Conversion Total Knee Arthroplasty After Failed Osteochondral Allograft Reconstruction: Similar Functional Performance With Lower Patient Satisfaction.

BACKGROUND: This study presents surgical techniques used in conversion total knee arthroplasty (cTKA) following early failure of large osteochondral allograft joint replacement and compares postoperative patient reported outcomes measures (PROMs) and satisfaction scores with a contemporary primary total knee arthroplasty (pTKA) cohort. METHODS: We retrospectively evaluated 25 consecutive cTKA patients (26 procedures) to define the utilized surgical techniques, radiographic disease severity, preoperative and postoperative PROMs (visual analog scale [VAS] pain, knee injury and osteoarthritis outcome score for joint replacement [KOOS-JR], University of California Los Angeles Activity), expected improvement and postoperative satisfaction (5-point Likert), and reoperations in comparison with an age and body mass index propensity matched cohort of 50 pTKA performed for osteoarthritis (52 procedures). RESULTS: Revision components were used in 12 cTKA cases (46.1%), with 4 cases requiring augmentation (15.4%), and 3 cases utilizing varus-valgus constraint (11.5%). While no significant differences were noted in expectation level or in other PROMs, mean patient reported satisfaction was lower in the conversion group (4.4 ± 1.1 versus 4.8 ± 0.5 points, P = .02). High cTKA satisfaction was associated with a higher postoperative KOOS-JR (84.4 versus 64.2 points, P = .01) and a trend towards higher University of California Los Angeles activity (6.9 versus 5.7 points, P = .08). Four patients in each group underwent manipulation (15.3 versus 7.6%, P = .42), and 1 pTKA patient was treated for early postoperative infection (0 versus 1.9%, P = 1.0). CONCLUSION: cTKA following failed biological replacement was associated with similar postoperative improvement as in pTKA. Lower patient-reported cTKA satisfaction was associated with lower postoperative KOOS-JR scores.

Use of a Hyperosmolar Saline Solution to Mitigate Proinflammatory and Degradative Responses of Articular Cartilage and Meniscus for Application to Arthroscopic Surgery.

PURPOSE: This study was designed to evaluate differences in proinflammatory and degradative mediator production and extracellular matrix degradation from osteoarthritic knee articular cartilage and meniscus explants treated with either hyperosmolar saline or isotonic saline. METHODS: 6 mm-diameter full-thickness explants were created from articular cartilage and menisci recovered after patients underwent knee surgery. One explant half was treated for 3 hours with hyperosmolar saline (600 mOsm/L) and the corresponding half with isotonic saline (300 mOsm/L). Explants were subsequently cultured for 3 days in tissue culture media. On day 3, media were collected for biomarker analyses. Results were normalized to tissue wet weight and analyzed statistically. RESULTS: Articular cartilage was collected from 10 patients (5 male, 5 female; mean age = 66.9 years) and menisci were collected from 8 patients (2 male, 6 female; mean age = 66 years). Articular cartilage media concentrations of monocyte chemoattractant protein-1 (P = .001) and interleukin (IL)-6 (P = .049) were significantly lower in explants treated with hyperosmolar saline. Meniscus media concentrations of prostaglandin E2 (P = .008), monocyte chemoattractant protein-1 (P = .011), IL-6 (P = .029), IL-8 (P = .012), matrix metalloproteinase-2 (P = .011), and glycosaminoglycan (P = .008) were significantly lower in explants treated with hyperosmolar saline. CONCLUSIONS: Treatment of cartilage and meniscus explants with hyperosmolar saline effectively mitigated key proinflammatory mediator production, as well as degradative mediator production and glycosaminoglycan loss from meniscus, with no detrimental effects noted compared to isotonic saline. CLINICAL RELEVANCE: These results suggest that hyperosmolar saline irrigation fluid may provide a safe alternative to standard isotonic saline irrigation fluid, and could mitigate untoward effects associated with inflammatory responses after standard-of-care knee arthroscopy.

Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs.

