Patient Preferences for Graft Selection in Anterior Cruciate Ligament Reconstruction.

Background: Selecting an appropriate graft for anterior cruciate ligament (ACL) reconstruction requires consideration of a patient's preferences, goals, age, and physical demands alongside the risks and benefits of each graft choice. Purpose: To determine the most popular ACL reconstruction grafts among patients and the most important factors influencing their decisions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients undergoing ACL reconstruction between October 2022 and April 2023 completed a survey either before (nonconsult group) or after (consult group) speaking with their surgeon, who provided an evidence-based description of the pros and cons of an allograft and the following autografts: bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT). Patient characteristics, graft choice, information influencing their graft choice, and surgeon recommendation were collected and compared between the groups. Results: Among the 100 included patients, 59.0% were male, and the mean age was 28.3 ± 10.4 years. The most popular grafts were the BPTB (56.0%), followed by the QT (29.0%), HT (8.0%), and allograft (7.0%). No significant difference was observed in the graft selection between the consult group (n = 60; BPTB, 46.7%; QT, 38.3%; HT, 8.3%; allograft, 6.7%) and nonconsult group (n = 40; BPTB, 70.0%; QT, 15.0%; HT, 7.5%; allograft, 7.5%) (P = .0757). In the consult group, 81.7% of patients selected the graft recommended to them by their surgeon. The top 2 graft selection reasons were usage in professional athletes and failure rates, while the top 2 ACL surgery concerns were returning to their desired level of athletics and graft failure risk. Among the 93 patients who researched their ACL graft options before their visit, the most popular information source was some form of media (72.0% [67/93]). Conclusion: The study findings underscore the importance of patient preference and surgeon recommendation in a patient's graft selection and highlight the need to be cognizant of the information sources available to patients when researching their graft options.

Clinical Outcomes of a Novel Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Large Single-Center Case Series With a Minimum 2-Year Follow-up.

Background: A novel hybrid transtibial (HTT) approach to femoral tunnel drilling in anterior cruciate ligament reconstruction (ACLR) has been developed that circumvents the need for knee hyperflexion and orients the graft in the most anatomic position without sacrificing the tunnel length or aperture. Hypothesis: Patients who underwent ACLR utilizing the HTT technique would achieve excellent patient-reported outcome scores and experience low rates of graft failure and reoperations. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent primary ACLR at a single institution between 2005 and 2020 were retrospectively reviewed. Patients treated with the HTT, anteromedial portal (AMP), and transtibial (TT) approaches were matched based on age, sex, and body mass index ±3 kg/m2. Demographic and surgical data as well as femoral tunnel angle measurements on anteroposterior and lateral radiographs were collected for the 3 groups. However, clinical outcomes were only reported for the HTT group because of concerns of graft heterogeneity. Results: A total of 170 patients (median age, 26.5 years [interquartile range (IQR), 18.0-35.0 years]) who underwent ACLR using the HTT approach were included. The median coronal- and sagittal-plane femoral tunnel angles were 47° (IQR, 42°-53°) and 40° (IQR, 34°-46°), respectively. The sagittal-plane femoral tunnel angles in the HTT group were significantly more horizontal compared with those in the TT group (P < .0001), whereas the coronal-plane femoral tunnel angles in the HTT group were found to be significantly more vertical compared with those in the AMP group (P = .001) and more horizontal compared with those in the TT group (P < .0001). The graft failure and reoperation rates in the HTT group at a minimum 2-year follow-up were 1.8% (3/170) and 4.7% (8/170), respectively. The complication rate was 6.5% (11/170), with the most common complication being subjective stiffness in 7 patients. The median Lysholm score was 89.5 (IQR, 79.0-98.0); the median International Knee Documentation Committee score was 83.9 (IQR, 65.5-90.8); and the median Veterans RAND 12-Item Health Survey physical and mental component summary scores were 55.0 (IQR, 52.6-55.9) and 56.2 (IQR, 49.1-59.3), respectively. Conclusion: ACLR using the HTT technique was associated with low graft retear and revision surgery rates and good patient-reported outcome scores at medium-term follow-up and demonstrated femoral tunnel obliquity on postoperative radiographs that correlated with optimal parameters previously reported in cadaveric and biomechanical studies.

Perioperative non-opioid analgesia strategies after high tibial osteotomy: a systematic review of prospective studies.

