Surgeon Performance as a Predictor for Patient-Reported Outcomes After Arthroscopic Partial Meniscectomy.

Background: Surgeon performance has been investigated as a factor affecting patient outcomes after orthopaedic procedures to improve transparency between patients and providers. Purpose/Hypothesis: The purpose of this study was to identify whether surgeon performance influenced patient-reported outcomes (PROMs) 1 year after arthroscopic partial meniscectomy (APM). It was hypothesized that there would be no significant difference in PROMs between patients who underwent APM from various surgeons. Study Design: Case-control study; Level of evidence, 3. Methods: A prospective cohort of 794 patients who underwent APM between 2018 and 2019 were included in the analysis. A total of 34 surgeons from a large multicenter health care center were included. Three multivariable models were built to determine whether the surgeon-among demographic and meniscal pathology factors-was a significant variable for predicting the Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain subscale, the Patient Acceptable Symptom State (PASS), and a 10-point improvement in the KOOS-Pain at 1 year after APM. Likelihood ratio (LR) tests were used to determine the significance of the surgeon variable in the models. Results: The 794 patients were identified from the multicenter hospital system. The baseline KOOS-Pain score was a significant predictor of outcome in the 1-year KOOS-Pain model (odds ratio [OR], 2.1 [95% CI, 1.77-2.48]; P < .001), the KOOS-Pain 10-point improvement model (OR, 0.57 [95% CI, 0.44-0.73), and the 1-year PASS model (OR, 1.42 [95% CI, 1.15-1.76]; P = .002) among articular cartilage pathology (bipolar medial cartilage) and patient-factor variables, including body mass index, Veterans RAND 12-Item Health Survey-Mental Component Score, and Area Deprivation Index. The individual surgeon significantly impacted outcomes in the 1-year KOOS-Pain mixed model in the LR test (P = .004). Conclusion: Patient factors and characteristics are better predictors for patient outcomes 1 year after APM than surgeon characteristics, specifically baseline KOOS-Pain, although an individual surgeon influenced the 1-Year KOOS-Pain mixed model in the LR test. This finding has key clinical implications; surgeons who wish to improve patient outcomes after APM should focus on improving patient selection rather than improving the surgical technique. Future research is needed to determine whether surgeon variability has an impact on longer-term patient outcomes.

Evaluation of Differences in Patellar Height After Patellar Stabilization Procedures Not Intended to Address Patella Alta: A Multicenter Study.

Background: Recent studies have reported conflicting results as to whether isolated medial patellofemoral ligament reconstruction (MPFLr) leads to decreased patellar height. Purpose: To investigate if patellar stabilization surgery not intended to address patella alta influences patellar height. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective chart review was conducted, and patients who underwent MPFLr, medializing tibial tuberosity osteotomy (TTO), and/or trochleoplasty between 2016 and 2020 were included. The Caton-Deschamps index (CDI) was calculated from radiographs obtained preoperatively, 2 weeks postoperatively, and 3 months postoperatively. The preoperative CDI value was compared with the 2-week postoperative and 3-month postoperative values according to stabilization procedure (isolated MPFLr, isolated TTO, MPFLr + TTO, MPFLr + trochleoplasty, and MPFLr + trochleoplasty + TTO) using the paired t test. Analyses of the 1-bundle versus 2-bundle MPFLr technique and the presence of lateral retinacular release or lateral retinacular lengthening were conducted on the isolated MPFLr and combined MPFLr + TTO cohorts. Results: A total of 356 knees were included. Statistically significant pre- to postoperative decreases in CDI were seen in all stabilization procedures analyzed (P≤ .017 for all). Within the isolated MPFLr cohort, this significant decrease was seen at 2 weeks postoperatively with the 2-bundle technique (ΔCDI = -0.09; P < .001) but not with the 1-bundle technique (ΔCDI = -0.01; P = .621). Conclusion: The different surgical techniques analyzed in the current study affected patellar height, even when a distalizing TTO was not performed. The decrease was dependent on surgical technique, with a 2-bundle MPFLr leading to a statistically significant decrease and a 1-bundle MPFLr effecting no change.

A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study.

Background: Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears. Purpose: To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement. Results: There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case. Conclusion: This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Patellar Dislocation in Adolescent Patients: Influence on Cartilage Properties Based on T1ρ Relaxation Times.