BACKGROUND: The rate of shoulder arthroplasty has continued to increase at an exponential rate during the past decade in large part owing to approval by the Food and Drug Administration of reverse shoulder arthroplasty. Whereas reverse shoulder arthroplasty has resulted in expanded surgical indications, there are numerous reports of relatively high complication rates. The increased prevalence of both anatomic and reverse shoulder arthroplasty underscores the need to elucidate whether perioperative outcomes are influenced by type of total shoulder arthroplasty. The purpose of this study was to determine the impact of shoulder arthroplasty type, anatomic or reverse, with respect to perioperative adverse events, in-hospital death, prolonged hospital stay, nonroutine disposition, and hospital charges in a nationally representative sample. METHODS: By use of the Nationwide Inpatient Sample database from 2011, the first year that reverse total shoulder arthroplasty received a unique International Classification of Diseases, Ninth Revision procedure code, an estimated 51,052 patients undergoing total shoulder arthroplasty were separated into anatomic total shoulder arthroplasty (58%) and reverse total shoulder arthroplasty (43%). Comparisons of early outcome measures between anatomic and reverse total shoulder cohorts were performed by bivariate and multivariable analyses with logistic regression modeling. RESULTS: Compared with anatomic shoulder arthroplasty recipients, patients undergoing reverse shoulder replacement were at higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, increased hospital cost, and nonroutine discharge. CONCLUSION: Despite the expanding indications for reverse shoulder arthroplasty, it is an independent risk factor for inpatient morbidity, mortality, and hospital costs and should perhaps be offered more judiciously and performed in the hands of appropriately trained shoulder specialists.

Analysis of perioperative morbidity and mortality in shoulder arthroplasty patients with preexisting alcohol use disorders.

BACKGROUND: Shoulder arthroplasty is becoming increasingly popular in the United States. Given the high prevalence of alcohol abuse and its implications in postoperative morbidity and the increasing incidence of shoulder arthroplasty, it is prudent to explore the effect of alcohol use disorders (AUDs) in this patient population. In this study, we considered numerous outcome variables, including perioperative complications, in-hospital death, prolonged hospital stay, and nonroutine discharge. METHODS: Using the Nationwide Inpatient Sample, we performed a retrospective cohort study to identify a population of 422,371 adults (≥18 years old) undergoing total shoulder arthroplasty or hemiarthroplasty between January 1, 2002, and December 31, 2011. We then further subdivided this cohort into those who were classified as having AUDs and those who did not. Comparisons of early postoperative outcome measures were performed by bivariate and multivariable analyses with logistic regression modeling. RESULTS: Compared with those without AUDs, patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood to experience death, pneumonia, deep venous thrombosis, acute renal failure, transfusion, prolonged length of stay, and nonroutine discharge irrespective of age, gender, race, and other medical comorbidities. Patients with a preexisting AUD are 2.7 times more likely to experience perioperative complications after shoulder arthroplasty. CONCLUSION: Patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood of perioperative complications and health care resource utilization after shoulder arthroplasty. Presurgical alcohol screening may prove effective in identifying at-risk patients, and providing interventions before surgery may effectively limit the complication profile.

Outcomes of augmented allograft figure-of-eight sternoclavicular joint reconstruction.

BACKGROUND: Sternoclavicular joint (SCJ) instability is a rare condition resulting in impaired function and shoulder girdle pain. Various methods for stabilizing the SCJ have been proposed, with biomechanical analysis demonstrating superior stiffness and peak load properties with a figure-of-8 tendon graft technique. The purpose of this study was to evaluate the clinical outcomes of SCJ reconstruction with an interference screw figure-of-8 allograft tendon technique. METHODS: A retrospective analysis of a consecutive cohort of patients from 2007 to 2011 was performed for all patients undergoing SCJ reconstruction for instability. All patients were treated for SCJ instability with a figure-of-8 allograft reconstruction augmented by 2 tenodesis screws. Outcomes were performed with the American Shoulder and Elbow Surgeons (ASES) score, the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and the visual analog scale (VAS) for pain score for all patients. Intraoperative and postoperative complications were recorded. RESULTS: A total of 10 patients were included in the study, with an average follow-up of 38 months (range, 11.6-66.8 months). Preoperatively, the mean ASES score was 35.3 points (range, 21.7-55 points), whereas the postoperative mean ASES score increased to 84.7 points (range, 66.6-95 points). The mean VAS score improved from 7.0 (range, 5-10) before surgery to 1.15 (range, 0-3) at follow-up, and the QuickDASH score average was 17.0 points (range, 0 to 38.6 points). Minor postoperative complications were noted in 2 patients. CONCLUSION: Patients who underwent repair of SCJ instability by an augmented figure-of-8 allograft tendon reconstruction report marked improvements in both shoulder function and pain relief.