PURPOSE: Little is known about the optimal analgesia regimen after HTO. Thus, this study systematically reviewed the literature on clinical and patient-reported outcomes of pain management strategies for patients after HTO. METHODS: A comprehensive search of the PubMed, Cochrane CENTRAL, and CINAHL databases was conducted from inception through September 2023. Studies were included if they evaluated pain reduction with analgesia strategies after HTO and were excluded if they did not report pain control outcomes. RESULTS: Five studies with 217 patients were included. Patients with a multimodal intraoperative injection cocktail to the knee, femoral nerve block (FNB), or adductor canal block (ACB) for HTO had significant improvement in visual analog scale (VAS) and numerical rating scale (NRS) scores in the first 12 h postoperatively compared to controls. Patients on duloxetine had significantly lower NRS scores at 1, 7, and 14 days postoperatively and significantly lower nonsteroidal anti-inflammatory drug (NSAID) usage throughout the two-week postoperative period than the control group. Patients receiving an ACB had significantly lower opioid consumption than controls at 12 h postoperative. In patients with an FNB or ACB, no significant difference in quadriceps strength or time to straight leg raise postoperatively was observed compared to controls. CONCLUSION: A multimodal periarticular injection cocktail, FNB, or an ACB effectively reduces pain on the first day after HTO, with an ACB able to reduce opioid consumption on the first postoperative day. Duloxetine combined with an ACB effectively decreases pain for two weeks postoperatively while reducing NSAID consumption in patients after HTO. LEVEL OF EVIDENCE: IV.

Early Postoperative Complications and Associated Variables After Tibial Tubercle Osteotomy: A 15-Year Experience From a Single Academic Institution.

Background: Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patients with patellofemoral disorders. Purpose: To determine the rate of early (≤90 day) postoperative complications after TTO and variables related to postoperative complications. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent TTO at a single academic institution within a 15-year period (2008-2022) were identified. All patients with a minimum 90-day follow-up were considered for study inclusion. Exclusion criteria were age younger than 14 years and revision surgery. Patient characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. Results: A total of 344 knees in 313 patients met eligibility criteria and were included in the final analysis. One intraoperative complication (0.3%), a premature closure of the incision before repair of the vastus medialis, was identified. There were 141 postoperative complications (138 surgical, 3 medical) in 118 patients for a complication rate of 34.3%. The most common complications were stiffness requiring a nonstandard-of-care intervention (16.3%), superficial wound infection/wound dehiscence (8.1%), and hemarthrosis/effusion requiring aspiration (5.8%). Patients experiencing postoperative complications were older (mean difference, 3.49 years; 95% CI, 1.26-5.73 years; P = .002), had a higher mean Charlson Comorbidity Index (mean difference, 0.26; 95% CI, 0.08-0.45; P = .006), and were more likely to be current smokers (P = .015) compared with patients with no complications. Inpatient surgery (defined as surgery in a hospital setting with at least 1 overnight stay) was associated with postoperative complications (odds ratio [OR], 2.29; 95% CI, 1.39-3.77; P = .001); this association remained significant generation of a multivariate model (OR, 2.07; 95% CI, 1.19-3.58; P = .010). Previous surgery on the ipsilateral knee (P < .001) and concomitant autologous chondrocyte implantation (P = .046) were also associated with postoperative complications. Conclusion: The study findings indicated a low intraoperative complication rate (0.3%) and a relatively high early postoperative (≤90 day) complication rate (34.3%) after TTO. Variables associated with postoperative complications included greater age, higher Charlson Comorbidity Index, surgery in an inpatient setting, previous surgery on the ipsilateral knee, and concomitant autologous chondrocyte implantation.

Early Postoperative Complications and Associated Variables After High Tibial Osteotomy and Distal Femoral Osteotomy: A 15-Year Experience From a Single Academic Institution.

BACKGROUND: High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) are well-recognized treatments to address varus and valgus malalignment, respectively, in the setting of symptomatic unicompartmental arthritis of the tibiofemoral joint. The existing literature is limited in its ability to characterize complications after HTO or DFO procedures. PURPOSE: The objective of this study was to determine the rate of early (≤90 days) postoperative complications and associated variables from the 15-year experience of a single academic institution. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients treated at a single academic institution between 2008 and 2022 who underwent HTO or DFO procedures were identified. All patients with minimum 90-day follow-up were considered for inclusion in the study. Exclusion criteria were inadequate follow-up, unavailable medical records, age <14 years, and revision osteotomy. Patient demographic characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. All intraoperative complications were recorded. RESULTS: A total of 243 knees in 232 patients met eligibility and were included in the final analysis. Three intraoperative complications (1.2%) involving fracture extension of the osteotomy occurred. There were 127 early postoperative complications (121 surgical, 6 medical) in 102 knees (68 with HTO and 34 with DFO). Medical complications included pulmonary embolus in 3 patients (1.2%), urinary tract infection in 2 patients (0.8%), and postoperative ileus requiring prolonged hospitalization in 1 patient (0.4%). The most common complications were stiffness requiring a non-standard of care intervention (17.7%), superficial wound infection or wound dehiscence (13.2%), and hemarthrosis or effusion requiring aspiration (6.6%). The rate of deep infection requiring irrigation and debridement was 4.1%. Variables associated with early postoperative complications included smoking (odds ratio [OR], 3.05; 95% CI, 1.34-6.94; P = .008), concomitant chondroplasty and/or loose body removal (OR, 2.55; 95% CI, 1.50-4.33; P = .001), and concomitant ligament reconstruction (OR, 3.97; 95% CI, 1.37-11.53; P = .011). CONCLUSION: These 15-year data revealed a low rate of intraoperative complications (1.2%) and a relatively high rate of early (≤90 days) postoperative complications (42.0%) after an HTO or DFO procedure. Surgeons should be aware of the increased postoperative complications associated with smoking, concomitant chondroplasty, and concomitant ligament reconstruction and should use this information to counsel patients regarding appropriate expectations in the postoperative period.

