Increasing Diversity in Orthopaedic Surgery Residency: A Case Report of One Program's Experience Using Pipeline Programs.

Introduction: African American, Hispanic, Asian, and Pacific Islanders are groups who are underrepresented in medicine (URM groups). Similarly, although women comprise more than 50% of medical students in the United States, women comprise a smaller percentage of all orthopaedic surgery trainees. Therefore, underrepresented in orthopaedics (URiO) represents the URM groups and women. The purpose of this study is to examine the impact of specific steps to recruit a qualified, diverse trainee complement within a single academic orthopaedic surgery residency program between 2000 and 2023. We aim to explore changes in the representation of URiO during this period as well as explore the strategies and programs implemented by the department that may have impacted recruitment of a diverse complement of trainees. Methods: Match lists from a large, academic, orthopaedic surgery residency between 2000 and 2023 were collected and reviewed for racial and gender data. Match lists were then divided into 6-year quantiles to identify any trends in the recruitment of URiO students. Self-reported racial and gender data from Electronic Residency Application Service applicant reports and the Accreditation Council for Graduate Medical Education (ACGME) data books between 2018 and 2022 were collected and reviewed. In addition, the department's strategies implemented during the study period with the goal of enhancing URiO exposure to orthopaedic surgery were also explored. Results: The department implemented proactive strategies to increase exposure to orthopaedic surgery for URiO students. An increase in URiO representation was noted between 2000 and 2023 with Hispanic, Black/African American, and Native Hawaiian/Pacific Islander resident representation increasing by 5%, 11%, and 1%, respectively. In addition, women representation increased by 27% between 2000 and 2023. The overall attrition rate among URiO residents was 1% with only one resident not completing the program. Self-reported racial and gender data from ACGME data books demonstrated that Black/African American, Hispanic, and Native Hawaiian/Pacific Islander residents comprised 5%, 4%, and 0.04%, respectively, of orthopaedic surgery residents between 2018 and 2022. Conclusions: These results provide insight for other programs to use similar strategies to potentially improve recruitment, retain, and provide support to URiO residents.

MCP-1 in synovial fluid as a predictor of inferior clinical outcomes after meniscectomy.

PURPOSE: To evaluate knee intra-articular cytokine concentrations in patients undergoing isolated meniscectomy and determine if these concentrations are associated with clinical outcomes. METHODS: Concentrations of ten biomarkers were quantified in synovial fluid aspirated from the operative knees of patients who underwent isolated meniscectomy from 10/2011-12/2019. Patients completed a survey at final follow-upincluding VAS, Lysholm, Tegner, and KOOS Physical Function Short Form (KOOS-PS). Failure was defined as subsequent TKA or non-achievement of the Patient Acceptable Symptom State (PASS) for knee pain defined as VAS > 27/100. Regression analysis investigating the relationship between cytokine concentrations and failure was performed. RESULTS: The study consisted of 100 patients, including 50 males (50.0%) with a mean age of 51.1 ± 11.7 years, a median BMI of 28.9 kg/m2 [25.5, 32.4], and a mean follow-up of 8.0 ± 2.2 years. There were no demographic or clinical differences between failures (n = 41) and non-failures (n = 59) at baseline. Monocyte Chemotactic Protein 1 (MCP-1) concentration was significantly higher in failures than in non-failures (344.3 pg/ml vs. 268.6 pg/ml, p = 0.016). In a regression analysis controlling for age, sex, BMI, symptom duration, length of follow-up, and ICRS grade, increased MCP-1 was associated with increased odds of failure (p = 0.002). CONCLUSIONS: The concentration of MCP-1 on the day of arthroscopic meniscectomy was predictive of failure as defined by an unacceptable pain level at intermediate- to long-term follow-up. This finding may help identify patients at high risk for poor postoperative outcomes following isolated meniscectomy and serve as a target for future postoperative immunomodulation research.

Differential analysis of the impact of lesions' location on clinical and radiological outcomes after the implantation of a novel aragonite-based scaffold to treat knee cartilage defects.