BACKGROUND: Adolescents who experience a patellar dislocation have an elevated risk of patellofemoral posttraumatic osteoarthritis. Magnetic resonance imaging (MRI)-based T1ρ relaxation times were measured for adolescents to evaluate patellofemoral cartilage after patellar dislocation. Long T1ρ relaxation times are an indicator of cartilage degradation. HYPOTHESIS: The primary hypothesis is that patellofemoral cartilage T1ρ relaxation times will be elevated in the acute phase after patellar dislocation. The secondary hypothesis is that T1ρ relaxation times will be higher for knees with multiple rather than single dislocations due to repeated traumatic injury. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: In total, 23 adolescents being treated for a recent patellar dislocation, 13 for a first-time dislocation (47 ± 38 days since most recent dislocation) and 10 for multiple dislocations (55 ± 24 days since most recent dislocation), and 10 healthy controls participated in MRI-based T1ρ relaxation time mapping. For multiple regions of the patellofemoral joint, mean T1ρ values were compared between the 3 groups with multiple group comparisons and post hoc tests. T1ρ relaxation times were also correlated against measures of patellofemoral anatomy and alignment for single and multiple dislocations. Statistical significance was set at P < .05. RESULTS: T1ρ relaxation times were significantly longer for injured knees (single and multiple dislocations) than controls at the medial and central patella and central trochlear groove. For the regions on the patella, significant differences between injured and control knees exceeded 15%. No significant differences were identified between single and multiple dislocations. For the initial dislocation group, T1ρ relaxation times within multiple regions of the patellofemoral joint were significantly correlated with lateral patellar alignment or patellar height. CONCLUSION: Elevated patellofemoral cartilage T1ρ relaxation times are consistent with a high risk of long-term patellofemoral osteoarthritis for adolescents who experience patellar dislocations. T1ρ relaxation times were elevated for multiple regions of patellofemoral cartilage. T1ρ relaxation times were expected to increase with additional dislocation episodes, but relaxation times after single and multiple dislocations were similar. After a first dislocation, parameters related to patellar maltracking were correlated with cartilage degradation.

Incidence of Early Adverse Events After Tibial Tubercle Osteotomy.

Background: Tibial tubercle osteotomy (TTO) is a commonly utilized surgical procedure for the treatment of patellofemoral instability. Although midterm and long-term outcomes are known, perioperative complications have not been consistently reported. Purpose: To identify the incidence and predictors of adverse events in the first 90-day perioperative period after TTO. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing primary TTO between January 1, 2010, and December 31, 2019, were included. Readmissions in the first 90 days after surgery were collected, and data were collected for the following variables: age, sex, smoking status, body mass index, laterality, preoperative diagnosis, presence of trochlear dysplasia, tourniquet use, TTO procedure, tibial tubercle distalization, trochleoplasty, chondral procedure, number of screws, and use of an epidural catheter. Predictors of readmission for any reason were identified using multivariable logistic regression analysis. Results: A total of 345 TTO procedures were included in the final analysis. The incidence of readmissions for any reason was 20.6% (71/345). The most common reason for readmission was postoperative pain (26/345 [7.5%]), followed by wound complications (19/345 [5.5%]) and epidural catheter-related complications (overall: 16/345 [4.6%]; specific: 16/167 [9.6%]. The incidence of major complications was 2.0% (7/345). The number of patients with each major complication was as follows: 1 for deep vein thrombosis, 2 for pulmonary embolism, 1 for septic arthritis, 1 for tibial tubercle fracture, and 2 for loss of fixation. Female sex and smoking were associated with readmission for pain. Conclusion: The incidence of major complications after TTO was very low (2.0%), but 20.6% of cases required readmission, primarily for an indwelling epidural catheter (3.5%) and postoperative pain (7.5%). Concomitant soft tissue procedures and the number of screws were associated with readmission after TTO. Utilizing individualized postoperative pain management and preoperative discussions about expected pain may help to avoid readmission for pain after TTO.

Do Patellar Tendon Repairs Have Better Outcomes than Quadriceps Tendon Repairs? A Prospective Cohort Analysis.

