Autograft and Allograft ACLR in Patients Greater Than 40 Years Old Have Similar Short-Term Patient-Reported Outcomes with Higher Rates of ACL Graft Failure in Allograft Patients.

PURPOSE: The purpose of this study was to evaluate short-term patient-reported outcomes (PROs) in patients aged 40 and older after primary ACLR between patients that received allograft or autograft. Secondary aims included assessing the effect of pre-existing osteoarthritis on short-term PROs. METHODS: A retrospective review of an ambulatory surgery center's electronic medical record was conducted for patients who underwent primary ACLR between 2009 and 2022. Patients aged younger than 40, those who underwent index revision procedures and/or concomitant ligament repair/reconstructions, and those with incomplete baseline or short-term (1- or 2-year) KOOS scores were excluded. Allograft and autograft patients were matched according to sex and body mass index (BMI) in a 2:1 fashion. PROs used included KOOS and Single Assessment Numeric Evaluation (SANE) at baseline and short-term follow up (minimum of 1 year). Minimum clinically important difference was calculated in a distribution-based fashion. Osteoarthritis severity was determined based on Kellgren-Lawrence grading of perioperative knee x-rays. Preexisting osteoarthritis was defined as KL grade 1 or more. RESULTS: A total of 331 patients were included after matching (215 allograft and 116 autograft patients). The average age was 47.7 ± 6.0 (range: 40-66). Age differed significantly between the two groups, with the allograft cohort having an average age of 48.6 ± 6.0 years and the autograft cohort having an average age of 46.1 ± 5.7 years (p < 0.001). Short-term change in KOOS and SANE scores did not differ by graft type (p = 0.154, p = 0.556, respectively). Sixty-seven percent of all patients met MCID for KOOS and 82% of patients with complete baseline and short-term SANE scores met MCID for SANE. There was a statistically significant difference in rupture rates between the allograft and autograft cohorts (n = 9 allograft vs n = 0 autograft; p = 0.030). There was no difference in re-operation rates between the autograft and allograft cohorts (p = 0.453). Perioperative Kellgren-Lawrence grading did not affect outcomes for either graft type (allograft: p = 0.905 vs. autograft: p = 0.522). CONCLUSION: Middle-aged patients undergoing ACLR with allograft or autograft demonstrate similar short-term patient reported outcomes. Pre-existing osteoarthritis similarly did not significantly affect short-term outcomes. However, rerupture rates were significantly higher in the allograft cohort than the autograft cohort. LEVEL OF EVIDENCE: Level III - Therapeutic.

Similar two-year improvement in patient-reported outcomes in patients 40 years and older with outerbridge grade III and IV lesions following ACL reconstruction.

PURPOSE: This study aims to evaluate clinical and patient-reported outcome measures (PROMs) of patients 40 years and older that underwent anterior cruciate ligament reconstruction (ACLR) and determine the influence of preexisting arthritis and chondral wear on ACLR outcomes. We hypothesized that patients aged 40+ with ACLR would have excellent clinical outcomes and PROMs regardless of preexisting arthritic changes. METHODS: A total of 118 patients were included. Patients aged 40 years and older who underwent ACLR in a single healthcare system between 2009 and 2016 were eligible. Outcomes assessed include Knee Injury and Osteoarthritis Outcome Scores (KOOS), Single Assessment Numeric Evaluation (SANE) scores, intraoperative Outerbridge grading, preoperative Kellgren-Lawrence (KL) grading and postoperative complication rates over a 2-year period. RESULTS: Average increase in KOOS and SANE scores were 21.2 ± $\pm $ 19.9 and 23.5 ± $\pm $ 31.3, respectively. Patients with Outerbridge grade III and IV lesions in weight-bearing compartments had lower baseline SANE and KOOS scores than those without (47.1 ± 22.0 vs. 64.5 ± 23.6 baseline SANE and 43.1 ± 18.1 vs. 63.5 ± 15.9 baseline KOOS; p = 0.002 and p < 0.001, respectively) with no significant difference in the amount of change in SANE or KOOS scores (p = 0.111 and p = 0.165 respectively). Patients with KL-grade 2+ osteoarthritis experienced similar changes in KOOS and SANE over the 2-year period to their counterparts (p = 0.598 and p = 0.643, respectively). CONCLUSION: There is no correlation between preexisting osteoarthritic changes or chondral defects and PROs. KOOS and SANE scores both increased postoperatively. When treating older patients with an ACL tear, surgeons should consider the activity level and desires of the patient as they determine appropriate treatment. Preexisting osteoarthritis does not correlate with patient-reported outcomes for ACLR. LEVEL OF EVIDENCE: Level IV.