PURPOSE: There is limited comparative evidence on patient outcomes following cartilage repair in various knee compartments. The aim of this study was to compare clinical and imaging outcomes after treating cartilage defects in femoral condyles and trochlea with either an aragonite-based scaffold or surgical standard of care (SSoC, i.e., debridement/microfractures) in a large multicentre randomized controlled trial. METHODS: 247 patients with up to three knee joint surface lesions (ICRS grade IIIa or above) in the femoral condyles, trochlea or both ("mixed"), were enrolled and randomized to surgery with either a cell-free aragonite scaffold or SSoC. Patients were followed for up to 48 months by analysing subjective scores (KOOS and IKDC), radiological outcomes (defect filling on MRI), as well as treatment failure rates and adverse events. A differential analysis of outcomes for condylar, trochlear and mixed lesions was performed. RESULTS: The scaffold group significantly outperformed the SSoC group regardless of lesion location with statistically significantly better KOOS Overall scores at 24 months (all p ≤ 0.0009) and 48 months (all p ≤ 0.02). Similar results were observed for KOOS subscales and IKDC scores. For KOOS responder rates, superiority of the implant group was demonstrated at 24, 36, and 48 months (all p ≤ 0.004). Higher defect filling on MRI for implants was observed for all locations. Lower treatment failure rates for the implant were observed in condylar and mixed lesions. CONCLUSION: The aragonite-based scaffold was safe and effective regardless of the defect location, providing superior clinical and radiological outcomes compared to SSoC up to four years follow-up. LEVEL OF EVIDENCE: I - Randomized controlled trial.

Leukocyte-Poor Platelet-Rich Plasma as a Treatment for Patellar Tendinopathy A Multicenter, Randomized Controlled Trial.

PURPOSE: The purpose of this study was to compare regimens of eccentric exercise and dry-needling, with and without an ultrasound-guided leukocyte-poor platelet-rich plasma (LP-PRP) injection, in patients with patellar tendinopathy. METHODS: Patients with symptomatic patellar tendinopathy based on physical examination and magnetic resonance imaging and who had failed at least 6 weeks of nonoperative treatment were enrolled and randomized at two centers to receive ultrasound-guided dry-needling (DN) alone or in addition to an injection of LP-PRP coupled with standardized eccentric strengthening exercises. Participants completed patient-reported outcome surveys at baseline and at 3, 6, 9, 12, and 26 weeks post-treatment. The primary outcome measure was the Victorian Institute of Sports Assessment (VISA) score for patellar tendinopathy (VISA-P) at 12 weeks, and secondary measures included the visual analog scale (VAS) for pain, Tegner activity scale, Lysholm knee scale (Lysholm), and Veterans Rand 12-Item Health Survey (VR12) questionnaire at 12 and 26 weeks. RESULTS: Thirty-one subjects were enrolled in the study (15 DN, 16 LP-PRP). Twenty-three patients were available for follow-up at all time points. There were no statistically significant differences between the two groups at baseline. At 12 weeks post-treatment, both the LP-PRP and DN groups demonstrated statistically significant (p < 0.05) improvements from baseline with respect to Lysholm score (34.5 ± 15.1 and 31.7 ± 18.4), VAS pain scale (-1.58 ± 2.1 and -2.8 ± 1.9, respectively), and VISA score (19.2 ± 15.9 and 28.4 ± 19.4, respectively). At 26 weeks post-treatment both groups demonstrated statistically significant (p < 0.05) improvements in Lysholm score (23.6 ± 23.1 and 24.5 ± 17.3, respectively) and VAS pain score (-1.67 ± 2.3 and -2.18 ± 2.9, respectively). The LP-PRP group failed to show significance for VISA-P score from 0 to 26 weeks, though the DN group did (22.0 ± 14.6). There were no statistically significant differences between the two groups in mean VISA, VAS, Lysholm, or the Short Form Health Survey (SF-12) scores at either the 12 week or 26-week follow-up time points. CONCLUSION: The results of the current study demonstrate that both DN and DN plus LP-PRP are effective treatment options in the management of symptomatic patellar tendinopathy, however, LP-PRP did not add any additional improvement over DN alone.

The Effectiveness of Alpha-2-Macroglobulin Injections for Osteoarthritis of the Knee.