Patellar tendon (PT) and quadriceps tendon (QT) ruptures represent significant injuries and warrant surgical intervention in most patients. Outcome data are predominantly retrospective analyses with low sample sizes. There are also minimal data comparing QT and PT repairs and the variables impacting patient outcomes. The level of evidence of the study is level II (prognosis). From the prospective OME cohort, 189 PT or QT repairs were performed between February 2015 and October 2019. Of these, 178 were successfully enrolled (94.2%) with 1-year follow-up on 141 (79.2%). Baseline demographic data included age, sex, race, BMI, years of education, smoking status, and baseline VR-12 MCS score. Surgical and follow-up data included surgeon volume, fixation technique, baseline, and 1-year Knee Injury and Osteoarthritis Outcome Score-Pain (KOOS-Pain), Knee Injury and Osteoarthritis Outcome Score-Physical Function (KOOS-PS), and 1-year Patient Acceptable Symptom State (PASS) scores and complications. Multivariable regression analysis was utilized to identify prognosis and significant risk factors for outcomes-specifically, whether KOOS-Pain or KOOS-PS were different between QT versus PT repairs. There were 59 patients in the PT cohort and 82 patients in QT cohort. Baseline demographic data demonstrated that PT cohort was younger (45.1 vs. 59.5 years, p <0.001), included significantly fewer patients of White race (51.7 vs. 80.0%, p = 0.001), lesser number of years of education (13.9 vs. 15.2 years, p = 0.020), a higher percentage of "high" surgeon volume (72.9% vs. 43.9%, p = 0.001) and 25.4% of PT repairs had supplemental fixation (QT had zero, p <0.001). Multivariable analysis identified gender (female-worse, p = 0.001), years of education (higher-better, p = 0.02), and baseline KOOS-Pain score (higher-better, p <0.001) as the risk factors that significantly predicted KOOS-Pain score. The risk factors that significantly predicted KOOS-PS were gender (female worse, p = 0.033), race (non-White-worse, p <0.001), baseline VR-12 MCS score (higher-better, p <0.001), and baseline KOOS-PS score (higher better, p = 0.029). KOOS-Pain and KOOS-PS scores improved after both QT and PT repairs. Patient reported pain and function at 1 year were similar between PT and QT repairs after adjusting for known risk factors. Multivariable analysis identified female gender and low baseline KOOS scores as predictors for worse outcomes.

Anatomical Characteristics Contributing to Patellar Dislocations Following MPFL Reconstruction: A Dynamic Simulation Study.

Pathologic anatomy is a primary factor contributing to redislocation of the patella following reconstruction of the medial patellofemoral ligament (MPFL). A pivot landing was simulated following MPFL reconstruction, with the hypothesis that position of the tibial tuberosity, depth of the trochlear groove, and height of the patella are correlated with lateral patellar maltracking. Thirteen dynamic simulation models represented subjects being treated for recurrent patellar instability. Simplified Hertzian contact governed patellofemoral and tibiofemoral joint reaction forces. Pivot landing was represented with and without an MPFL graft in place. Measurements related to patellar height (Caton-Deschamps index), trochlear groove depth (lateral trochlear inclination), and position of the tibial tuberosity (lateral tibial tuberosity to posterior cruciate attachment distance, or lateral TT-PCL distance) were measured from the models and correlated with patellar lateral shift with the knee extended (5 deg of flexion) and flexed (40 deg). The patella dislocated for all models without an MPFL graft and for two models with a graft represented. With an MPFL graft represented, patellar lateral shift was correlated with Caton-Deschamps index (r2 > 0.35, p < 0.03) and lateral trochlear inclination (r2 ≥ 0.45, p < 0.02) at both 5 deg and 40 deg of flexion. For a simulated pivot landing with an MPFL graft in place, lateral patellar tracking was associated with a high patella (alta) and shallow trochlear groove. The study emphasizes the importance of simulating activities that place the patella at risk of dislocation when evaluating patellar stability.

Lack of race/ethnic minority representation in ulnar collateral ligament reconstruction in baseball athletes: a systematic review.

