has changed as biomechanical studies have demonstrated the importance of meniscal integrity in load distribution across the knee joint. Meniscal injury causes altered joint mechanics, which is postulated to be related to the onset of arthrosis. Arthroscopic meniscal root repair has been shown to restore more normal joint mechanics and is considered a treatment option in the appropriately indicated patient. Short- and midterm clinical results of meniscal root repair are promising, but long-term results are yet to be established. Herein, we review meniscal root injuries and repairs with respect to their anatomy, biomechanics, clinical diagnosis, treatment indications, operative techniques, potential complications, postoperative management, and clinical outcomes.

Shoulder and elbow injuries have been described in baseball players as early as the 1940s. Ulnar collateral ligament (UCL) tears have been recognized as a significant source of disability for baseball players and have been seen in increasing frequency as training regimens and level of play have become more intense and rigorous. Our understanding and treatment of these injuries have also evolved over time. This article summarizes the evolution of the treatment of UCL tears and discusses future directions for the treatment and prevention of these injuries.

BACKGROUND:Tissue excision in the setting of a meniscal tear has been shown to dramatically increase peak contact stresses in the affected tibiofemoral joint compartment, leading to the development of degenerative changes and osteoarthritis. PURPOSE/HYPOTHESIS/UNASSIGNED:The current in vitro study utilized a porcine model to evaluate the effectiveness of segmental medial meniscal grafting following partial meniscectomy. The study hypothesis was that the procedure would normalize medial tibofemoral joint compartment pressure magnitudes, areas, and locations relative to an intact meniscus. STUDY DESIGN/METHODS:Controlled laboratory study. METHODS:Using pressure film, medial tibiofemoral joint compartment peak, and mean pressure magnitudes, peak pressure location and peak pressure area were determined using 12 potted, fresh frozen, porcine knee specimens. Data were collected at three different knee flexion angles (90°, 45°, and 0°) for three conditions: intact medial meniscus, following resection of the central third of the medial meniscus, and following segmental medial meniscal grafting. For each condition, the potted femur was positioned horizontally in a bench vise clamp, while a 20 pound (88.96 N) axial compression force was manually applied for a 60 s duration by the primary investigator through the base of the potted tibia using a digital force gauge. RESULTS:Loss of the central 1/3 of the medial meniscus resulted in significant increases in the mean and peak pressures of the medial tibiofemoral joint compartment and decreased peak pressure area. Segmental meniscal grafting of the central third defect closely recreated the contact pressures and loading areas of the native, intact medial meniscus. CONCLUSION/CONCLUSIONS:From a static, time zero biomechanical perspective, segmental medial meniscus grafting of a partially meniscectomized knee restored mean pressure, peak pressure, and mean peak contact pressure areas of the medial tibiofemoral joint compartment back to levels observed in the intact medial meniscus at different knee flexion angles. In-vivo analysis under dynamic conditions is necessary to verify the healing efficacy and ability of the healed segmental medial meniscal allograft to provide long-term knee joint homeostasis when confronted with dynamic shear, rotatory, and combined, higher magnitude physiologic loading forces.