Faculty Bibliography

BACKGROUND/UNASSIGNED:Isolated medial compartment knee osteoarthritis (OA) presents a challenging problem to treat for knee surgeons, with a multitude of options from conservative management, including injections and unloader braces, meniscal procedures, osteotomies, and unicompartmental knee arthroplasty (UKA). A new medial implantable shock absorber (MISHA) allows for offloading 142 N of the medial compartment during stance phase of gait. INDICATIONS/UNASSIGNED:US Food and Drug Administration approval was obtained on April 10, 2023, with the following indications: isolated medial knee OA (Kellgren-Lawrence grades I-IV) that failed 6 months of conservative management, ages 25 to 65 years, body mass index <35 or body weight <300 lbs, <15° of varus, no flexion contracture >10°, and no significant medial osteophytes or medial meniscal extrusion. TECHNIQUE DESCRIPTION/UNASSIGNED:A longitudinal medial knee incision is made 1 cm proximal to the medial epicondyle to the pes insertion, around 3 cm medial to the tibial tubercle, exposing the superficial medial collateral ligament, and medial joint line. The establishment of the femoral anisometric point is critical to provide a 4-mm posterior condylar offset in 90° of flexion compared to full extension. A trial implant can be placed to confirm appropriate anisometry, implant loading in extension, and relaxation in flexion. The final implant is placed and the titanium femoral and tibial baseplates are fixed with 3 unicortical titanium locking screws each. RESULTS/UNASSIGNED:Expected results per recommended postoperative protocol are immediate weightbearing without range of motion restrictions. From author experience, patients typically feel improvement and return to sport more rapidly than with anterior cruciate ligament reconstructions. Recovery and return to work are faster than osteotomies or UKAs based on comparative short-term studies. While long-term results are lacking given the novelty of the procedure, prospective studies have demonstrated 100% arthroplasty-free survival at 2 years and 85% survival at 5 years. DISCUSSION/CONCLUSION/UNASSIGNED:The MISHA is a viable option for isolated medial compartment knee OA that provides a joint-preserving alternative to arthroplasty and a less morbid alternative to osteotomy. This treatment can be technically difficult to perform, but several pearls and techniques can offer a reproducible, minimally invasive surgery and good functional results. PATIENT CONSENT DISCLOSURE STATEMENT/UNASSIGNED:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

PURPOSE/OBJECTIVE:The purpose of the current study was to define the incidence of minor and major complications following TTO at a tertiary-care institution, with determination of predictive factors related to the occurrence of a major complication. STUDY DESIGN/METHODS:Retrospective case series. METHODS:Patients who underwent TTO from 2011 to 2023 were retrospectively identified. Patients who did not have at least 30 days of follow-up and revision cases were excluded. Complications classified as "major" included intraoperative fracture, postoperative fracture, loss of fixation, delayed union, non-union, pulmonary embolism (PE), patella tendon rupture, deep infection, painful hardware requiring removal, arthrofibrosis requiring reoperation, recurrent patellar instability, reoperation for other indications, readmission, and revision. Complications classified as minor included superficial infection, deep venous thrombosis, wound dehiscence, and postoperative neuropraxia. Chi-square tests were used for categorical variables, t-tests for continuous variables. RESULTS:Four hundred and seventy-six TTOs in 436 patients were included in the final cohort with a mean follow-up of 1.9 years (range 1 month-10 years). Patients were 68.5% female with average age 28.3 years (range 13-57 years). The overall complication rate was 27.5 percent. Major complications were recorded in 23.7% of TTOs, and minor complications in 8.4% of TTOs. Reoperation was required in 16.6% of TTOs at a mean of 14 months following the index procedure. The most common complications were painful hardware requiring removal (6.5%), superficial infection (5.7%), and arthrofibrosis requiring return to the operating room (OR) (5.0%). Prior ipsilateral surgery was identified as a significant independent predictor of major complication by regression analysis. Hardware removal was more common with headed screws. Arthrofibrosis requiring reoperation was more common in patients who underwent a concomitant cartilage restoration/repair procedure. CONCLUSION/CONCLUSIONS:The overall complication rate following tibial tubercle osteotomy was 27.5%, with painful hardware requiring removal (6.5%) as the most common complication, and an overall reoperation rate of 16.6%. TTOs with major complications were performed at earlier years, in patients who were older, had a previous ipsilateral arthroscopic knee surgery, had an indication of cartilage lesion/arthritis, and had a steeper osteotomy cut angle. Hardware removal was found to be more common in patients with headed as compared to headless screws. Complications also varied based on timing after surgery.

» Partial-thickness rotator cuff tears (PTRCTs) are a common pathology with a likely high asymptomatic incidence rate, particularly in the overhead athlete.» The anatomy, 5-layer histology, and relationship to Ellman's classification of PTRCTs have been well studied, with recent interest in radiographic predictors such as the critical shoulder angle and acromial index.» Depending on the definition of tear progression, rates of PTRCT progression range from 4% to 44% and appear related to symptomatology and work/activity level.» Nearly all PTRCTs should be managed conservatively initially, particularly in overhead athletes, with those that fail nonoperative management undergoing arthroscopic debridement ± acromioplasty if <50% thickness or arthroscopic conversion repair or in situ repair if >50% thickness.» Augmentation of PTRCTs is promising, with leukocyte-poor platelet-rich plasma having the most robust body of supportive data. Mesenchymal signaling cell biologics and the variety of scaffold onlay augments require more rigorous studies before regular usage.

PURPOSE/OBJECTIVE:To compare clinical outcomes and the rate of return to sport among patients that have undergone minimally invasive repair versus open approach of an acute Achilles tendon rupture. METHODS:Patients who underwent surgical repair of acute Achilles tendon rupture at a single urban academic institution from 2017 to 2020 with minimum 2-year follow-up were reviewed retrospectively. Preinjury sport participation and preinjury work activity information, the Achilles tendon Total Rupture Score (ATRS), the Tegner Activity Scale, Patient-Reported Outcomes Measurement Information System for mobility and pain interference were collected. RESULTS:In total, 144 patients were initially included in the study. Of these, 63 patients were followed with a mean follow-up of 45.3 ± 29.2 months. The mean operative time did not significantly differ between groups (p = 0.938). Patients who underwent minimally invasive repair returned to sport at a rate of 88.9% at a mean of 10.6 ± 5.8 months, compared to return rate of open procedures of 83.7% at 9.5 ± 5.5 months. There were no significant differences in ATRS (p = 0.246), Tegner (p = 0.137) or VAS pain (p = 0.317) scores between groups. There was no difference in cosmetic satisfaction between PARS and open repair groups (88.4 vs. 76.0; p = 0.244). CONCLUSION/CONCLUSIONS:Patients who underwent minimally invasive repair of acute Achilles tendon ruptures demonstrate no significant differences with respect to cosmesis, operative time, patient-reported outcomes and the rate and level of return to activities when compared to an open approach. LEVEL OF EVIDENCE/METHODS:III.