Inconsistencies in reporting risk factors for ulnar collateral ligament reconstruction failure: a systematic review.

BACKGROUND: When return to sport (RTS) at a competitive level is desired, treatment of injury to the ulnar collateral ligament (UCL) frequently involves surgical reconstruction. Although RTS rates between 66% and 98% have been reported, there remains a paucity of comparative clinical studies, with far fewer reporting statistically significant risk factors for reconstruction failure. The goal of this study was to perform a systematic review of the literature to demonstrate the variety and inconsistency with which risk factors associated with reconstruction failure are reported. MATERIALS AND METHODS: A systematic review of the PubMed Central and MEDLINE databases was performed to identify clinical outcome studies reporting ≥1 statistically significant risk factor associated with failure of UCL reconstruction. Failure was defined as (1) reinjury, recurrent instability, or need for revision surgery; (2) failure show improvement in postoperative patient-reported outcomes (PROs); or (3) failure to RTS at the preinjury level (RSL). RESULTS: A total of 349 unique studies were initially identified, of which 12 were deemed eligible for inclusion in our study. Of these 12 studies, 4 defined outcomes based on recurrent instability, reinjury, or revision surgery; 2 defined outcomes based on PROs; and 6 defined outcomes based on RSL. In the group with instability, reinjury, or revision failure, 11 significant risk factors were identified across all studies: age, height, body mass index, professional experience, injury to the nondominant arm, history of competitive throwing, mechanism of injury, history of a psychiatric diagnosis, presence of preoperative instability or stiffness, postoperative workload, and time to RTS. In the PRO failure group, 12 risk factors were identified across all studies: age, status as a military cadet, injury to the nondominant arm, graft type, baseball position, current injury to the ipsilateral arm, current level of competition attributed to reconstruction surgery, shoulder surgery after reconstruction, no competitive throwing history, non-throwing mechanism of injury, history of a psychiatric diagnosis, and preoperative instability or stiffness. In the RSL failure group, 4 risk factors were identified across all studies: age, ulnar neuritis, level of professional play, and amount of time spent at the professional level. CONCLUSIONS: Age, level of professional play prior to surgery, postoperative workload, and time at the professional level are the most commonly reported risk factors associated with UCL reconstruction failure. There remains a paucity of data associating risk factors with patient-specific outcomes and marked levels of inconsistency and conflict among the studies that report such data.

Adjustable-loop cortical suspension device for posterolateral corner reconstruction in the setting of fibular avulsion fracture: a case series and novel technique description.

INTRODUCTION: A novel technique using an adjustable-loop cortical suspension toggle device for reduction of a fibular head avulsion fracture (arcuate fracture) in posterolateral corner (PLC) reconstruction is described. Results of clinical follow-up are presented. MATERIALS AND METHODS: 9 patients were retrospectively identified who underwent posterolateral corner reconstruction using an adjustable-loop cortical suspension toggle device. Radiographic examination was used to evaluate the successful healing of the avulsed fibular head fragments post-operatively. RESULTS: 7 patients reported satisfactory results with their clinical outcome with no feelings of knee instability or objective instability on exam at final follow-up. Post-operative radiographs obtained > 6 months following reconstruction demonstrated well reduced and healed fracture in 5 of 6 patients, with 1 patient demonstrating maintained reduction but incomplete fracture union at 6 months. CONCLUSION: This novel surgical technique for PLC reconstruction with an avulsed fibular head fracture is a viable alternative to previously described methods. The majority of patients report subjective satisfaction with a stable knee post-operatively. LEVEL OF EVIDENCE: IV.

Isolated Osteochondral Autograft Versus Allograft Transplantation for the Treatment of Symptomatic Cartilage Lesions of the Knee: A Systematic Review and Meta-analysis.