OBJECTIVES: To assess the reporting and representation of ethnic and racial minorities in comparative studies of ulnar collateral ligament (UCL) injuries and treatment in baseball athletes. METHODS: A systematic review of the literature was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. The literature search was conducted by two independent reviewers using the PubMed, Scopus, and Cochrane Library databases. Studies were included if they were UCL of the elbow clinical comparative studies, including randomized clinical trials, cohort studies, case series, and epidemiological studies. Studies were excluded if they were related to ulnar collateral ligament of the thumb, lateral ulnar collateral ligament of the elbow, biomechanical studies, non-surgical studies, non-baseball studies, and systematic reviews and meta-analyses. The Methodological Index for Non-Randomized Studies (MINORS) criterion was used to assess quality of studies included. RESULTS: A total of 108 studies were included for analysis, of which only one reported race and ethnicity in their demographics. Additionally, of the 108 studies included, only four reported Country of Origin, a subset of Race and Ethnicity, in their demographics. CONCLUSION: Race and Ethnicity demographics are scarcely reported in comparative studies evaluating ulnar collateral ligament reconstruction. Future studies evaluating similar populations should strongly consider reporting racial and ethnic demographics as this may provide clarity on any potential effect these might have on post-surgical outcomes, particularly in high-level pitchers.

Agreement between intraoperative and magnetic resonance imaging assessments of rotator cuff pathology and 2 magnetic resonance imaging-based assessments of supraspinatus muscle atrophy.

Background: Magnetic resonance imaging (MRI)-based rotator cuff assessment is often qualitative and subjective; few studies have tried to validate such preoperative assessments. This study investigates relationships of preoperative MRI assessments made by conventional approaches to intraoperative findings of tear type, location, and size or MRI-assessed muscle occupation ratio. Methods: Intraoperatively, surgeons assessed tear type, location, anterior-posterior (AP) width, and medial-lateral length in 102 rotator cuff repair patients. Two musculoskeletal radiologists independently assessed the preoperative MRI scans for these same parameters and supraspinatus muscle atrophy by both Warner classification and quantitative occupation ratio. Exact agreement proportions, kappa statistics, and correlation coefficients were used to quantify agreement relationships. Results: Agreement between MRI readers' and surgeons' observations of tear status averaged 93% with κ = 0.38, and that of tear location averaged 77% with κ = 0.50. Concordance correlations of MRI and intraoperative measures of anterior-posterior and medial-lateral tear length averaged 0.59 and 0.56 across readers, respectively. Despite excellent interrater agreement on Warner classification (exact agreement proportion 0.91) and occupation ratio (concordance correlation 0.93) separately, correlations between these 2 measures were -0.54 and -0.64 for the 2 readers, respectively. Patients with Warner grade 0 had occupation ratios ranging from 0.5 to 1.5. Conclusion: Correlations of preoperative MRI tear dimensions and muscle atrophy assessed by conventional approaches with intraoperatively measured tear dimensions and quantitative occupation ratio, respectively, were only fair. Since tear size and muscle atrophy are known strong predictors of outcomes following rotator cuff repair that may influence treatment decisions, surgeons need to be aware of the limitations of MRI methods. Continued development and validation of quantitative preoperative imaging methods to accurately assess these parameters are needed to improve surgical planning and prognosis.

Evaluation of Health Care Disparities in Patients With Anterior Cruciate Ligament Injury: Does Race and Insurance Matter?

Background: It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR). Hypothesis: Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS). Results: The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear. Conclusion: There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear.

Posteromedial Tibial Bone Bruise After Anterior Cruciate Ligament Injury: An MRI Study of Bone Bruise Patterns in 208 Patients.

Background: Bone bruise patterns after anterior cruciate ligament (ACL) rupture may predict the presence of intra-articular pathology and help explain the mechanism of injury. Lateral femoral condyle (LFC) and lateral tibial plateau (LTP) bone bruises are pathognomic to ACL rupture. There is a lack of information regarding medial tibial plateau (MTP) and medial femoral condyle (MFC) bone bruises. Purpose: To summarize the prevalence and location of MTP bone bruises with acute ACL rupture and to determine the predictors of MTP bone bruises. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Inclusion criteria were patients who underwent ACL reconstruction between February 2015 and November 2017, magnetic resonance imaging (MRI) within 90 days of injury, and participation in the database. Exclusion criteria included previous ipsilateral surgery, multiligamentous injuries, and incomplete imaging. Due to the large number of cases remaining (n = 600), 150 patients were selected randomly from each year included in the study, for a total of 300 patients. Two readers independently reviewed injury MRI scans using the Costa-Paz bone bruise grading system. Logistic regression was used to identify factors associated with MTP bone bruises. Results: Included were 208 patients (mean age, 23.8 years; mean body mass index, 25.6). The mechanism of injury was noncontact in 59% of injuries, with over half from soccer, basketball, and football. The median time from injury to MRI scan was 12 days. Of the 208 patients, 98% (203/208) had a bone bruise, 79% (164/208) had an MTP bone bruise, and 83% (172/208) had bruises in both medial and lateral compartments. The most common pattern, representing 46.6% of patients (97/208), was a bruise in all 4 locations (MFC, LFC, MTP, and LTP). Of the 164 MTP bruises, 160 (98%) involved the posterior third of the plateau, and 161 were grade 1. The presence of an MFC bruise was the only independent risk factor for an MTP bruise (odds ratio, 3.71). The resulting nomogram demonstrated MFC bruise, sport, and mechanism of injury were the most important predictors of an MTP bruise. Conclusion: MTP bruise after acute ACL rupture was as prevalent as lateral bruises. The presence of a posterior MTP bruise suggested anterior tibial translation at the time of injury and could portend more medial compartment pathology at the time of injury than previously recognized.