Diabetes as a risk factor for poorer early postoperative outcomes after shoulder arthroplasty.

BACKGROUND: Although diabetes has been associated with increased perioperative morbidity and mortality after hip and knee arthroplasty, its impact on early postoperative outcomes after shoulder replacement remains relatively unexplored. The purpose of the study was to determine the association of diabetes with in-hospital death, complications, length of stay, non-homebound disposition, and cost in patients undergoing shoulder arthroplasty. METHODS: By use of the Nationwide Inpatient Sample database for the year 2011, an estimated 66,485 patients having undergone shoulder arthroplasty were identified and separated into groups with (21%) and without (79%) diabetes mellitus. Comparisons of specific outcome measures between diabetic and nondiabetic cohorts were performed by bivariate and multivariable analyses with logistic regression modeling. RESULTS: Diabetes mellitus was independently associated with in-hospital death, a number of perioperative complications, prolonged hospital stay, and increased non-homebound disposition after shoulder arthroplasty. The presence of diabetes was not associated with increased hospital cost. CONCLUSION: Patients with preexisting diabetes are at higher risk for perioperative morbidity and mortality after shoulder arthroplasty. Future prospective research should explore in more detail the relationship between diabetes and shoulder arthroplasty outcomes.

Two-Portal Arthroscopic Knotless All-Suture Anchor Posterior Labral Repair.

Isolated posterior shoulder instability accounts for approximately 10% of shoulder instability cases. Patients may present after an acute trauma or with insidious onset and associated posterior shoulder pain. Knotless and all-suture anchor devices have become increasing popular and are often used in arthroscopic shoulder instability cases to avoid knot stacks and allow for the ability to re-tension the fixation. This technical note describes our technique for 2-portal posterior labral repair using knotless all-suture anchors with the patient in the lateral decubitus position.

The Floating Clavicle: Surgical Technique for Management of an Ipsilateral Acromioclavicular and Sternoclavicular Joint Dislocation.

Bipolar "floating" clavicle injuries are infrequent upper-extremity injuries that occur secondary to a high-energy trauma, which can cause dislocation at the sternoclavicular (SC) and acromioclavicular joints. Given the rarity of this injury, there is not a consensus regarding clinical management. Although anterior dislocations can be managed nonoperatively, posterior dislocations may pose a threat to chest-wall structures and typically are managed surgically. Here, we present our preferred technique for concomitant management of a locked posterior SC joint dislocation with associated grade 3 acromioclavicular joint dislocation. Reconstruction of both ends of the clavicle was performed in this case, using a figure-of-8 gracilis allograft and nonabsorbable suture reconstruction for the SC joint, and an anatomic acromioclavicular joint and coracoclavicular ligament reconstruction with semitendinosus allograft and nonabsorbable suture.

Securing the Root: Meniscus Root Repair with Rip Stop and Cannulated Drilling.

Meniscal root pathology has garnered increased attention over the past decade. Meniscal root tears are considered to essentially represent a meniscus-deficient state, which has led to a rise in the surgical fixation of this pathology. Meniscus root tears are classified as either radial tears within 1 cm of the root insertion, or a direct avulsion of meniscal root. These injuries are important to recognize because they contribute to impaired joint mechanics and rapid articular cartilage degeneration. Given this, there remains significant interest in identifying novel surgical techniques that may facilitate better surgical repair and enhance patient outcomes. The purpose of this technical note is to describe a surgical technique for a medial meniscus root ripstop repair with cannulated drilling. This technique is simple and reproducible, while also allowing for the augmentation of potentially poor tissue quality.

Making the Case for Hyperosmolar Saline Arthroscopic Irrigation Fluids: A Systematic Review of Basic Science, Translational, and Clinical Evidence.