BACKGROUND: Intra-articular (IA) injections of plateletrich plasma (PRP) have been increasingly used in the nonoperative treatment of knee osteoarthritis (OA) but have considerable heterogeneity in both formulation and clinical results. Alpha-2-macroglobulin (A2M) is a large plasma protein found in PRP that inhibits cartilage-degrading enzymes and could be an efficacious OA treatment independently. The purpose of this study was to compare the short-term clinical efficacy of IA injection of A2M-rich PRP concentrate to conventionally prepared PRP and corticosteroids in the management of symptomatic knee OA. METHODS: This double-blinded, randomized, controlled clinical trial was conducted at a single medical center with enrollment from June 2018 to May 2019. Subjects with symptomatic Kellgren-Lawrence (KL) grade 2 or 3 knee OA were randomized to IA injection with A2M, PRP, or methylprednisolone (MP) and followed for 12 weeks post-injection. Knee pain and function were assessed at pre-treatment baseline and at 6-week and 12-week followup with patient-reported outcome (PRO) surveys including the visual analog scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and Tegner score. RESULTS: Seventy-five subjects were enrolled in the trial, of whom 68 (90.7%) completed the 12-week follow-up. The majority of subjects (73%) were female with a mean age of 59 years (range: 37 to 75 years). There were no significant differences in age (p = 0.30), sex (p = 0.44), or KL grade (p = 0.73) between treatment groups. By 12 weeks postinjection, the A2M group showed significant improvement in VAS, WOMAC, KOOS, and Tegner (p < 0.05), the PRP group showed no significant improvement in any PROs (p > 0.05), and the MP group showed significant improvement in Lysholm only (p = 0.01). However, the changes in PRO scores between baseline and 12-week follow-up did not significantly differ between the three groups (p > 0.05). CONCLUSIONS: Alpha-2-macroglobulin IA injection shows comparable efficacy to PRP and corticosteroids in the treatment of mild-to-moderate knee OA. Alpha-2-macroglobulin treatment resulted in modest improvement in knee pain and function at 6-week follow-up, albeit inconsistently across PRO measures and to a similar degree as PRP and corticosteroids. Given its non-superior short-term efficacy compared to established IA injections, as well as its increased cost of preparation, A2M may not be a justifiable option for routine treatment of knee OA.

The Impact of Adding a Tibial Tubercle Osteotomy to Medial Patellofemoral Ligament Reconstruction in the Treatment of Patellar Instability.

BACKGROUND: An isolated medial patellofemoral ligament (MPFL) reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient reported outcomes. METHODS: A retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, sex, and follow-up time. Recurrent instability (including re-dislocation and subluxation), visual analog scale (VAS) for pain score, Kujala score, and satisfaction were evaluated. RESULTS: There were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow-up time. The mean age was 25.0, 76.3% were female, and the mean follow-up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p = 0.311), or revision surgeries (10.2% vs. 10.2%) between groups. CONCLUSION: There was a low complication rate, excellent patient reported outcomes, and a low rate of recurrent patellar instability following TTO and MPFLR with allograft.

Synovial Fluid Biomarker Alternatives Can Plasma and Urine Samples Shed Light on the Post-Traumatic Intra-Articular Microenvironment?

The purpose of this study was to analyze the relationship between the intra-articular inflammatory response and any associated systemic inflammatory response following knee injury requiring operative management. Patients undergoing primary knee arthroscopy provided synovial fluid, blood, and urine samples immediately prior to surgery. Samples were analyzed using a multiplex magnetic bead immunoassay for the concentrations of cytokines and growth factors that have been shown to be associated with post-injury inflammation. One hundred and fifty-one patients undergoing arthroscopic management of meniscus, ACL, and focal chondral lesions were included in the analysis. After correction for multiple tests, there were no statistically significant correlations between synovial fluid biomarkers and biomarkers in plasma or urine for any of the intra-articular pathologies assessed. This analysis suggests that the most accurate measurement of the post-injury inflammatory response must be sampled from the intra-articular space. In the post-traumatic knee, there is no substitute for synovial fluid biomarker analysis.

Levels of Synovial Fluid Inflammatory Biomarkers on Day of Arthroscopic Partial Meniscectomy Predict Long-Term Outcomes and Conversion to TKA: A 10-Year Mean Follow-up Study.