Factors Associated With Pain and Function Before Medial Patellofemoral Ligament Reconstruction.

Background: Medial patellofemoral ligament (MPFL) reconstruction is performed to treat recurrent patellar instability. Measurement of joint pain and function at the time of surgery has been demonstrated to be a predictor of the final outcomes in many surgical procedures. Purpose/Hypothesis: The purpose of this study was to evaluate the relationship between baseline patient characteristics, mental health, and intraoperative findings and patient-reported knee pain and function at the time of MPFL reconstruction. We hypothesized that patient characteristics and associated pathology would be associated with the degree of pain and dysfunction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were skeletally mature patients who underwent unilateral open MPFL reconstruction between 2015 and 2020 at a single institution. Baseline descriptive information was collected, and the following outcome measures were administered preoperatively: the Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS) and the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain, Physical Function Short Form (PS), and Quality of Life (QoL) subscales. Intraoperative findings were collected in a standardized format. Patient characteristics, preoperative variables, intraoperative findings, and VR-12 MCS were used as risk factors, and multivariate analysis was conducted to assess for relationships with the KOOS subscale scores. Results: In total, 201 patients with patella dislocations were included in this analysis. Intraoperatively, 122 patients (60.7%) had either normal cartilage or grade 1 or 2 cartilage injury, 79 patients (39.3%) had grade 3 or 4 cartilage injury, 35 patients (17.4%) had a loose body, and 3 patients (1.49%) had evidence of synovitis. Younger age (P = .012), male sex (P < .001), never having smoked (P = .029), and lower baseline VR-MCS (P < .001) were significantly associated with higher baseline KOOS Pain scores. Older age (P = .035), female sex (P = .003), higher body mass index (P = .005), and lower baseline VR-12 MCS (P < .001) were significantly associated with higher baseline KOOS PS scores. Younger age (P = .003), male sex (P < .001), lower baseline VR-12 MCS (P < .001), and no dysplasia (P = .023) were significantly associated with higher baseline KOOS QoL scores. Conclusion: Patient age, sex, and baseline VR-12 MCS were associated with all 3 baseline KOOS subscale scores, whereas intraoperative findings outside of trochlear dysplasia were not associated with any of the KOOS subscale scores.

Are There Racial Disparities in Knee Symptoms and Articular Cartilage Damage in Patients Presenting for Arthroscopic Partial Meniscectomy?

The purpose of the present study was to examine whether Black patients presenting for arthroscopic partial meniscectomy (APM) have worse baseline knee pain, worse knee function, and greater articular cartilage damage than White patients. Methods: A cohort of 3,086 patients (84% of whom were White; 13%, Black; and 3%, other race, with a median age of 53 years) who underwent APM were enrolled. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with the preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) for pain (KOOS-pain) and the KOOS-Physical Function Short Form (KOOS-function) and the intraoperative assessment of cartilage damage (highest modified Outerbridge grading) were determined by multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Summary (VR-12 MCS) score. Results: The 3 factors most strongly associated with worse KOOS-pain and KOOS-function were a lower VR-12 MCS score, increased BMI, and increased age. The 3 factors most strongly associated with higher-grade articular cartilage damage were increased age, increased BMI, and meniscal tear location. All of these factors had an unequal distribution between Black and White patients. After adjusting for confounding variables, the KOOS-pain score for Black patients was a mean of 2.6 points lower than that for White patients regardless of insurance status; the KOOS-function score for Black patients with commercial insurance was a mean of 2.4 points lower than that for White patients with commercial insurance but was not lower than that for Black patients on Medicare. Compared with commercially insured White patients, commercially insured Black patients had 1.4-fold greater odds of having higher-grade articular damage, and no difference in risk was detected among Medicare-insured Black patients. Conclusions: There are clinically important differences in the distribution of risk factors between Black and White patients presenting for APM regarding several factors associated with worse knee pain, knee function, and greater articular cartilage damage. When controlling for these confounding factors, a significant, but not clinically relevant, racial disparity remained with respect to knee pain, knee function, and cartilage damage. Two of the 3 major risk factors for all 3 included age and BMI. The third factor for knee pain and function was mental health, and the location of a meniscal tear was the third factor for articular cartilage damage. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Elevated Patellofemoral and Tibiofemoral T1ρ Relaxation Times Following a First Time Patellar Dislocation.