Commonly used isotonic arthroscopic irrigation fluids, such as normal saline or lactated Ringer's, were initially formulated for intravenous administration so they do not replicate the physiologic properties of healthy synovial fluid. Synovial fluid plays an important role in regulating joint homeostasis such that even transient disruptions in its composition and physiology can be detrimental. Previous studies suggest that hyperosmolar solutions may be a promising alternative to traditional isotonic fluids. This manuscript sought to systematically review and synthesize previously published basic science, translational, and clinical studies on the use of hyperosmolar arthroscopic irrigation fluids to delineate the optimal fluid for clinical use. A systematic literature search of MEDLINE/PubMed and Embase databases was performed in accordance with Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA) guidelines. The search phrases were: ("cartilage" AND "hyperosmolar"); ("arthroscopy" OR "arthroscopic" AND "hyperosmolar"). The titles, abstracts, and full texts were screened for studies on hyperosmolar solutions and articular cartilage. Study quality was assessed, and relevant data were collected. A meta-analysis was not performed due to study heterogeneity. A risk of bias assessment was performed on the included translational and clinical studies. There were 10 basic science studies, 2 studies performed in translational animal models, and 2 clinical studies included in this review. Of the basic science studies, 7 utilized a mechanical injury model. The translational studies were carried out in the canine shoulder and equine stifle (knee) joint. Clinical studies were performed in the shoulder and knee. Multiple basic science, translational, and clinical studies highlight the short-term safety, cost-effectiveness, and potential benefits associated with use of hyperosmolar solutions for arthroscopic irrigation. Further work is needed to develop and validate the ideal formulation for a hyperosmolar irrigation solution with proven long-term benefits for patients undergoing arthroscopic surgeries.

Prospective Randomized Controlled Clinical Trial Comparing Hyperosmolar Saline to Standard Isotonic Irrigation Fluid for Arthroscopic Knee Surgery: Initial Clinical Outcomes.

Numerous in vitro studies suggest higher osmolarity irrigation fluids potentiate a chondroprotective environment, and a recent clinical study using hyperosmolar saline for shoulder arthroscopy reported potential clinical advantages. This prospective randomized double-blind controlled clinical trial was designed to assess initial clinical outcomes associated with use of a hyperosmolar irrigation solution in patients undergoing arthroscopic knee surgery. With institutional review board approval and informed consent, patients scheduled for arthroscopic knee surgery were randomized to surgery with either isotonic lactated Ringer's (273 mOsm/L) or hyperosmolar saline (593 mOsm/L) irrigation solution. Outcomes included perioperative blood pressure, knee girth, visual analogue scale (VAS) pain scores, and narcotic pain medication consumption. Forty-six patients underwent arthroscopic knee surgery with isotonic (n = 23) or hyperosmolar (n = 23) irrigation fluids. There were 11 males and 12 females (mean age = 44.0 years) in the isotonic cohort and 8 males and 15 females (mean age = 40.2 years) in the hyperosmolar cohort. There were no significant differences with respect to surgical duration (pump time) or amount of irrigation fluid used between the two cohorts. There were no significant differences with respect to change in knee girth, blood pressure, or VAS pain scores. However, patients treated with hyperosmolar saline consumed less narcotic medication on postoperative day 3 (4.0 ± 7.6 vs. 15.5 ± 17.4 mg, p = 0.01). The results of this randomized clinical trial suggest that a hyperosmolar irrigation solution is safe and relatively inexpensive for use in patients undergoing arthroscopic knee surgery and contributes to a reduction in initial postoperative narcotic pain medication consumption. A hyperosmolar saline irrigation fluid was not associated with any detrimental effects on the execution of the surgical procedure, postoperative pain, or periarticular fluid extravasation. Taken together with previous basic science, translational, and clinical studies, hyperosmolar saline irrigation fluid is promising alternative to traditional isotonic irrigation fluids for knee arthroscopy. This study is a prospective trial and reflects level of evidence I.

Medial Patellofemoral Ligament Reconstruction in Obese Patients Results in Low Complication Rates and Improved Subjective Outcomes.