BACKGROUND: The purpose of the present study was to evaluate the relationships of the concentrations of pro- and anti-inflammatory biomarkers in the knee synovial fluid at the time of arthroscopic partial meniscectomy (APM) to long-term patient-reported outcomes (PROs) and conversion to total knee arthroplasty (TKA). METHODS: A database of patients who underwent APM for isolated meniscal injury was analyzed. Synovial fluid had been aspirated from the operatively treated knee prior to the surgical incision, and concentrations of pro- and anti-inflammatory biomarkers (RANTES, IL-6, MCP-1, MIP-1ß, VEGF, TIMP-1, TIMP-2, IL-1RA, MMP-3, and bFGF) were quantified. Prior to surgery and again at the time of final follow-up, patients were asked to complete a survey that included a visual analog scale (VAS) for pain and Lysholm, Tegner, and Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS) questionnaires. Clustering analysis of the 10 biomarkers of interest was carried out with the k-means algorithm. RESULTS: Of the 82 patients who met the inclusion criteria for the study, 59 had not undergone subsequent ipsilateral TKA or APM, and 43 (73%) of the 59 completed PRO questionnaires at long-term follow-up. The mean follow-up time was 10.6 ± 1.3 years (range, 8.7 to 12.4 years). Higher concentrations of individual pro-inflammatory biomarkers including MCP-1 (ß = 13.672, p = 0.017) and MIP-1ß (ß = -0.385, p = 0.012) were associated with worse VAS pain and Tegner scores, respectively. K-means clustering analysis separated the cohort of 82 patients into 2 groups, one with exclusively higher levels of pro-inflammatory biomarkers than the second group. The "pro-inflammatory phenotype" cohort had a significantly higher VAS pain score (p = 0.024) and significantly lower Lysholm (p = 0.022), KOOS-PS (p = 0.047), and Tegner (p = 0.009) scores at the time of final follow-up compared with the "anti-inflammatory phenotype" cohort. The rate of conversion to TKA was higher in the pro-inflammatory cohort (29.4% versus 12.2%, p = 0.064). Logistic regression analysis demonstrated that the pro-inflammatory phenotype was significantly correlated with conversion to TKA (odds ratio = 7.220, 95% confidence interval = 1.028 to 50.720, p = 0.047). CONCLUSIONS: The concentrations of synovial fluid biomarkers on the day of APM can be used to cluster patients into pro- and anti-inflammatory cohorts that are predictive of PROs and conversion to TKA at long-term follow-up. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Characterization of bone marrow edema patterns among patients with Segond fracture in the setting of acute anterior cruciate ligament injury: A comparative MRI study.

PURPOSE: The purpose of this study is to investigate the anatomic distribution of bone marrow edema on MRI among patients who sustained a Segond fracture compared to those with an isolated ACL tear. METHODS: A retrospective cohort study was performed of patients aged 18-40 years old who presented with an acute isolated ACL tear between January 2012 and May 2022. Two blinded readers reviewed all knee MRIs to assess bone marrow edema using the Whole-Organ Magnetic Resonance Imaging Score and the area of each sub-compartment was scored. RESULTS: There were 522 patients in the final analysis, of which 28 patients (5.4%) were identified to have a Segond fracture. The Segond group demonstrated significantly greater rates of WORMS grades 2 and 3 in the central lateral femoral condyle, as well as the anterior, central, and posterior lateral tibial plateau. Furthermore, the Segond group demonstrated significantly greater rates of WORMS grades 2 and 3 in the central medial femoral condyle and the anterior medial tibial plateau. Bone edema at the central lateral femoral condyle (R = 0.034, p = 0.019) and central tibial plateau (R = 0.093, p = 0.033) were significantly correlated with lateral meniscus tears, while the edema in the posterior medial femoral condyle was correlated with medial meniscus tears (R = 0.127, p = 0.004). CONCLUSION: Patients who present with ACL tear and a concomitant Segond fracture demonstrate significantly more extensive bone marrow edema in both the medial and lateral compartments of the knee compared to patients with an isolated ACL tear.

Partial-Thickness Rotator Cuff Tears: Current Concepts.

¼ Partial-thickness rotator cuff tears (PTRCTs) are a common pathology with a likely high asymptomatic incidence rate, particularly in the overhead athlete.¼ The anatomy, 5-layer histology, and relationship to Ellman's classification of PTRCTs have been well studied, with recent interest in radiographic predictors such as the critical shoulder angle and acromial index.¼ Depending on the definition of tear progression, rates of PTRCT progression range from 4% to 44% and appear related to symptomatology and work/activity level.¼ Nearly all PTRCTs should be managed conservatively initially, particularly in overhead athletes, with those that fail nonoperative management undergoing arthroscopic debridement ± acromioplasty if <50% thickness or arthroscopic conversion repair or in situ repair if >50% thickness.¼ Augmentation of PTRCTs is promising, with leukocyte-poor platelet-rich plasma having the most robust body of supportive data. Mesenchymal signaling cell biologics and the variety of scaffold onlay augments require more rigorous studies before regular usage.