OBJECTIVE: The study was performed to evaluate cartilage within the knee following a first-time patellar dislocation, using elevated MRI-based T1ρ relaxation times as an indicator of low proteoglycan concentration. The hypothesis is that MRI-based T1ρ relaxation times for patellofemoral and tibiofemoral cartilage are significantly longer for knees being treated for patellar dislocation than for healthy control knees. DESIGN: Twenty-one subjects being treated for a first-time, unilateral dislocation of the patella and 16 healthy controls participated in MRI-based T1ρ relaxation time mapping. Mean relaxation times were quantified for patellofemoral and tibiofemoral regions for injured knees, the contralateral knees, and healthy controls. T1ρ values for each region were compared between the 3 groups with generalized estimating equations. Linear regressions were also performed to correlate T1ρ relaxation times with time from injury. RESULTS: The knees with a disloction had longer T1ρ relaxation times than the contralateral knees and control group at the medial patella and longer relaxation times than the control group at the lateral tibia (P < 0.05). T1ρ relaxation times at the medial patella also decreased with time from injury (r2 = 0.21, P = 0.037). CONCLUSIONS: Compositional changes to cartilage on the medial patella are related to traumatic impact during a dislocation. Potential exists for cartilage properties at the medial patella to improve with time. Cartilage degradation at the lateral tibia is not directly related to traumatic impact. The current baseline data are a starting point to characterize the pathway from a first-time dislocation to progressive cartilage degradation and osteoarthritis.

Opioid Use After Simple Arthroscopic Knee Surgery.

BACKGROUND: Evidence-based prescribing guidelines are lacking for opioids after most orthopaedic surgical procedures. HYPOTHESIS: Opioids are commonly overprescribed after simple knee arthroscopy. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A cohort of 174 patients who underwent simple arthroscopic knee surgery were prospectively evaluated using data from the Outcome Management and Evaluation database. All patients received 10 combined hydrocodone 5 mg and acetaminophen 325 mg pills postoperatively. Patients were excluded if they (1) had revision surgery, (2) had concomitant complex surgery (eg, ligament surgery, osteotomy), (3) had current opioid use, (4) had open surgery for removal of hardware, (5) or had bilateral knee surgery. Total opioid consumption was reported at the first postoperative visit, and a distribution was created based on patient response. Based on the distribution, patients were separated into low (0-2 pills) versus high (3 or more pills) opioid consumption groups for evaluating risk factors for opioid use. The risk factors included were age, body mass index, smoking status, education level, baseline pain (Knee injury and Osteoarthritis Outcome Score pain subscale [KOOS Pain]), and baseline mental health (Veterans RAND 12-Item Health Survey Mental Component Score), as well as intraoperative findings such as synovial characteristics and extent of osteoarthritis in the multivariate model. RESULTS: Total opioid consumption ranged from 0 to 19 pills. The median pill count was 2 (25th; 75th interquartile range, 0; 4). Of total patients, 59% were categorized as having low opioid consumption, and the remaining 41% were in the high opioid consumption group. Only 23 patients (13.2%) took 6 or more pills. Preoperative pain as measured by KOOS Pain score was a significant predictor of high opioid consumption postoperatively (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .003). CONCLUSION: The clinically relevant conclusion is that opioids are overprescribed after simple arthroscopic knee surgery. Based on distribution, the authors recommend that 4 pills be prescribed after simple arthroscopic knee surgery. After accounting for confounding variables, preoperative pain was associated with higher postoperative opioid consumption.