Acute Surgical Site Complications in Direct Anterior Total Hip Arthroplasty: Impact of Local Subcutaneous Tissue Depth and Body Mass Index.

Background: Body mass index (BMI) is an imperfect measure of patients' adiposity and operative risk. Radiographic and direct subcutaneous measurements have been utilized in attempts to more accurately characterize the risk of postoperative complications, including surgical site infection. This study aims to evaluate whether direct tissue depth measurement is a more accurate predictor of skin complication following direct anterior total hip arthroplasty (THA). Methods: A retrospective chart review of patients who underwent elective THA between April 30, 2020, and January 31, 2023, was performed. Baseline demographics, antibiotics, anticoagulation, and intraoperatively measured tissue depths at proximal, middle, and distal portions of the incision were recorded. Patient follow-up was reviewed to assess the development of skin complication in the acute postoperative period. Results: Data were collected from 280 patients who underwent THA via direct anterior approach by a single surgeon. The mean age was 66.0 years, and 52.1% were female. A total of 18/280 (6.4%) patients developed an abrasion (5/18) or superficial surgical site infection (13/18) within the first 60 days postoperatively. Patients who developed skin complications had a significantly higher BMI (33.7 kg/m2 vs 29.9 kg/m2; P = .0021). Patients with a BMI >30 kg/m2 had more than 5 times increased odds of developing a superficial skin complication in the acute 60-day postoperative period compared to those with a BMI <30 kg/m2 (Odds ratio = 5.318, P = .0059). None of the measured tissue depths, nor their average together, were shown to be significant predictors of skin complications. Conclusions: This study showed that BMI is a significant predictor of acute skin complications in direct anterior THA patients. No other significant predictors were found to be associated with increased risk, including proximal, middle, and distal tissue depths.

Effect of post-operative NSAID use on rotator cuff repair outcomes.

Background: The impact of non-steroidal anti-inflammatory drugs (NSAIDs) on rotator cuff repair is an ongoing area of study within orthopedics, with conflicting results in current literature. Despite concerns over the deleterious effects of NSAIDs on rotator cuff healing, they are becoming an integral part of a multimodal post-operative pain control regiment. The purpose of this study was to compare post-operative patient-reported outcomes (PROs), complications rates, and retear rates of arthroscopic rotator cuff repairs in patients using ibuprofen post-operatively to those who abstained from NSAIDs for six weeks after surgery. It was hypothesized that a short course of ibuprofen post-operatively would not lead to inferior PRO scores, increased retear rates, nor increased complication rates after arthroscopic rotator cuff repair. Methods: Patients of the primary surgeon who underwent arthroscopic rotator cuff repair between 2012 and 2022 were evaluated by retrospective chart review. In May 2017 the primary surgeon changed his protocol from avoiding NSAIDs for six weeks after surgery to routinely prescribing two weeks of Ibuprofen 800 mg TID post-operatively. Patients who avoided NSAIDs for six weeks were compared to patients who were prescribed NSAIDs post-operatively. Patient demographic data, pre-operative MRI results, pre-operative and post-operative PROs were collected from the EMR. Additionally, post-operative complications and repair failures requiring reoperation within one year were evaluated. Results: 125 patients met inclusion criteria for this study with 36 patients in the NSAID group and 89 in the no NSAID group. When comparing improvement in PROs, the NSAID group reached MCID at one year in 83.8 % of patients and the no NSAID group reached MCID at one year in 73.9 % of patients. There was no significant difference between the groups in reaching MCID improvement at one year (p = 0.471). Five post-operative complications were reported in the no NSAID group and two in the NSAID group (5.7 % vs 5.4 %, respectively, p = 0.827). Finally, there was no significant difference in the percentage of post-operative rotator cuff repair failures requiring revision in the first year between the groups (2.3 % vs 2.7 %, p = 1.000). Conclusion: There was no difference in percent of patients improving their PRO by the MCID between the groups that used ibuprofen and the group that did not. There was also no difference in post-operative complication rates and rates of symptomatic retear requiring reoperation between the groups. This supports that a short course of NSAIDs post-operatively, specifically ibuprofen, after rotator cuff repair does not increase reoperation rates nor lead to a clinically significant decrease in PROs at one year.