More negative sagittal tibial tuberosity-trochlear groove distances are correlated with larger patellofemoral chondral lesion size.

PURPOSE: The purpose of this study is to assess the association between sagittal tibial tuberosity-trochlear groove (sTT-TG) distance and patellofemoral chondral lesion size in patients undergoing cartilage restoration procedures. METHODS: A retrospective cohort analysis of patients who underwent an osteochondral allograft transplantation or matrix-induced autologous chondrocyte implantation in the patellofemoral compartment, from 2010 to 2020, were included if they had patellofemoral high-grade lesions, magnetic resonance imaging (MRI) and minimum 2-year follow-up. The preoperative sTT-TG distance was measured independently on axial T2-weighted MRI sequences by two authors, each at least two weeks apart. Intraoperative lesion size was reported according to operative report measurements by the attending surgeon. An interclass correlation coefficient (ICC) was calculated to assess intra- and inter-rater reliability, and categorical data analysis and linear regression models were used to assess the relationship between sTT-TG and lesion size. RESULTS: A total of 80 patients (50 females) with a mean age of 31.5 ± 10.4 years, body mass index of 27.0 ± 5.9 kg/m2 and follow-up of 61.5 ± 21.4 months were included. A total of 107 lesions were present: 63 patients with unipolar (patella = 41, trochlea = 22) and 22 with bipolar lesions. The mean MRI defect size was 1.6 ± 1.0 cm2 and the mean intraoperative defect size was 3.8 ± 2.4cm2. Intra- (ICC: 0.99,0.98) and inter-rater reliability (ICC: 0.96) were excellent for both MRI defect size and sTT-TG measurements. The mean sTT-TG was -4.8 ± 4.9 mm and was significantly inversely related to MRI defect size (-0.45, p < 0.01), intraoperative patellar lesion size (-0.32, p = 0.01), total lesion area (-0.22, p = 0.04), but not trochlear lesion size (-0.09, p = 0.56). Multivariable regression demonstrated a more negative sTT-TG remained an independent variable correlated with larger MRI-measured patellofemoral defect sizes and intraoperative patellar lesions. CONCLUSION: A more negative sTT-TG was an independent variable correlated with larger patellofemoral lesions in patients undergoing patellofemoral cartilage restoration. LEVEL OF EVIDENCE: Level III, Diagnostic.

Video Analysis of Anterior Cruciate Ligament Injuries in National Basketball Association Athletes.

PURPOSE: Research surrounding the biomechanics and video analysis of anterior cruciate ligament (ACL) injuries at the professional level has emerged in recent years as a tool to screen athletes for potential biomechanical deficits. The purpose of this study was to analyze and discuss the most common mechanism, body position, and activity at the time of ACL injury among NBA players. METHODS: Anterior cruciate ligament injuries over 10 consecutive NBA seasons (2009-2010 to 2019-2020) were reviewed from publicly available sources. A 10-question survey was developed and utilized to analyze each video clip. These questions were divided into three categories: 1. contact mechanism, 2. activity at the time of injury, and 3. position of the involved lower extremity at the time of injury. Two reviewers analyzed the videos individually, and differing answers were resolved via consensus review, with a senior author arbitrating in the case of any discrepancies. RESULTS: Overall, 23 ACL ruptures were included. The most common injury mechanism was indirect contact with another player without knee contact (56.5%), and no patients had an ACL rupture as a result of direct knee contact with another player. The most common action at the time of injury was pivoting (47%), and the most common basketball action was dribbling (43.5%). Additionally, the vast majority of patients were injured while on offense (91.3%). The most common knee positions were early flexion (73.9%) and abduction (95.7%). The most common foot positions were abduction relative to the knee (82.6%), in eversion (73.9%), and dorsiflexion (56.5%). The most common hip position was early flexion (87%), and all hips were abducted (100%). CONCLUSION: Our study found that the majority of ACL ruptures occurred during offensive play and over half were secondary to contact with an opposing player (but without a direct blow to the injured knee), indicating that such perturbations may alter the kinematics of the players' movement. Additionally, a large majority of ACL injuries occurred while the hip was abducted with the knee in abduction relative to the hip and while the knee was in early flexion from 0° to 45°.

The influence of tibial length on radiographic posterior tibial slope measurement: How much tibia do we need?

