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.

Posterior Cruciate Ligament Reconstruction Current Concepts Review.

Posterior cruciate ligament (PCL) injuries are a rare form of knee injury often seen in the setting of high energy polytraumas; however, these injuries can occur in isolation as well. Often, the posterolateral corner (PLC) is involved, which imparts further posterior translational and rotational instability to these injuries. While non-operative management is certainly a reliable option for low grade isolated PCL tears, high grade injuries with concomitant PLC involvement, additional intra-articular pathologies requiring operative management, multiligamentous injuries, or patients who have failed non-operative management require PCL repair or reconstruction. The current review focuses on the many facets of PCL reconstruction, including single versus double bundle reconstruction, tibial slope implications, graft selection, multiligamentous injury considerations, tunnel management, and onlay versus inlay tibial footprint creation. We conclude with a proposed algorithm in the management of this injury.

Hip Arthroscopy Improves Sexual Function in Receptive Partners with Femoroacetabular Impingement Syndrome.

BACKGROUND: Hip pain due to femoroacetabular impingement (FAI) is thought to adversely impact sexual satisfaction because of exacerbation of symptoms with hip ROM. However, the effect of FAI on sexual satisfaction and improvement after surgery to treat FAI is largely absent from published studies, despite patients' apparent interest in it as registered by the frequent appearance of these topics on online anonymous discussion platforms. In addition, details regarding its impact on the decision to pursue surgery and the success of hip arthroscopy in alleviating FAI-related sexual dysfunction based on the specific role assumed during intercourse (penetrative versus receptive) remains unknown. QUESTIONS/PURPOSES: Given that sexual intercourse involves different amounts of hip ROM depending on whether patients assume the penetrative or receptive role, this study evaluated the effect of FAI and hip arthroscopy on sexual activity based on role. Compared with patients who participate in the penetrative role during sexual intercourse, do patients who participate in the receptive role (1) experience greater difficulty with sexual function because of FAI symptoms, (2) take longer to return to sexual intercourse after hip arthroscopy, and (3) experience greater improvements in reported sexual function after hip arthroscopy for FAI? METHODS: This was a retrospective cohort study of patients undergoing hip arthroscopy for FAI. Between January 2017 and December 2021, 293 patients were treated with hip arthroscopy for FAI and enrolled in our longitudinally maintained database. Among all patients treated surgically, 184 patients were determined to be potentially eligible for study inclusion based on a minimum follow-up of 6 months postoperatively. The 6-month timepoint was chosen based on published data suggesting that at this timepoint, nearly 100% of patients resumed sexual intercourse with minimal pain after hip arthroscopy. Of the potentially eligible patients, 33% (61 patients) could not be contacted by telephone to obtain verbal consent for participation and 9% (17 patients) declined participation, leaving 106 eligible patients. Electronic questionnaires were sent to all eligible patients and were returned by 58% (61 patients). Forty-two percent of eligible patients (45) did not respond to the questionnaire and were therefore excluded from the analysis. Two percent (2) completed most survey questions but did not specify their role during intercourse and were therefore excluded. The mean age of included patients was 34 ± 9 years, and 56% were women The mean follow-up time was 2 ± 1 years. In total, 63% of included patients reported participating in the receptive role during sexual intercourse (49% receptive only and 14% both receptive and penetrative). Hip symptoms during sexual intercourse preoperatively and postoperatively were evaluated using a questionnaire created by our team to answer our study questions, drawing from one of the only published studies on the matter and combining the questionnaire with sexual position-specific questions garnered from arthroplasty research. Patients who reported participating in the receptive role during intercourse (either exclusively or in addition to the penetrative role) were compared with those who participated exclusively in the penetrative role. There were no specific postoperative recommendations in terms of the timing of return to sexual intercourse, other than to resume when comfortable. RESULTS: Overall, 61% of patients (36 of 59) reported that hip pain somewhat or greatly interfered with sexual intercourse preoperatively. Patients who participated in receptive intercourse were more likely to experience preoperative hip pain that interfered with intercourse than patients who participated exclusively in penetrative intercourse (odds ratio 5 [95% confidence interval 2 to 15]; p = <0.001). Postoperatively, there was no difference in time until return to sexual activity between those in the penetrative group (median 6 weeks [range 2 to 14 weeks]) and those in the receptive group (median 6 weeks [range 4 to 14 weeks]; p = 0.28). Postoperatively, a greater number of patients participating in the penetrative role reported no or very little pain, compared with patients participating in the receptive role (67% [14 of 21] versus 49% [17 of 35]). However, with regard to preoperative to postoperative improvement, patients who participated in the receptive role had greater pain with positions involving more hip flexion and abduction and experienced a greater improvement than their penetrative counterparts in these positions postoperatively. Despite this improvement, however, 33% of patients (7 of 21) participating in the penetrative role and 51% of patients (18 of 35) participating in the receptive role continued to report either some or a great amount of pain at final follow-up. CONCLUSION: Hip pain secondary to FAI interferes with sexual relations, particularly for partners who participate in the receptive role. Postoperatively, both patients participating in receptive and penetrative intercourse resumed sexual intercourse at a median of 6 weeks. After hip arthroscopy, the greatest improvement in pain was seen in receptive partners during sexual positions that involved more hip flexion and abduction. Despite this improvement, most patients, regardless of sexual role assumed, reported some degree of residual pain. Patients planning to undergo arthroscopic surgery for FAI, particularly those who participate in receptive intercourse, should be appropriately counseled about reasonable postoperative expectations based on our findings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Increased kinesiophobia leads to lower return to sport rate and clinical outcomes following osteochondral allograft transplantation of the knee.