BACKGROUND: Focal cartilage lesions of the knee remain a difficult entity to treat. Current treatment options include arthroscopic debridement, microfracture, autograft or allograft osteochondral transplantation, and cell-based therapies such as autologous chondrocyte transplantation. Osteochondral transplantation techniques restore the normal topography of the condyles and provide mature hyaline cartilage in a single-stage procedure. However, clinical outcomes comparing autograft versus allograft techniques are scarce. PURPOSE: To perform a comprehensive systematic review and meta-analysis of high-quality studies to evaluate the results of osteochondral autograft and allograft transplantation for the treatment of symptomatic cartilage defects of the knee. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 2. METHODS: A comprehensive search of the literature was conducted using various databases. Inclusion criteria were level 1 or 2 original studies, studies with patients reporting knee cartilage injuries and chondral defects, mean follow-up ≥2 years, and studies focusing on osteochondral transplant techniques. Exclusion criteria were studies with nonknee chondral defects, studies reporting clinical outcomes of osteochondral autograft or allograft combined with other procedures, animal studies, cadaveric studies, non-English language studies, case reports, and reviews or editorials. Primary outcomes included patient-reported outcomes and failure rates associated with both techniques, and factors such as lesion size, age, sex, and the number of plugs transplanted were assessed. Metaregression using a mixed-effects model was utilized for meta-analyses. RESULTS: The search resulted in 20 included studies with 364 cases of osteochondral autograft and 272 cases of osteochondral allograft. Mean postoperative survival was 88.2% in the osteochondral autograft cohort as compared with 87.2% in the osteochondral allograft cohort at 5.4 and 5.2 years, respectively (P = .6605). Patient-reported outcomes improved by an average of 65.1% and 81.1% after osteochondral autograft and allograft, respectively (P = .0001). However, meta-analysis revealed no significant difference in patient-reported outcome percentage change between osteochondral autograft and allograft (P = .97) and a coefficient of 0.033 (95% CI, -1.91 to 1.98). Meta-analysis of the relative risk of graft failure after osteochondral autograft versus allograft showed no significant differences (P = .66) and a coefficient of 0.114 (95% CI, -0.46 to 0.69). Furthermore, the regression did not find other predictors (mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location) that may have significantly affected patient-reported outcome percentage change or postoperative failure between osteochondral autograft versus allograft. CONCLUSION: Osteochondral autograft and allograft result in favorable patient-reported outcomes and graft survival rates at medium-term follow-up. While predictors for outcomes such as mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location did not affect the comparison of the 2 cohorts, proper patient selection for either procedure remains paramount to the success and potentially long-term viability of the graft.

Clinical and Radiologic Outcomes after Meniscal Root Repair: A Case Series.

This study aimed to describe the demographics, clinical outcomes, and radiologic outcomes of patients who underwent meniscal root repair at a single, large academic institution. Patients who underwent meniscal root repair between January 2011 and April 2015 were identified. Patient demographics, injury characteristics, and intraoperative findings of medial femoral condyle chondromalacia and other concomitant pathology were retrospectively recorded. Enrolled patients returned to clinic for prospectively collected International Knee Documentation Committee (IKDC) subjective and objective forms, knee radiographs, and magnetic resonance imaging (MRI). A total of 25 root injuries (23 patients) were included in the final analysis. Majority of root injuries were medial menisci (68%) and repaired using transosseous pull-out technique (80%). Most patients (65%) were male, relatively young (median age = 37 years), overweight (median body mass index [BMI] = 26 kg/m2), and reported a traumatic event associated with their injury (60%). Also, 36% (9/25) of root repairs were performed concomitantly with an anterior cruciate ligament (ACL) reconstruction; 100% (8/8) lateral meniscal root injuries were associated with a concomitant ACL injury compared with 6% (1/17) of medial root injuries. Overall, 53% (9/17) of medial meniscal root repairs were performed in the setting of high-grade (Outerbridge's grade III/IV) chondral pathology of the ipsilateral femoral condyle. Median follow-up was 16 months. The Kellgren-Lawrence radiographic scale progressed in two knees that underwent meniscal root repair based on comparison of preoperative to follow-up radiographs. MRI showed 88% (22/25) of meniscal roots had completely healed, 6% (1/17) of the medial root repairs showed evidence of extrusion, and 44% (11/25) of repairs were associated with progressive chondromalacia. All patients had normal or near normal IKDC objective scores at time of follow-up. Surgeons should have a high suspicion for concomitant ACL injuries in the setting of lateral meniscal root tears, and be wary of concomitant high-grade chondral damage in the setting of medial meniscal root tears. Most meniscal root repairs appeared completely healed with low rates of medial meniscal extrusion on MRI at short-term follow-up, despite a high rate of chondromalacia progression. Present study is a large case series with prospective follow-up and reflects level of evidence IV.

The Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Finite Element Analysis Model of Graft Bending Angles and Peak Graft Stresses in Comparison With Transtibial and Anteromedial Portal Techniques.