PURPOSE: The purpose of this study was to determine whether significant differences exist when comparing posterior tibial slope (PTS) measured using increasing lengths of the tibia to determine the anatomical axis. METHODS: Patients with full-length weight-bearing tibial radiographs were retrospectively identified from 2014 to 2022 at a single institution. Patients were excluded if there was any previous history of lower extremity fracture or osteotomy. The anatomical axis of the tibia was determined using the full length of tibial radiographs, and the "reference PTS" was measured using this axis. Using the same radiograph, the PTS was measured using four different anatomical axes at standardized tibial lengths. While the center of the proximal circle remained constant at 5-cm below the tibial plateau, the center of the distal circle was drawn at four points: a) overlapping circles; b) 10-cm distal to the tibial plateau; c) 15-cm distal to the tibial plateau; d) half the length of the tibia, measured from the tibial plateau to the tibial plafond. Bivariate correlation and frequency distribution analysis (measurements >2-degrees from reference PTS) were performed between the reference PTS and PTS measured at each of the four other lengths. RESULTS: A total of 154 patients (39.8 ± 17.4 years old, 44.2% male) were included in the final analysis. Measurements at each of the four tibial lengths were all significantly different from the reference PTS (p < 0.001). The correlation strength improved with increasing tibial length (overlapping: R = 0.681, 10-cm: R = 0.821, 15-cm: R = 0.937, and half-tibia: R = 0.963). The number of PTS measurements >2-degree absolute difference from the reference PTS decreased with increasing tibial length (overlapping: 40.3%, 10-cm: 24.0%, 15-cm: 26.0%, and half-tibia: 18.8%). CONCLUSION: Assessment of PTS is dependent on the length of the tibia utilized to obtain the anatomical axis. Accuracy and precision of PTS measurements improved with increasing length of tibia used to determine the anatomical axis. STUDY DESIGN: Case series.

Clinical outcomes following transtibial medial meniscal root repair are maintained at long-term follow-up.

PURPOSE: To evaluate long-term outcomes of patients treated with posterior medial meniscal root tear (PMMRT) repair through assessment of functional outcome scores and to identify patient surgical and magnetic resonance imaging (MRI) characteristics associated with improved outcomes. METHODS: This was a single-centre, retrospective study evaluating patients who had undergone a PMMR repair using a transtibial suture pullout technique with two locking cinch sutures. This was performed as a follow-up to previously published 2-year and 5-year outcome studies, using the same cohort. All patients from the prior short-term and midterm studies were invited to participate. Patient-reported outcome (PROs) scores, including the International Knee Documentation Committee (IKDC) and Lysholm scores, were collected. Previously collected demographic data were updated based on review of the electronic medical record. Patient outcomes were assessed preoperatively, as well as at 2-year, 5-year and 8-year postoperatively. MRI outcome measurements were assessed at 2-year and 5-year follow-ups. All statistical analysis was performed using SPSS version 26. RESULTS: Seventeen patients of the original 18 patients (94.4%) were included in the final analysis. Additionally, three patients who had additional ipsilateral surgery were excluded from the analysis of PROs. The IKDC score significantly increased from 44.7 ± 11.6 at preoperative baseline to 71.2 ± 21.3 at 8-year post-operation (p = 0.001). There were no significant differences in IKDC score between 2-year and 8-year follow-ups (p = n.s.) or 5-year and 8-year follow-ups (p = n.s.). The Lysholm score significantly increased from 49.6 ± 7.3 at preoperative baseline to 76.4 ± 17.2 at 8-year follow-up (p < 0.001). There was no significant difference in Lysholm scores between 2-year and 8-year follow-ups (p = n.s.) or 5-year and 8-year follow-ups (p = n.s.). A linear regression analysis found that 5-year IKDC scores were significantly correlated with 8-year IKDC scores (ß = 0.681, p = 0.038). At 8-year follow-up, four (23.5%) patients required additional procedures on their operative knee (one total knee arthroplasty conversion). CONCLUSION: Patients treated with repair of PMMRT had maintenance of clinical outcome improvements at long-term follow-up despite worsening MRI outcomes at short-term and medium-term follow-ups. While a high proportion of patients required additional procedures on their operative knee at 8-year follow-up, few of these patient's additional procedures were related to failure of their primary surgery. Providers and patients may expect durable clinical outcomes following the repair of PMMRT, irrespective of radiographic appearance. LEVEL OF EVIDENCE: Level IV.