PURPOSE: The purpose of this study is to describe the postoperative psychological state of patients following osteochondral allograft (OCA) transplantation in the knee and to determine whether patient-perceived kinesiophobia is associated with the rate of return to sport (RTS). METHODS: A retrospective review of the electronic medical record at a single institution was conducted for all patients that underwent OCA transplantation from January 2010 to 2020. Patient-reported outcomes including the visual analog scale (VAS), knee injury and osteoarthritis outcome score (KOOS) and the Tampa scale of kinesiophobia-11 (TSK-11) were collected. Patients were surveyed regarding their postoperative RTS status. RESULTS: A total of 38 patients (52.6% female) were included in our analysis. Overall, 24 patients (63.2%) returned to sport with 12 (50%) of these patients returning at a lower level of play. When comparing patients that return to sport to those that did not, patients that return had significantly superior KOOS pain (p = 0.019) and KOOS QOL (p = 0.011). Measures of kinesiophobia (TSK-11) were significantly higher among patients that did not return to sport (p = 0.014), while satisfaction (n.s.) and pain intensity (n.s.) were comparable between groups. Logistic regression models controlling for demographic factors, VAS pain scores and lesion size showed that for every one-point increase in TSK-11 kinesiophobia score, patients were 1.33 times more likely to return to sport at a lower level (p = 0.009). For every one-point increase in TSK-11 scores KOOS QOL decreased by 2.4 points (p < 0.001). CONCLUSION: Fear of reinjury decreases the likelihood that patients will return to their preoperative level of sport after OCA transplantation. Patients that do not return to sport report significantly greater fear of reinjury and inferior clinical outcomes, despite similar levels of satisfaction and pain compared to those that return. LEVEL OF EVIDENCE: Level III.

Perceptions and Opinions on Cannabidiol in the Orthopaedic Sports Medicine Community.