PURPOSE: The purpose of this finite element analysis was to compare femoral tunnel length; anterior cruciate ligament reconstruction graft bending angle; and peak graft stress, contact force, and contact area created by the transtibial, anteromedial portal (AMP), and hybrid transtibial techniques. METHODS: Finite element analysis modeling was used to examine anterior cruciate ligament reconstruction models based on transtibial, AMP, and hybrid transtibial femoral tunnel drilling techniques. An evaluation of femoral tunnel length, graft bending angle, peak graft stress, contact force, and contact area was done in comparison of these techniques. RESULTS: The femoral tunnel created with the hybrid transtibial technique was 45.3 mm, which was 13.3% longer than that achieved with the AMP technique but 15.2% shorter than that with the transtibial technique. The femoral graft bending angle with the hybrid transtibial technique (105°) was less acute than that with the AMP technique (102°), but more acute than that with the transtibial technique (109°). At 11° knee flexion, the hybrid transtibial technique had 22% less femoral contact force, 21% less tibial contact force, 21% less graft tension than the AMP technique. Yet, the hybrid transtibial technique had 41% greater femoral contact force, 39% greater tibial contact force, 33% greater graft tension, and 6% greater graft von Mises stress than the transtibial technique. A similar trend was found for the anterior knee drawer test. At both 6-mm anterior tibial displacement and 11° knee flexion, the hybrid transtibial and AMP techniques had at least 51% more femoral contact area than the transtibial technique. CONCLUSION: This finite element analysis highlights that the hybrid transtibial technique is a true hybrid between the AMP and transtibial techniques for femoral tunnel drilling regarding femoral tunnel length, graft bending angle, and peak graft stress.

Outcomes and failure rates after revision meniscal repair: a systematic review and meta-analysis.

PURPOSE: The purpose of this meta-analysis is to determine the outcomes and failure rates for revision meniscus repairs in patients with re-tears after primary repair failure. METHODS: A literature search was conducted using PubMed and Embase with the terms "Meniscus," "Meniscal," "Revised," and "Revision." The search strategy was based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) protocol and included four articles (79 patients). The search criteria were limited to studies reporting outcomes and failure rates. The exclusion criteria included languages other than English, biomechanical studies, letters to editors, non-full text, review articles, meta-analysis, and case reports. RESULTS: Four comparative studies with 79 patients (53 males, 26 females) with a mean age of 23.9 ± 6.4 years treated with a revision meniscus repair were included in the final analysis. Within this analysis, we found a failure rate of 25.3% (20 of 79 patients). Of these failed repairs, 30.95% (13 of 42) were of the medial meniscus, and 18.9% (7 of 37) were of the lateral meniscus. In the four articles, the postoperative Tegner sports activity score was found to be 6.1 ± 1.6 (range, 2 to 10). The post-operative Lysholm score was reported in three articles (45 patients). At a mean follow-up of 58.3 ± 23.9 months, the mean post-operative Lysholm score was 89.1 ± 7.6 (range, 38 to 100). The Coleman score for the included articles ranged between 52 and 59. CONCLUSION: This analysis found that revision meniscus repairs in patients with re-tears after primary repair failure result in clinical outcomes similar to that of primary repairs.

Distal Clavicle Excision: An Epidemiologic Study Using the National Ambulatory Surgery Sample Database.

BACKGROUND: This study aimed to examine national trends pertaining to patient demographics and hospital characteristics among distal clavicle excision (DCE) procedures performed in the United States. METHODS: The National Ambulatory Surgery Sample (NASS) database was queried for data. Encounters with Current Procedural Terminology (CPT) code 29824 were selected. Metrics derived from these encounters included patient demographic information such as age, geographic location, median household income per zip code, and primary expected insurance payer. Hospital characteristics derived included total charges for DCE procedures, location of the hospital, disposition of the patient, hospital census region, control/ownership of the hospital, and location/teaching status of the hospital. The proportion of DCE performed concomitantly with rotator cuff repair (RCR) was also analyzed. P-values were obtained from continuous variables using a t-test with a linear regression model. P-values were obtained from event variables using chi-square analysis. RESULTS: The incidence of arthroscopic DCE in the US decreased from 99,070 in 2016 to 93,678 (5.5%) in 2018. Of note, the proportion of DCE performed concomitantly with RCR significantly increased from 50.4% in 2016 to 52.8% in 2018 (P < 0.0001). Median patient age increased from 2016 to 2018 (56.4 to 57.2; P < 0.0001). The income quartile that saw the highest number of encounters was between $43,000 and $53,999 (P < 0.0001). Hospital trends display an increasing cost from $16,944 to $18,855 over the study period (P = 0.0016). Private insurance, including health maintenance organizations (HMOs), were the largest payers for this procedure; however, a decreasing trend in DCE covered by private insurance was noticed (50.2% to 47.3%; P < 0.0001). Medicare was the second-largest payer ranging from 27.9% in 2016 to 29.9% in 2018. The urban teaching model of hospitals continues to see the highest number of encounters for this procedure. CONCLUSIONS: In both 2016 and 2018, private insurance was the most common payer, most DCEs were performed in urban teaching hospitals, and most patients undergoing the procedure had a median household income between $43,000 and $59,000. Between 2016 and 2018, there was a significant increase in costs associated with DCE, as well as an increase in the median age of patients undergoing the procedure. The proportion of DCE performed concurrently with RCR also significantly increased during the study period.

Intraoperative and Early (90-Day) Postoperative Complications and Associated Variables with Multiligamentous Knee Reconstruction: 15-year Experience from a Single Academic Institution.