Comparable Clinical and Functional Outcomes Between Osteochondral Allograft Transplantation and Autologous Chondrocyte Implantation for Articular Cartilage Lesions in the Patellofemoral Joint at a Mean Follow-up of 5 Years.

PURPOSE: To assess clinical outcomes and return to sport (RTS) rates among patients who undergo osteochondral allograft (OCA) transplantation and autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI), for patellofemoral articular cartilage defects. METHODS: A retrospective review of patients who underwent an OCA or ACI/MACI from 2010 to 2020 was conducted. Patient-reported outcomes collected included visual analog scale for pain/satisfaction, Knee Injury and Osteoarthritis Outcome Score (KOOS), and RTS. The percentage of patients that met the patient acceptable symptom state for KOOS was recorded. Logistic regression was used to identify predictors of worse outcomes. RESULTS: A total of 95 patients were included (78% follow-up) with ACI or MACI performed in 55 cases (57.9%) and OCA in 40 (42.1%). A tibial tubercle osteotomy was the most common concomitant procedure for OCA (66%) and ACI/MACI (98%). Overall, KOOS pain was significantly poorer in OCA than ACI/MACI (74.7, 95% confidence interval 68.1-81.1 vs 83.6, 95% confidence interval 81.3, 88.4, P = .012), whereas the remaining KOOS subscores were nonsignificantly different (all P > .05). Overall, RTS rate was 54%, with no significant difference in return between OCA or ACI/MACI (52% vs 58%, P = .738). There were 26 (27%) reoperations and 5 (5%) graft failures in the entire group. Increasing age was associated with lower satisfaction in OCA and poorer outcomes in ACI/MACI, whereas larger lesion area was associated with lower satisfaction and poorer outcomes in ACI/MACI. CONCLUSIONS: Clinical and functional outcomes were similar in patients who underwent OCA or ACI/MACI for patellofemoral articular cartilage defects at a mean follow-up of 5 years. Patients who received OCA had a greater proportion of degenerative cartilage lesions and, among those with trochlear lesions, reported greater pain at final follow-up than their ACI/MACI counterparts. Overall, increasing age and a larger lesion size were associated with worse patient-reported outcomes. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Superior Pain Reduction with Anteromedialization Tibial Tubercle Osteotomy Versus Non-Operative Management for Patellofemoral Osteoarthritis.

PURPOSE: The purpose of this study was to compare the clinical outcomes of patients with patellofemoral osteoar-thritis (PFOA) treated non-operatively with those treated operatively with an unloading anteromedialization tibial tubercle osteotomy (TTO). METHODS: A retrospective chart review was performed to identify patients with isolated PFOA who were either managed non-operatively or surgically with a TTO and who had a minimum follow-up of 2 years. Patients were surveyed with the visual analog scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), Anterior Knee Pain scale (Kujala), and Tegner Activity scale. Statistical analysis included two-sample t-testing, one-way ANOVA, and bivariate analysis. RESULTS: The clinical outcomes of 49 non-operatively managed patients (mean age: 52.7 ± 11.3 years; mean follow-up: 1.7 ± 1.0 years) and 35 operatively managed patients (mean age: 31.8 ± 9.4 years; mean follow-up: 3.5 ± 1.7 years) were assessed. The mean VAS improved sig-nificantly in both groups [6.12 to 4.22 (non-operative), p < 0.0001; 6.94 to 2.45 (TTO); p < 0.0001], with operatively treated patients having significantly lower postoperative pain than non-operatively managed patients at the time of final follow-up [2.45 (TTO) vs. 4.22 (non-operative), p < 0.001]. The mean KOOS-JR score was significantly greater in the operative group at time of final follow-up [78.7 ± 11.6 (TTO) vs. 71.7 ± 17.8 (non-operative), p = 0.035]. There was no significant difference in Kujala or Tegner scores between the treatment groups. Additionally, there was no sig-nificant relationship between the number of intra-articular injections, duration of NSAID use, and number of physical therapy sessions on clinical outcomes in the non-operatively treated group (p > 0.05). CONCLUSIONS: An unloading anteromedialization TTO provides significantly better pain relief and restoration of function compared to non-operative management in the treatment of symptomatic PFOA.

Matrix-Induced Autologous Chondrocyte Implantation Versus Autologous Chondrocyte Implantation of the Knee A Retrospective Comparison.