Purpose: To compare outcomes, activity scores, and complication rates of obese and non-obese patients undergoing medial patellofemoral ligament (MPFL) reconstruction. Methods: A retrospective review identified patients undergoing MPFL reconstruction for recurrent patellofemoral instability. Patients were included if they had undergone MPFL reconstruction and had follow-up for a minimum of 6 months. Patients were excluded if they underwent surgery less than 6 months earlier, had no outcome data recorded, or underwent concomitant bony procedures. Patients were divided into 2 groups based on body mass index (BMI): BMI of 30 or greater and BMI less than 30. Presurgical and postsurgical patient-reported outcomes including Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and the Tegner score were collected. Complications requiring reoperation were recorded. P < .05 was defined as a statistically significant difference. Results: A total of 55 patients (57 knees) were included. There were 26 knees with a BMI of 30 or greater and 31 knees with a BMI less than 30. There were no differences in patient demographic characteristics between the 2 groups. Preoperatively, no significant differences were found in KOOS subscores or Tegner scores (P = .21) between groups. At minimum 6-month follow-up (range, 6.1-70.5 months), patients with a BMI of 30 or greater showed statistically significant improvements in the KOOS Pain, Activities of Daily Living, Symptoms, and Sport/Recreation subscores. Patients with a BMI less than 30 showed a statistically significant improvement in the KOOS Quality of Life subscore. The group with a BMI of 30 or greater had significantly lower KOOS Quality of Life (33.34 ± 19.10 vs 54.47 ± 28.00, P = .03) and Tegner (2.56 ± 1.59 vs 4.78 ± 2.68, P = .05) scores. Complication rates were low, with 2 knees (7.69%) requiring reoperation in the cohort with a BMI of 30 or greater and 4 knees (12.90%) requiring reoperation in the cohort with a BMI less than 30, including 1 reoperation for recurrent patellofemoral instability (P = .68). Conclusions: In this study, MPFL reconstruction in obese patients was safe and effective, with low complication rates and improvements in most patient-reported outcomes. Compared with patients with a BMI less than 30, obese patients had lower quality-of-life and activity scores at final follow-up. Level of Evidence: Level III, retrospective cohort study.

Primary Repair of Peroneus Longus Myofascial Herniation With Symptomatic Superficial Peroneal Nerve Compression.

Symptomatic myofascial herniations of the extremities occur infrequently; however, they can contribute to significant pain, weakness, and neuropathy with activity. Muscle herniation typically occurs through either a traumatic or congenital focal defect in the deep overlying fascia. Patients may present with an intermittently palpable subcutaneous mass and may have neuropathic symptoms, depending on the degree of nerve involvement. Patients are initially treated with conservative modalities, whereas surgery is reserved for patients who demonstrate persistent functional limitations and neurologic symptoms. Here, we demonstrate a technique for primary repair of a symptomatic lower-leg fascial defect.

Diabetic Pilon Factures: Are They as Bad as We Think?

OBJECTIVE: To identify how diabetes impacts the risk of complications requiring further surgery (deep surgical site infection, nonunion, amputation, and arthrodesis) after pilon fracture fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS: Two hundred seventy-nine pilon fractures (276 patients) were identified. A retrospective review was performed to find patients who presented for open reduction and internal fixation of a tibial pilon fracture (OTA/AO 43). Patient demographics, medical comorbidities, OTA/AO fracture type, and surgical outcomes were reviewed. INTERVENTION: Patients were stratified into cohorts based on the presence or absence of diabetes at the time of surgery. MAIN OUTCOME MEASUREMENTS: The complications of interest that proved significant during univariate analyses were then entered into a multivariable logistic regression model using a stepwise method to identify the independent predictors for complications. RESULTS: There were 43 fractures (15.4%) in patients with diabetes mellitus; 17 (39.5%) of whom were insulin-dependent diabetics. Diabetic patients were significantly more likely to have a higher body mass index (34.81 vs. 29.57, P = 0.002) and be older (55.30 ± 16.3 years vs. 41.70 ± 14.05, P < 0.001) at the time of injury. Patients without diabetes were more likely to sustain an OTA/AO 43-C3 fracture (36.0% vs. 11.6%, P = 0.001). Diabetic patients were 5.5 times more likely to require an arthrodesis [95% confidence interval (CI) = 1.894-16.214; P = 0.001] and 2.7 times more likely to develop a deep infection (95% CI = 1.261-5.630; P = 0.008). CONCLUSIONS: Overall, diabetic patients in this study were 3.64 times more likely (95% CI = 1.854-7.159; P < 0.001) to experience any complication, despite having less complex fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Hyperosmolar Saline Solution Fortified with Anti-Inflammatory Components Mitigates Articular Cartilage Pro-Inflammatory and Degradative Responses in an In Vitro Model of Knee Arthroscopy.