Background: Cannabidiol (CBD) is a known pain modulator that is garnering increased attention in the orthopaedic world. There may be a considerable knowledge gap among orthopaedic sports medicine providers and their perception of its therapeutic value. Purpose: To (1) examine the knowledge and beliefs of sports medicine orthopaedic providers with respect to CBD, (2) deliver an educational component, and (3) elucidate potential barriers to its widespread application. Study Design: Cross-sectional study. Methods: A 3-component, 25-question online survey was distributed to members of the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America between July and October 2022. The first 20 questions assessed baseline knowledge and opinions regarding CBD, followed by an educational component, and then 5 questions assessing whether the respondents' opinions had changed after learning more about CBD. Responses were compared according to age, practice setting, and state's cannabinoid legalization status using the chi-square test, and changes in opinions from before to after the educational component were compared using the paired t test. Results: There were 101 survey responses, for a response rate of approximately 1%. Most respondents believed that there is a role for CBD in postoperative pain management (76%), acute pain and inflammation after an injury (62%), and chronic pain (94%). Most respondents admitted that they were not knowledgeable about the mechanism of action (89%) or their state's laws (66%) concerning CBD. A minority (25%) believed that CBD has psychoactive properties. While most respondents (76%) did not believe that they would be stigmatized if they were to suggest CBD to a patient, only 48% had ever suggested CBD. Notably, 94% of respondents had encountered patients who reported trying CBD to treat pain. After reading the fact sheet, 51% of respondents stated that their opinion on CBD had changed, and 63% felt inclined to investigate the topic further. Conclusion: Most survey respondents believed that CBD has a role in postoperative and chronic pain management. Although there was a relative familiarity with CBD, there was a knowledge gap, suggesting that increased attention, education, and research are necessary.

Brain Glutathione Increase and Seizure Burden Decrease in Patients with Intractable Epilepsy on Ketogenic Diet.

Background and Purpose: Ketogenic diet (KD) improves seizure control in patients with drug-resistant epilepsy. As increased mitochondrial levels of glutathione (GSH) might contribute to a change in seizure susceptibility, we quantified changes of absolute GSH levels in the brain by in vivo 1H magnetic resonance spectroscopy (1H MRS) and correlate that with degree of seizure control in patients on KD. Methods: Five cognitively normal adult patients with drug-resistant epilepsy were initially included and 2 completed the study. Each patient was evaluated by a neurologist and registered dietitian at baseline, 1, 3, and 6 months for seizure status and diet adherence after initiation of a modified atkins diet. Multiple metabolites including GSH were quantified using LCModel (version 6.3-1P; Stephen Provencher, Oakville, ON, CA) on a short echo time single-voxel 1H MRS in parieto/occipital grey matter and parietal white matter on a 3 Tesla General Electric magnet prior to starting the ketogenic diet and at 6 months. Results: Both patients (42-years-old male and 35-years-old female) demonstrated marked increases in absolute GSH level in both gray matter (0.12 to 1.40 and 0.10 to 0.70 international unit [IU]) and white matter (0.65 to 1.50 and 0.80 to 2.00 IU), as well as 50% improvements in seizure duration and frequency. Other metabolites including ketone bodies did not demonstrate consistent changes. Conclusions: Markedly increased levels of GSH (7-fold and 14-fold) were observed in longitudinal prospective study of two adult patients with intractable epilepsy with 50% seizure improvement after initiation of ketogenic diets. This pilot study supports the possible anticonvulsant role of GSH in the brain.

Cannabis Use Disorder Not Associated With Opioid Analgesic Use or Patient-Reported Outcomes After ACL Reconstruction: A Retrospective Matched-Cohort Analysis.