Limb Length Discrepancy After Intraosseous Line Malpositioning: A Case Report.

CASE: We will present the case of a 6-year-old girl who presented with a 3-cm limb length discrepancy after intraosseous line placement at age 14 months without other known history of trauma or infection to account for the growth arrest. Imaging revealed a left proximal tibial physeal bar amenable to surgical resection with autologous lipotransfer. At 10 months postoperatively, physical examination and imaging demonstrated a stable 3-cm leg length discrepancy with an interval increase in the length of the left tibia in proportion to the growth of the right side with an increase in valgus alignment that will continue to be monitored and addressed as indicated. CONCLUSION: Pediatric intraosseous line placement presents unique challenges and can ultimately lead to physeal injury and growth arrest in the case of malpositioning.

Outcomes of Name-brand Versus Generic Cephalomedullary Nail Fixation for Intertrochanteric and Subtrochanteric Fractures: A Matched Cohort Study.

This study aims to compare 90-day and 6-month outcomes and implant costs of intertrochanteric and subtrochanteric fracture fixation using cephalomedullary nails (CMNs) from a single name-brand company to fixation using generic CMNs. This was a retrospective matched cohort study. All CMN procedures for a single surgeon in a single US metropolitan institution from 2021 to 2022 were identified using current procedural terminology codes. Nearest neighbor 1:1 matching was conducted between the name-brand and generic cohorts controlling for (1) age, (2) American Society of Anesthesiologists score, and (3) Charlson Comorbidity Index. A total of 50 patients were successfully matched (25 namebrand versus 25 generic). The average implant cost per case for the name-brand group was $3,587 versus $1,615 for the generic group. Cost of disposables averaged $109 for the generic implant sets versus $916 for the name-brand (P < 0.001). Overall, a cost savings of 61% could be generated per case with the use of generic implants and disposables. Fixation of intertrochanteric and subtrochanteric fractures using generic CMNs produces similar outcomes compared with using name-brand CMNs for approximately half the implant cost.

Early Versus Delayed Definitive Fixation Relative to Fasciotomy Closure in High-Energy Tibial Plateau Fractures With Compartment Syndrome.