OBJECTIVE: The purpose of this study was to compare the short-term clinical outcomes of matrix-induced autologous chondrocyte implantation (MACI) to those seen following traditional autologous chondrocyte implantation (ACI) in the management of symptomatic cartilage lesions of the knee. METHODS: This was a retrospective cohort study of patients who underwent either ACI or MACI from January 2011 to March 2018. Patients with a minimum postoperative follow-up of 18 months were contacted. Demographic information, intraoperative findings, and patient-reported functional outcomes scores were collected. Comparisons were made between the two cell-based cartilage repair techniques. RESULTS: Fifty-six patients were included in the study (39 ACI, 17 MACI). Visual analog scale (VAS) for pain scores improved significantly in both groups, with MACI patients demonstrating significantly lower postoperative pain scores compared to those treated with ACI. In the ACI group, there was a decrease in the Tegner Activity score compared to the preoperative baseline, while no significant difference was seen between pre- and postoperative activity levels in the MACI group. Patients were generally satisfied with the outcome of their procedures, and there was no significant difference in satisfaction between groups. No patients re-quired additional surgery during the follow-up period. CONCLUSION: Both ACI and MACI demonstrated good short-term postoperative clinical results with improved pain and activity levels compared to the preoperative baseline. Patients treated with the MACI technique demonstrated greater reductions in pain scores compared to ACI, and while ACI resulted in a decrease in levels of postoperative activity, activity levels for MACI remained stable.

Segond fracture: an indicator for increased risk of lateral meniscus injury in patients with acute anterior cruciate ligament ruptures.

PURPOSE: The purpose of this study was to investigate the incidence and anatomic distribution of meniscus injury in patients who have sustained acute ACL injuries with and without concomitant Segond fracture. We hypothesized that patients who have sustained a torn ACL with a concomitant Segond fracture would have a higher incidence of lateral meniscal injuries than patients with an isolated ACL injury. METHODS: Patients who underwent ACL reconstruction from 2012 to 2022 were retrospectively reviewed. Segond fractures were identified on knee radiographs. Inclusion criteria were age 18-40, injury during sports activity, and reconstruction within 90 days of injury. Sports activity, anatomic location of meniscus injury, and meniscus treatment were documented. Multivariable regression was used to identify predictors of meniscus injury/treatment. RESULTS: There were 25 of 603 (4.1%) patients who had an ACL tear with concomitant Segond fracture. The incidence of lateral meniscus injury in the Segond group (72%) was significantly higher than in the non-Segond cohort (49%; p = 0.024). A significantly smaller proportion of medial meniscus injuries among patients with Segond fractures were repaired (23.1%) compared to the non-Segond group (54.2%; p = 0.043). Multivariate analysis found patients with Segond fractures to have increased odds of lateral meniscus injury (OR 2.68; [1.09, 6.60], p = 0.032) and were less likely to have medial meniscus injuries repaired (OR 0.35; [0.15, 0.81], p = 0.014). Additionally, males had increased odds of lateral meniscus injury (OR 1.54; [1.08 - 2.91], p = 0.017), which were more likely to require repair (OR 1.48; [1.02, 2.14], p = 0.038). CONCLUSIONS: Among acute ACL injuries, the incidence of lateral meniscus injury is greater among patients with Segond fractures. Patients with Segond fracture were less likely to undergo repair of medial meniscal injuries.

Medial quadriceps tendon femoral ligament reconstruction and medial patellofemoral ligament reconstruction have no significant differences in clinical outcomes for treatment of lateral patellar instability: a matched-cohort study.

OBJECTIVES: The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. METHODS: A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. RESULTS: Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p â€‹= â€‹0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p â€‹= â€‹0.47), return to sport (MQTFLR 50%, MPFLR 75%, p â€‹= â€‹0.61), return to work (MQTFLR 100%, MPFLR 88%, p â€‹= â€‹1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p â€‹= â€‹0.31). CONCLUSION: There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. LEVEL OF EVIDENCE: III.

The Expanding Use of Knee Osteotomies in the Treatment of Malalignment and Joint Preservation.

This review highlights the expanding use of knee-based osteotomies in the treatment of knee joint malalignment and joint preservation. Planning and outcomes of traditional high tibial osteotomies and distal femoral osteotomies are discussed in addition to some of the challenges encountered with these procedures. Lastly, the role of patient-specific instrumentation and three-dimensional guided templating in performing osteotomies is discussed with respect to procedures that involve biplanar corrections and those performed in combination with other joint preservation procedures.