BACKGROUND: The purpose of this study was to compare opioid analgesic use and patient-reported outcomes (PROs) after anterior cruciate ligament reconstruction (ACLR) between patients with and without cannabis use disorder (CUD). HYPOTHESIS: We hypothesized that patients with CUD would have greater postoperative opioid usage with comparable improvement in PROs. STUDY DESIGN: Retrospective matched-cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: We identified patients with CUD who underwent primary ACLR at a single center and had minimum 3-month follow-up. Patients with CUD were propensity score matched 1:1 to non-CUD controls with respect to age, sex, and follow-up time. Total refills, days supply, and morphine milligram equivalents (MMEs) of opioid analgesics prescribed were calculated for up to 1 year postoperatively. Patient-Reported Outcome Information System (PROMIS) instruments were used to assess PROs. Opioid use and outcomes were compared between CUD and control groups using Mann-Whitney U test and Fisher's exact test. P values <0.05 were considered significant. RESULTS: A total of 104 patients with CUD were matched to 104 controls. Both groups were majority male (65.4% male, 34.6% female). The CUD group had a mean age of 29.9 years and mean follow-up time of 16.1 months. There was no significant intergroup difference in opioid prescription rates (CUD 82.7% vs control 83.7%, P ≥ 0.99). Among patients prescribed opioids, there were no significant intergroup differences in total days supply (P = 0.67), total MMEs (P = 0.71), or MMEs per day (P = 0.65). There were no significant differences in pre- to postoperative improvement in PROMIS Pain Intensity (P = 0.51), Pain Interference (P = 0.81), Mobility (P = 0.90), Mental Health (P = 0.74), or Physical Health (P = 0.94). CONCLUSION: There were no significant differences detected in opioid usage or PRO improvement after ACLR between patients with CUD and those without. However, because a sample size was not determined a priori, a larger sample may show a difference. CLINICAL RELEVANCE: CUD does not appear to correlate with inferior outcomes after ACLR.

Home ownership, full-time employment, and other markers of higher socioeconomic status are predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction.

BACKGROUND: The purpose of this study was to identify socioeconomic predictors of time to initial evaluation, time to surgery, and postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction (MPFLR). METHODS: We conducted a retrospective review of patients at our institution who underwent primary MPFLR with allograft from 2011 to 2019 and had minimum 12-month follow-up. Patients were administered an email survey in January 2022 to assess symptom history, socioeconomic status, and postoperative outcomes including VAS satisfaction and Kujala score. Predictors of time to initial evaluation, time to surgery, and postoperative outcomes were identified using multivariable linear and logistic regression with stepwise selection. RESULTS: Seventy patients were included in the cohort (mean age 24.8 years, 72.9% female, mean follow-up time 45.7 months). Mean time to evaluation was 6.4 months (range 0-221) and mean time to surgery was 73.6 months (range 0-444). Having a general health check-up in the year prior to surgery was predictive of shorter time to initial evaluation (ß = - 100.5 [- 174.5, - 26.5], p = 0.008). Home ownership was predictive of shorter time to surgery (ß = - 56.5 [- 104.7, 8.3], p = 0.02). Full-time employment was predictive of higher VAS satisfaction (ß = 14.1 [4.3, 23.9], p = 0.006) and higher Kujala score (ß = 8.7 [0.9, 16.5], p = 0.03). CONCLUSION: Markers of higher socioeconomic status including having a general check-up in the year prior to surgery, home ownership, and full-time employment were predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes. LEVEL OF EVIDENCE:  IV, retrospective case series.

The Role of Needle Arthroscopy in the Assessment and Treatment of Ankle Sprains.

Lateral ankle ligament complex injuries are most commonly managed nonoperatively. If no improvements have been made following conservative management, surgical intervention is warranted. Concerns have been raised regarding complication rates following open and traditional arthroscopic anatomical repair. In-office needle arthroscopic anterior talo-fibular ligament repair provides a minimally invasive arthroscopic approach to the diagnosis and treatment of chronic lateral ankle instability. The limited soft tissue trauma facilitates rapid return to daily and sporting activities making this an attractive alternative approach to lateral ankle ligament complex injuries.

Acceptable clinical outcomes despite high reoperation rate at minimum 12-month follow-up after concomitant arthroscopically assisted anterior cruciate ligament reconstruction and medial meniscal allograft transplantation.