PURPOSE: We sought to determine the rate of intraoperative and early postoperative (90-day) complications of multiligamentous knee reconstruction surgeries, both medical and surgical, and associated variables from the 15-year experience of a single academic institution. METHODS: Patients treated at a single academic institution between 2005 and 2019 who underwent multiligament knee surgery were identified. Inclusion criteria included intervention with 2+ ligament reconstructions performed concurrently, and more than 90 days postoperative follow-up. Exclusion criteria included revision ligamentous knee surgery. Patient demographics, mechanism of injury, and associated injuries of patients with intraoperative and postoperative complications, time from injury to multiligamentous knee reconstruction, and surgical data, including tourniquet time, procedure time, and type of procedures performed were retrospectively recorded. RESULTS: 301 knees in 296 patients met the eligibility criteria. There were 11 intraoperative complications in 9 knees (rate of 3%) and 136 postoperative complications in 90 knees (rate of 30%). Shorter time from injury to date of surgery was associated with arthrofibrosis (P = .001) and superficial wound infections (P = .015). Concurrent head injuries were associated with less complications (P = .029). Procedural time >300 minutes was associated with intraoperative blood transfusions (P > .05), deep infections (P = .003) and arthrofibrosis (P = .012). Inside-out meniscal repair was associated with superficial and deep infections (P = .006 and .0004). Tibial-based posterolateral corner (PLC) reconstruction was associated with symptomatic hardware (P = .037) and arthrofibrosis (P = .019) in comparison with fibular-based PLC reconstruction. Posterior cruciate ligament (PCL) reconstruction was associated with deep infections (P = .015), arthrofibrosis (P = .003), and postoperative blood transfusions (P = .018). CONCLUSION: Our 15-year data reveal there is a low intraoperative complication rate and high early postoperative complication rate with multiligamentous knee surgery. Surgeons should be wary of the increased intraoperative and postoperative complications associated with longer procedure times, inside-out meniscal repair, tibia-based PLC reconstruction, PCL reconstruction, and shorter time to surgery. LEVEL OF EVIDENCE: Case series: IV.

Outcomes and reoperation rates after tibial tubercle transfer and medial patellofemoral ligament reconstruction: higher revision stabilization in patients with trochlear dysplasia and patella alta.

PURPOSE: To determine the reoperation rate, risk factors for reoperation, and patient-reported outcomes after isolated or combined tibial tubercle transfer and medial patellofemoral ligament reconstruction, for patellofemoral instability surgery. METHODS: Patient's records who underwent medial patellofemoral ligament reconstruction and/or tibial tubercle transfer for patellar instability by 35 surgeons from 2002 to 2018 at a single academic institution were retrospectively reviewed using CPT codes. Four-hundred-and-eighty-six patients were identified. Radiographic measurements, demographic parameters, and subsequent revision procedures and their indications were identified. A modified anterior knee pain survey was conducted by mail and with follow-up phone survey. RESULTS: The overall rate of reoperation was 120/486 (24.7%). The most common cause for reoperation was removal of hardware 42/486 (8.6%). The rate of reoperation for isolated medial patellofemoral ligament reconstruction 43/226 (19%) was lower than that of isolated tibial tubercle transfer 45/133 (33.8%) or a combined procedure 32/127 (25.2%) (P = 0.007). Woman had a higher rate of reoperation (29.4%) compared to men (15.9%) (P = 0.002). Patients at risk for a revision stabilization procedure included those with severe trochlear morphology (C or D) (6.1%) and those with Caton-Deschamps index > 1.3 (7.3%). Patients who underwent reoperation of any kind had poorer patient-reported outcomes. CONCLUSION: The overall reoperation rate after patellofemoral instability surgery remains high, and any reoperation portends worse patient-reported outcomes. Re-operations for instability are more likely in patients with trochlear dysplasia and patella alta and may benefit from more aggressive initial treatment, such as medial patellofemoral ligament reconstruction and tibial tubercle transfer in combination. Using the results of this study, surgeons will be able to engage in meaningful discussion with patients to counsel patients on expectations postoperatively. LEVEL OF EVIDENCE: IV.

Outcomes of posterior labral repair with or without concomitant high-grade glenohumeral chondral pathology: a retrospective cohort with minimum 2-year follow-up.