OBJECTIVE: To evaluate differences in pro-inflammatory and degradative mediator production from osteoarthritic knee articular cartilage explants treated with a hyperosmolar saline solution supplemented with anti-inflammatory components (l-glutamine, ascorbic acid, sodium pyruvate, epigallocatechin gallate [EGCG], and dexamethasone) or normal saline using an in vitro model for knee arthroscopy. DESIGN: Full-thickness 6 mm articular cartilage explants (n = 12/patient) were created from femoral condyle and tibial plateau samples collected from patients who received knee arthroplasty. One explant half was treated for 3 hours with hyperosmolar saline (600 mOsm/L) supplemented with anti-inflammatory components and the corresponding half with normal saline (308 mOsm/L). Explants were cultured for 3 days and then collected for biomarker analyses. Media biomarker concentrations were normalized to the wet weight of the tissue (mg) and were analyzed by a paired t test with significance set at P < 0.05. RESULTS: Cartilage was collected from 9 females and 2 males (mean age = 68 years). Concentrations of MCP-1 (P < 0.001), IL-8 (P = 0.03), GRO-α (P = 0.02), MMP-1 (P < 0.001), MMP-2 (P < 0.001), and MMP-3 (P < 0.001) were significantly lower in explant halves treated with the enhanced hyperosmolar solution. When considering only those cartilage explants in the top tercile of tissue metabolism, IL-6 (P = 0.005), IL-8 (P = 0.0001), MCP-1 (P < 0.001), GRO-α (P = 0.0003), MMP-1 (P < 0.001), MMP-2 (P < 0.001), MMP-3 (P < 0.001), and GAG expression (P = 0.0001) was significantly lower in cartilage explant halves treated with the enhanced hyperosmolar solution. CONCLUSIONS: Treatment of cartilage explants with a hyperosmolar saline arthroscopic irrigation solution supplemented with anti-inflammatory components was associated with significant decreases in inflammatory and degradative mediator production and mitigation of proteoglycan loss.

Age-Related Variances in Patients with Tibial Plateau Fractures.

Tibial plateau fractures account for approximately 8% of fractures in the elderly population. Treatment strategies in the elderly are similar to those for younger patients; however, practitioners must account for the elevated comorbidity burden in this population. To date, few studies have analyzed age-based outcomes in patients with tibial plateau fractures. Therefore, the purpose of this study was to determine age-related variances in demographics, fracture characteristics, mechanism of injury, and complications. A 10-year retrospective review was conducted to identify patients who received treatment for a tibial plateau fracture. There were 351 patients (360 tibial plateau fractures) who were identified and subsequently stratified according to their age at the time of injury. Patients were classified as elderly if they were 65 years of age or older at the time of injury; all other patients were included in the control cohort. These two cohorts were analyzed using bivariate analysis to isolate for age-related variations with respect to risk factors, mechanism of injury, and complications. There were 351 patients (360 tibial plateau fractures) with a median follow-up of 1.84 ± 2.44 years who met inclusion criteria. There were a greater proportion of women in the elderly cohort as compared with the younger cohort (60.0 vs. 43.4%, p = 0.06). Elderly patients were significantly more likely to present with diabetes (33.3 vs. 16.1%, p = 0.01) or osteoporosis (14.3 vs. 1.6%, p = 0.001). Younger patients were significantly more likely to require further surgery to address ligament (12.6 vs. 0%, p = 0.008), meniscus (20.9 vs. 7.1%, p = 0.036), or cartilage pathology (13.6 vs. 0%, p = 0.005). There was no difference in the arthroplasty conversion rate (4.8% elderly vs. 7.9% control, p = 0.755). While elderly patients presented with a greater comorbidity burden, they had equivalent or better short-term outcomes when compared with their younger peers when treated with open reduction and internal fixation (ORIF). Despite the recent interest in primary total knee arthroplasty for elderly patients with tibial plateau fractures, the results of this study suggest that elderly patients may respond well when treated with ORIF following a tibial plateau fracture.

Initial clinical outcomes comparing frozen versus fresh meniscus allograft transplants.