BACKGROUND: Single-stage medial meniscus allograft transplantation (MAT) with concomitant anterior cruciate ligament reconstruction (ACLR) is a technically challenging procedure for management of knee pain and instability in younger patients, but clinical and functional outcomes data are sparse. The purpose of this study was to assess surgical and patient-reported outcomes following concomitant ACLR and medial MAT. METHODS: We conducted a retrospective case series of patients who underwent medial MAT with concomitant primary or revision ACLR at our institution from 2010 to 2021 and had minimum 12-month follow-up. Complications, reoperations, visual analog scale (VAS) pain, satisfaction, Lysholm score, return to sport, and return to work outcomes were assessed. Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference, Pain Intensity, and Physical Function Scores were used to measure patients' functional status relative to the US population. P-values < 0.05 were considered significant. RESULTS: The cohort consisted of 17 knees of 16 individual patients. The cohort was majority male (82.4%) with mean age of 31.9 years (range 19-49 years) and mean body mass index (BMI) of 27.9 kg/m2 (range 22.5-53.3 kg/m2). Mean follow-up time was 56.8 months (range 13-106 months). Most patients underwent revision ACLR (64.7%). The 1-year reoperation rate was high (23.5%), with two patients (11.8%) tearing their meniscus graft. Patient-reported outcomes indicated low VAS pain (mean 2.2), high satisfaction (mean 77.9%), and fair Lysholm score (mean 81.1). Return to work rate was high (92.9%), while return to sport rate was low (42.9%). Postoperative PROMIS scores were comparable or superior to the national average and correlated significantly with patient satisfaction (p < 0.05). CONCLUSIONS: The concomitant ACLR and MAT procedure is associated with excellent knee pain and functional outcomes and high rate of return to work after surgery, though the 1-year reoperation rate is high and rate of return to sport is low. LEVEL OF EVIDENCE: IV.

Corrigendum to: Glutathione Increase and Seizure Burden Decrease in Patients with Intractable Epilepsy on Ketogenic Diet.

[This corrects the article DOI: 10.14581/jer.23001.].

Needle Arthroscopy Demonstrates High Sensitivity and Specificity for Diagnosing Intra-Articular Shoulder and Knee Pathology.

INTRODUCTION:  Needle arthroscopy has been introduced in recent years as an alternative to magnetic resonance imaging (MRI) for the evaluation of knee and shoulder conditions. It has continued to evolve at a rapid rate with newer generation models making in-office integration simple. As MRI can sometimes prove inconclusive, it is worthwhile to consider these alternative options for evaluating musculoskeletal pathology as a primary diagnostic tool.  Purpose: The purpose of this study is to evaluate the specificity and sensitivity of needle arthroscopy in diagnosing intra-articular shoulder and knee pathology in a small case series of patients who ultimately underwent surgical arthroscopy. METHODS: A retrospective, single-centre, single-surgeon, cohort study was performed over a three-year period from August 2018 to June 2021. During this time, diagnostic needle arthroscopy was performed on patients with suspected shoulder or knee pathology based on MRI findings and clinical exams. These patients subsequently underwent standard surgical arthroscopy. RESULTS: Thirty-four patients were included in the study. There were 35 joints included, 25 shoulders and 10 knees, with a mean age of 41.88 +/- 11.32 years and BMI of 29.33 +/- 6.27 in the shoulder group and a mean age of 45.5 +/- 14.54 and BMI of 31.5 +/- 4.94 in the knee group. When evaluating shoulder pathologies, needle arthroscopy showed a sensitivity of 0.93 for rotator cuff tears, 1.00 for labral tears and 1.00 for loose bodies. Needle arthroscopy for the shoulder was found to be 100% specific for all shoulder pathologies. Needle arthroscopy for the knee was found to have a 1.00 sensitivity for detecting chondral defects and 0.80 sensitivity for meniscal tears. There were once again no false positive needle arthroscopy findings amongst the knee group. CONCLUSION: Needle arthroscopy is an accurate diagnostic tool for the evaluation of intra-articular knee and shoulder musculoskeletal pathology. It can provide a potential solution for MRI-derived diagnostic inaccuracies that can lead to missed pathologies or unindicated procedures. It is less invasive than surgical arthroscopy and should be considered a useful tool in the armamentarium of orthopedic surgeons.