BACKGROUND: The purpose of this study was to compare outcomes of patients who underwent posterior labral repair with and without concomitant glenohumeral chondral pathology. METHODS: A retrospective review was performed on patients aged ≥18 years who underwent primary posterior labral repair over 5 years. Charts were reviewed to determine the presence and location of high-grade (Outerbridge grade III or IV) pathology. Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Western Ontario Stability Index (WOSI), visual analog scale (VAS), and Simple Shoulder Test (SST) scores were collected at median 71.5-month follow-up and compared between patients with and without concomitant chondral pathology during the index procedure. RESULTS: Of 100 patients who underwent primary posterior labral repair, 43% had glenoid and/or humeral-sided high-grade chondral pathology. Patients with chondral pathology were older than those without (P < .001). A higher proportion of patients with chondral pathology underwent concomitant biceps tenodesis (19.3% vs. 37.2%, P = .046). The type of anchor (all-suture or solid body, P = .010) used was different between patients with and without chondral pathology at time of posterior labrum repair. There was no difference in reoperation rates at final follow-up between patients with and without chondral damage at time of index procedure (P = .200). All outcome scores were similar between all comer patients with and without chondral pathology. Isolated glenoid pathology was significantly associated with lower QuickDASH (P = .018), higher SST (P = .013), lower VAS (P = .016), and lower WOSI scores (P = .046) compared to patients with bipolar lesions. After stratifying by age, there was an association between chondral pathology and lower VAS and WOSI scores in patients aged <35 years, and there was an association between chondral pathology and lower SST scores in patients aged ≥35 years. CONCLUSION: Based on median QuickDASH, SST, WOSI, and VAS scores, subjective and functional outcomes after primary arthroscopic posterior labral repair were not negatively influenced by the presence of concomitant chondral damage at the time of surgery for patients aged <35 years at minimum 2-year follow-up. Although our primary outcome score, the QuickDASH, was not significantly associated with the presence of chondral damage in patients aged >35 years, SST scores were negatively influenced by concomitant chondral damage in this older cohort, but this may not be adequately powered. It appeared that patients with chondral damage localized to the glenoid tended to have better outcomes scores that those with bipolar damage.

Influence of graft type on sagittal plane knee biomechanics during stair ambulation following anterior cruciate ligament reconstruction.

BACKGROUND: Both graft type and surgical technique for anterior cruciate ligament reconstruction can affect knee biomechanics. Several studies reported the influence of graft type, but few have controlled the surgical technique and fully investigated stair ambulation. This study aimed to compare knee biomechanics during stair ambulation between patients treated with hamstring tendon graft and those treated with patellar tendon graft when anterior medial portal technique was used to drill femoral tunnel. METHODS: Two groups of patients (patellar tendon, n = 18; hamstring tendon, n = 18) at average 12 months after reconstruction surgery were recruited to ascend and descend a customized staircase in a gait lab. Joint kinematics and kinetics were calculated for both operated and contralateral intact limbs based on kinematic analysis and inverse dynamics. The influence of graft type on knee flexion angle and moment was identified using one-way mixed (graft type and limb side) analysis of variance with post-hoc paired t-test. FINDINGS: Significant interaction between graft and limb was found for knee flexion and range of motion. Only the hamstring tendon group had significant kinematic deficits on the operated limb than the contralateral limb during stair ascent and descent. No significant interaction was found for knee flexion moment. Both graft groups had significant deficits in peak knee flexion moment on the operated side during stair ascent and descent. INTERPRETATION: While the choice of graft type does not affect the restoration of knee dynamic loading, patellar tendon graft better restores knee flexion-extension kinematics during stair ambulation.

An update on graft-tunnel mismatch in anterior cruciate ligament reconstruction: A survey of the experts in the field of orthopedic sports medicine demonstrates no clear consensus in management.

BACKGROUND: The purpose of this study was to identify and report on the rate at which leaders in orthopaedic surgery are encountering GTM, their treatment methods and to identify whether these clinicians' demographics or techniques correlate with their GTM incidence and/or treatment algorithms. METHODS: A survey was sent to identify the rate at which member orthopaedic surgeons of the American Orthopaedic Society for Sports Medicine (AOSSM), the National Football League Physicians Society (NFLPS), and the Herodicus Society are encountering GTM in ACL reconstruction with BTB graft and to establish what methods are most commonly utilized. RESULTS: In total, 260 orthopaedic surgeons completed the survey. Respondents most frequently reported GTM in 1-5% of cases, with GTM most often between 5 and 10 mm. For lower levels of GTM, surgeons are most frequently recessing the femoral bone plug and adding a cortical suspensory device or outside-in fixation. Higher degrees of GTM are most commonly supplemented with a screw/post on the tibia. Those with >15 years of experience were more commonly using a transtibial femoral drilling with lower tibial tunnel angulation, and lower incidences of GTM than their less experienced counterparts. CONCLUSION: There is tremendous variability in the incidence and management of GTM in ACL reconstruction with BTB graft with no clear consensus among experts. Differences are seen in ACL reconstruction techniques and means of correcting GTM when evaluating based on years of surgical experience and Sports Medicine Fellowship completion.

Biomechanical Evaluation of an All-Inside Posterior Medial Meniscal Root Repair Technique Via Suture Fixation to the Posterior Cruciate Ligament.