BACKGROUND: To evaluate initial clinical outcomes using fresh meniscal allografts with high cell viability at transplantation time and meniscotibial ligament (MTL) reconstruction (Fresh) in comparison to standard fresh-frozen (Frozen) meniscus allograft transplantation (MAT). METHODS: Patients treated for medial and/or lateral meniscal deficiency using either Fresh or Frozen MAT with minimum of 1-year follow-up were identified from a prospective registry. Patient demographics, prior surgeries, MAT surgery data, complications, revisions, and failures were documented. Functional outcome scores were collected preoperatively, and 6 months and yearly after surgery and radiographic joint space measurements were performed. Treatment cohorts were compared for statistically significant (P < 0.005) differences using t-Tests and Fisher's exact tests. RESULTS: Twenty-seven patients (14 Fresh, 13 Frozen) met inclusion criteria and showed comparable characteristics. For Fresh MAT + MTL, 10 medial, two lateral, and two medial + lateral MAT were performed. For Frozen MAT, nine medial, and four lateral MAT were performed. There was significantly more improvement in the Fresh cohort compared to the Frozen cohort for VAS pain (P = 0.014), PROMIS Physical Function (P = 0.036) and Single Assessment Numeric Evaluation (P = 0.033) from preoperatively to 2 years postoperatively. Tegner Activity Scale and PROMIS Mobility score showed no significant differences. The International Knee Documentation Committee score revealed a clinically meaningful change for the Fresh group. Radiographic measurements showed no significant differences between groups. There were two Fresh MAT + MTL revisions and one conversion to TKA in each cohort. CONCLUSIONS: Fresh MAT + MTL is safe and associated with potential advantages with respect to initial pain relief and function compared to standard frozen MAT.

Meniscus Injuries: A Review of Rehabilitation and Return to Play.

Meniscal injury potentiates a sequence of events that leads to degenerative changes and early osteoarthritis. It is therefore imperative to preserve the meniscus whenever possible. Given the expanding indications for meniscus repair, it is important to continually analyze and advance the understanding of rehabilitation and return to play following meniscal surgery. This article presents evidence-based rehabilitation and return-to-play guidelines as well as a brief review of return-to-play outcomes following isolated meniscus repair.

Cooled Radio Frequency Ablation for the Treatment of Osteoarthritis-Related Knee Pain: Evidence, Indications, and Outcomes.

Knee osteoarthritis (OA) is a common condition associated with pain and physical impairment in a large segment of the population. The traditional treatment algorithm progresses from conservative modalities to nonsurgical options to surgical intervention. Surgical intervention often provides reliable pain relief but not all patients are surgical candidates and there are some patients who prefer not to have surgery. Cooled radio frequency ablation (C-RFA) is a treatment with the potential to provide pain relief for patients who no longer benefit from noninvasive modalities and who desire an alternative to surgery. The objective of this review article is to provide the rationale, available evidence, indications, and outcomes associated with C-RFA for the treatment of chronic knee OA. A total of eight reports that use C-RFA in the treatment of chronic knee pain were identified and analyzed. There were two prospective trials, one retrospective cohort study, and five case reports or case series. C-RFA is an emerging procedure with encouraging early results; however, additional long-term prospective clinical trials are necessary to further characterize how C-RFA can best be used to treat chronic knee pain.

Total Knee Arthroplasty versus Osteochondral Allograft: Prevalence and Risk Factors following Tibial Plateau Fractures.

Orthopaedic surgeons commonly have the misconception that patients with tibial plateau fractures will likely go on to posttraumatic knee arthritis requiring total knee arthroplasty (TKA). In younger patients, osteochondral allograft (OCA) transplantation is an alternative method to address posttraumatic knee arthritis. The purpose of this study was (1) to identify our institutional failure rate following tibial plateau open reduction and internal fixation (ORIF) (failure was defined as conversion to TKA or OCA); (2) to determine if there are patient- or injury-related risk factors predictive of failure; and (3) to characterize differences between patients treated with TKA versus those treated with OCA transplantation. A 10-year retrospective review was conducted to identify patients treated at our institution with a tibial plateau fracture. Patients included in the final analysis were at least 18 years of age with an articular fracture (AO/OTA 41 B/C). The primary outcome was subsequent ipsilateral OCA or TKA. There were 350 patients (359 tibial plateau fractures) with a mean follow-up of 22.3 months (range, 6-133 months) who met inclusion criteria. Twenty-seven fractures (7.5%) were subsequently converted to a TKA or OCA at an average of 3.75 ± 3.1 years following their initial surgery. Patients who consumed tobacco were 2.3 times more likely to require a joint replacement (confidence interval [CI], 1.0-5.2; p = 0.04). Those patients who received an OCAs were significantly younger as compared with their TKA peers, both at time of initial injury (37 vs. 51 years, p = 0.02) and at time of surgery (41 vs. 55 years, p = 0.009). The joint replacement rate in this study is similar to those studies in the published literature that focused solely on the prevalence of conventional TKA. Tobacco is a risk factor for failure following tibial plateau ORIF. Patients who were treated with an OCA were younger at time of injury and failure.