OBJECTIVES: To evaluate the timing of definitive fixation of tibial plateau fractures relative to fasciotomy closure with regard to alignment and articular reduction. DESIGN: Retrospective case series. SETTING: Four Level I trauma centers. PATIENT SELECTION CRITERIA: Patients with tibial plateau fractures (TPF) with ipsilateral compartment syndrome treated with fasciotomy between 2006 and 2018 met inclusion criteria. Open fractures, patients younger than 18 years, patients with missed or delayed treatment of compartment syndrome, patients with a diagnosis of compartment syndrome after surgical fixation, and patients whose plateau fracture was not treated with open reduction and internal fixation were excluded. Patients were divided into 2 groups depending on the relative timing of fixation to fasciotomy closure: early fixation (EF) was defined as fixation before or at the time of fasciotomy closure, and delayed fixation (DF) was defined as fixation after fasciotomy closure. OUTCOME MEASURES AND COMPARISONS: Radiographic limb alignment (categorized as anatomic alignment (no varus/valgus), ≤5 degrees varus/valgus, or >5 degrees varus/valgus) and articular reduction (categorized as anatomic alignment with no residual gap or step-off, <2 mm, 2-5 mm, and >5 mm of articular surface step-off) were compared between early and delayed fixation groups. In addition, superficial and deep infection rates were compared between those in the EF and DF cohorts. Subgroup analysis within the EF cohort was performed to compare baseline characteristics and outcomes between those that received fixation before closure and those that underwent concurrent fixation and closure within one operative episode. RESULTS: A total of 131 patients met inclusion criteria for this study. Sixty-four patients (48.9%) were stratified into the delayed fixation group, and 67 patients (51.1%) were stratified into the early fixation group. In the EF cohort, 57 (85.1%) were male patients with an average age of 45.3 ± 13.6 years and an average body mass index of 31.0 ± 5.9. The DF cohort comprised primarily male patients (44, 68.8%), with an average age of 46.6 ± 13.9 years and an average body mass index of 28.4 ± 7.9. Fracture pattern distribution did not differ significantly between the early and delayed fixation cohorts ( P = 0.754 for Schatzker classification and P = 0.569 for OTA/AO classification). The relative risk of infection for the DF cohort was 2.17 (95% confidence interval, 1.04-4.54) compared with the EF cohort. Patients in the early fixation cohort were significantly more likely to have anatomic articular reduction compared with their delayed fixation counterparts (37.5% vs. 52.2%; P < 0.001). CONCLUSIONS: This study demonstrated higher rates of anatomic articular reduction in patients who underwent fixation of tibial plateau fractures before or at the time of fasciotomy closure for acute compartment syndrome compared with their counterparts who underwent definitive fixation for tibial plateau fracture after fasciotomy closure. The relative risk of overall infection for those who underwent fasciotomy closure after definitive fixation for tibial plateau fracture was 2.17 compared with the cohort that underwent closure before or concomitantly with definitive fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improved Patient-reported Outcomes in Patients Aged 16 and Younger at Two Years After Anterior Cruciate Ligament Reconstruction Despite Relatively High Rates of Reinjury and Repeat Surgery.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) in adolescent patients, particularly those aged 16 and under, are increasingly common procedure that lacks robust clinical and patient-reported outcome (PRO) data. The purpose of this study was to report 2-year PROs of patients receiving ACLR aged 16 or younger using the single assessment numerical evaluation (SANE) and knee injury and osteoarthritis outcome score (KOOS). Secondary aims included characterizing treatment characteristics, return to sport (RTS), and clinical outcomes. METHODS: The institutional PRO database was queried for patients receiving ACLR from 2009 to 2020. Patients aged older than 16, revision procedures, concomitant ligament repairs/reconstructions, and patients without full outcome data at 2 years were excluded. Outcomes over 2 years after ACLR included SANE, KOOS, reinjuries, reoperations, and time to RTS. RESULTS: A total of 98 patients were included with an average age of 15.0 years. Most patients were females (77.6%). Bone-tendon-bone autograft (69.4%) was the most used. Average RTS was 8.7 months (range: 4.8 to 24.0 mo), with 90% of patients eventually returning to sport. A total of 23 patients (23.5%) experienced a reinjury and 24.5% (n = 24) underwent reoperation. Timing to RTS was not associated with reinjury, but patients who returned between 9.5 and 13.7 months did not sustain reinjuries. Mean KOOS and SANE scores at 2 years were 87.1 and 89.1, respectively, with an average improvement of +18.4 and +22.9, respectively. Change in KOOS was negatively impacted by reinjury to the anterior cruciate ligament graft and reoperation (anterior cruciate ligament failure: +10.0 vs 19.3, P = 0.081, respectively; reoperation: +13.2 vs +20.1, P = 0.051, respectively), though these did not reach statistical significance. CONCLUSION: Patients experienced improved SANE and KOOS scores after ACLR. Rates of reinjury and reoperation were relatively high and negatively impacted PRO scores but were not associated with the timing of RTS. Adolescent patients should be counseled regarding the risk of subsequent ipsilateral and contralateral knee injury after ACLR. LEVEL OF EVIDENCE: Level IV-case series.