Evaluation of Differences Between Non-Hispanic White and African American Patients With Sports Medicine-Related Hip Disabilities.

BACKGROUND: Racial disparities within the field of orthopaedics are well-documented in the spinal surgery, knee arthroplasty, and hip arthroplasty literature. Not much is known about racial differences in patients with sports medicine-related hip disabilities. PURPOSE: To investigate whether differences exist between African American and non-Hispanic White (White) patients evaluated for hip disabilities. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a multicenter retrospective cohort study of 905 patients who were evaluated over a 1-year period for hip-related orthopaedic concerns. Patient demographic data, disability characteristics, and hip radiographic findings were obtained from electronic medical records. We also obtained data on whether patients were offered physical therapy, magnetic resonance imaging (MRI), and/or surgery. Comparisons by race and insurance status were evaluated using univariate and multivariate analyses. RESULTS: African Americans comprised a significantly lower proportion of the patients evaluated for hip-related disabilities compared with Whites (6.5% vs 93.5%; P < .001). A significantly smaller proportion of African Americans with hip disabilities was recommended for surgery than White patients (35.6% vs 54.6%; P = .007). Cam deformities were more common in White vs African American patients (39.7% vs 23.7%; P = .021), as were labral tears (54.1% vs 35.6%; P = .009). Logistic regression demonstrated that neither race nor insurance status were significant determinants in surgery recommendations. Conversely, race was a determinant of whether an MRI was performed, as White patients were 2.74 times more likely to have this procedure. There were no differences with respect to obtaining an MRI between private and Medicaid insurance. CONCLUSION: Compared with White patients, there were differences in both the proportion of African Americans evaluated for hip-related disabilities and the proportion receiving a surgery recommendation. African Americans with sports medicine-related hip issues were also less likely to obtain an MRI. With regard to observed pathology, African American patients were less likely to have cam deformities and labral tears than White patients.

Patellar Tendon Imbrication for Patella Alta.

Patella alta is a significant contributor to patellar instability. Historically, distalizing tibial tubercle osteotomy has been recommended for this problem; however, complications such as nonunion, fracture and hardware irritation are concerning. Additionally, the procedure cannot be performed on skeletally immature patients without violation of the proximal tibial physis. The authors describe a technique of patellar tendon imbrication that does not involve hardware or osteotomy. This technique allows for reliable correction of patella alta and provides patellar stability without the complications associated with osteotomy.

Patient-Reported Outcomes After a Modified Albee Procedure.

BACKGROUND: Trochlear dysplasia (TD) is a recognized condition that can become a risk factor for patellofemoral instability. A modified Albee osteotomy procedure using a trapezoidal-shaped wedge to elevate the lateral wall of the trochlea can be used with the goal of preventing further dislocation. However, outcomes studies are lacking, and scores on patient-reported outcome measures (PROMs) are largely unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to identify PROM scores for the Kujala Anterior Knee Pain Scale (AKPS), International Knee Documentation Committee (IKDC), Activity Rating System (ARS), and 100-point pain visual analog scale (VAS) for patients having undergone the modified Albee osteotomy. The hypothesis was that patients will have acceptable pain and function at mid- to long-term follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2017, a total of 46 consecutive patients (49 knees) underwent a modified Albee procedure by a single surgeon at a single health care system. These 46 patients were contacted and asked to complete the AKPS, IKDC, ARS, and pain VAS. Additional demographic information was obtained via chart review. Frequencies and rates for categorical variables and means and standard deviations for continuous variables of the demographics and PROM scores were calculated. RESULTS: PROM scores were obtained in 28 (30 knees; 61%) of the 46 patients. At minimum follow-up of 82 months, the mean scores were 78.5 ± 18.2 for AKPS, 61.2 ± 11.4 for IKDC, 5.2 ± 5.3 for ARS, and 24.4 ± 28.7 for VAS pain. Notably, only 1 of the 28 patients reported a patellofemoral dislocation since surgery, and this was an isolated incident without further instability. CONCLUSION: A modified Albee trochlear osteotomy can be a successful adjunctive procedure to prevent recurrent patellar dislocations in patients with mild TD. However, owing to the loss of one-third of patient follow-up scores and the absence of baseline function scores in this study, the procedure deserves further investigation as a way to address a particularly difficult dilemma for a select subset of patients with patellofemoral instability.