PURPOSE: To evaluate the tibiofemoral contact mechanics of an all-inside posterior medial meniscal root repair technique via suture fixation to the posterior cruciate ligament (PCL) and to compare with that of the intact knee and the knee with a root tear. METHODS: Tibiofemoral contact mechanics were recorded in 8 human cadaveric knee specimens using pressure sensors. Each knee underwent 3 testing conditions related to the posterior medial meniscal root: (1) intact knee; (2) root tear; and (3) all-inside repair via suture fixation to the PCL. Knees were loaded with a 1000-N axial compressive force at 4 knee flexion angles (0°, 30°, 60°, 90°). Calculations were performed for contact area, mean contact pressure, and peak contact pressure. A generalized linear model with a Tukey adjusted least square means test was used to determine differences between testing conditions. RESULTS: Across all knee flexion angles, there was an overall mean 26.3% reduction in contact area with root tear (211.34 mm2 vs intact 286.64 mm2, P = .0002), and a 31.6% increase from root tear to repair (277.61 mm2, P = .0297). Across all knee flexion angles, there was an overall mean 24.3% increase in contact pressure with root tear (1849.12 N/mm2 vs. intact 1487.52 N/mm2, P < .0001), and a 31.1% decrease from root tear to repair (1410.7 N/mm2, P = .0037). Across all knee flexion angles, there was an overall mean 10.6% increase in peak contact pressure with root tear (4083.55 N/mm2 vs. intact 3693.68 N/mm2, P < .0001), and a 12.4% decrease from root tear to repair (3632.13 N/mm2, P = .531). CONCLUSIONS: In most testing conditions and with overall averaging across knee flexion angles, the all-inside posterior medial meniscal root repair with suture fixation to the adjacent PCL fibers restored contact area (from 26.3% reduction with root tear to 31.6% increase with repair), contact pressures (from 24.3% increase with root tear to 31.1% decrease with repair), and peak contact pressures (from 10.6% increase with root tear to 12.4% decrease with repair) to that of the intact knee This may be a future potential technique to limit complications associated with the traditional transtibial pull-out method of repair. CLINICAL RELEVANCE: This technique may provide a posterior medial meniscal root repair construct that restores most tibiofemoral contact mechanics and offers theoretical benefits of technical ease and potential for an acceptable, less "anatomic" repair location.

The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture.

BACKGROUND: The prevalence and severity of concomitant rotator cuff pathology in the setting of proximal biceps tendon ruptures are poorly understood. Concomitant rotator cuff disease may have important implications in the prognosis and natural history of this shoulder condition. Therefore, an observational cohort of patients with an acute rupture of the long head of the biceps tendon (LHBT) was evaluated to determine the prevalence and severity of concomitant rotator cuff disease. METHODS: Thirty consecutive patients diagnosed with acute proximal biceps tendon rupture were prospectively enrolled. Magnetic resonance imaging of the affected shoulder was obtained in 27 patients and reviewed by a fellowship-trained orthopedic surgeon. RESULTS: The cohort consisted of 20 men (74%) and 7 women (26%) (mean age, 61.0 years [range, 42-78 years]). The dominant side was involved in 20 injuries (74%), and a low-energy trauma mechanism of injury was involved in 23 (85%). Of the patients, 11 (41%) reported a history of antecedent shoulder pain. Magnetic resonance imaging assessment revealed that 93% of patients had evidence of rotator cuff disease, including 13 full-thickness tears. Of the full-thickness tears, 3 were small, 6 medium, 2 large, and 2 massive. Pathology of the subscapularis tendon was identified in 7 patients (26%). CONCLUSION: In this cohort, we found LHBT rupture to be highly correlated with the presence of rotator cuff disease, with the majority of patients presenting with full-thickness tears of the supraspinatus. These findings may have important implications in the treatment and prognosis of patients who present with acute LHBT ruptures.

Patellofemoral Osteochondral Allografts: Can We Improve the Matching Process?

An important consideration for the successful use of fresh osteochondral allografts for the patellofemoral joint is selection of appropriately sized donor allografts. This is particularly challenging for matching grafts to the patella because of the substantial variability in articular contour that exists. At present, selection of donor patellae is based only on the width of the proximal tibia, with no established means of quantifying basic patellar size, facet configuration, or articular contour. We hypothesized that using a combination of standard radiographic measurements to generate an accurate profile of the recipients native patella would result in a more accurate donor graft. We radiographically measured seven dimensions of 30 fresh frozen cadaveric patellar specimens, and then, following dissection, accurate ex vivo measurements of patellar morphology were taken. Measurements obtained on the merchant view included total width, width of the medial and lateral facets, central ridge height (CRH) and location, as well as the patellar angle. The lateral view was obtained to measure the articular length. Ex vivo measurements were subsequently taken using a standard ruler, caliper, and goniometer following removal of all soft tissue attachments. To simulate a larger population of knees, we then used bootstrapping methods with simple random selection and replacement to generate a sample of measurements from 4,500 knees. In the bootstrapping process, measurements from one random specimen are added to the "population" at each iteration until the target sample size is reached. Data from this bootstrapped population were subsequently used to calculate statistically significant radiographic predictors of each ex vivo measurement, using a multivariate regression model with backward elimination. These predictors were then used to compare the calculated values to the actual ex vivo measurements for each dimension in our original 30 specimens' sample. Overall, these formulas were very successful in predicting ex vivo measurements. While further validation is warranted, we propose that these formulas can be utilized to select a more accurate donor.