Editorial Commentary: Osteochondral Allograft of the Knee-Diffuse Edema at 6 Months on Magnetic Resonance Imaging Predicts Failure.

Cartilage defects alter natural function of articular cartilage and can predispose patients to further cartilage wear and eventual osteoarthritis. These injuries present a challenging problem with a multitude of treatment options and lack of consensus on when to employ each. Options include conservative measures (limited weightbearing and immobilization), debridement, microfracture, autologous chondrocyte implantation, and osteochondral autograft and allograft. Indications may be based on defect size, joint alignment, age, activity level, body mass index, and sex. One option, osteochondral allograft (OCA) transplantation, is typically reserved for large and severe defects or revision. With regard to OCA prognosis, older patients, revision cases, patellar defects, and bipolar lesions confer elevated risk of failure, whereas traumatic or idiopathic cases, unipolar lesions, and short duration of symptoms have reported higher levels of satisfaction. Following surgery, the patient with persistent symptoms can present a conundrum. Recent research shows that in such cases, diffuse edema at 6 months on magnetic resonance imaging often predicts ultimate failure, in which case arthroplasty may be required.

More Is Not Merrier: Increasing Numbers of All-Inside Implants Do Not Correlate with Higher Odds of Revision Surgery.

The purpose of this study was to evaluate the relationship between the number of all-inside meniscal repair implants placed and the risk of repair failure. We hypothesized that the use of higher numbers of all-inside meniscus repair implants would be associated with increased failure risk. A retrospective chart review identified 351 patients who underwent all-inside meniscus repair between 2006 and 2013 by a sports medicine fellowship-trained orthopaedic surgeon at a single institution. Patient demographics (age, body mass index [BMI], sex) and surgical data (number of implants used, concomitant anterior cruciate ligament reconstruction [cACLR], and tear type/size/location) were recorded. Patients who received repairs in both menisci or who had follow-up < 1-year postoperatively were excluded. Repair failure was identified through chart review or patient interviews defined as a revision surgery on the index knee such as partial meniscectomy, total knee arthroplasty, meniscus transplant, or repeat repair. Logistic regression modeling was utilized to evaluate the relationship between the number of implants used and repair failure. A total of 227 all-inside meniscus repairs were included with a mean follow-up of 5.0 ± 3.0 years following surgery. Repair failure was noted in 68 knees (30.3%)-in 28.1% of knees with fewer than four implants and in 35.8% of knees with four or more implants (p = 0.31). No significant increase in failure was observed with increasing number of all-inside medial (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.79-1.7; p = 0.46) or lateral (OR: 0.86; 95% CI: 0.47-1.57; p = 0.63) implants after controlling for patient age, BMI, cACLR, tear type, or size. Tears of the lateral meniscus located in the red-white and white-white zones had lower odds of failure (OR: 0.14; 95% CI: 0.02-0.88; p = 0.036) than tears within the red-red zone, and patients with cACLR had lower odds of repair failure (OR: 0.40; 95% CI: 0.18-0.86, p = 0.024) than those without. The number of all-inside implants placed during meniscus tear repair did not affect the likelihood of repair failure leading to reoperation after controlling for BMI, age, tear type, size, location, and cACLR. LEVEL OF EVIDENCE: III.

Incidence, Common Pathogens, and Risk Factors for Infection after Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review.

We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis, and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction.

Patient-Reported Outcomes Following Medial Patellofemoral Reconstruction With Peroneus Longus Allografts Demonstrate Good Results.

Purpose: To evaluate the recurrent dislocation risk and patient-reported outcomes of peroneus longus allograft tissue for medial patellofemoral ligament (MPFL) reconstruction. Methods: Patients who underwent MPFL reconstruction with peroneus longus allograft at an academic center between 2008 and 2016 were identified. Record review and patient contact were used to identify any cases of recurrent patellar dislocation and collect patient-reported outcomes scores (Knee injury and Osteoarthritis Outcome Score [KOOS], Norwich Patellar Instability score, Marx activity scale). Patients with 1-year minimum follow-up were included. Outcomes were quantified and the proportion of patients reaching a previously defined patient acceptable symptom state (PASS) for patellar instability was determined. Results: Sixty-one patients (42 female and 19 male) underwent MPFL reconstruction with peroneus longus allograft during the study period. Forty-six patients (76%) with 1-year minimum follow up were contacted at a mean of 3.5 years postoperative. The mean age at time of surgery was 22 ± 7.2 years. Patient-reported outcomes data were available in 34 patients. Mean KOOS subscale scores were as follows: Symptoms 83.2 ± 19.1, Pain 85.2 ± 17.6, Activities of Daily Living 89.9 ± 14.8, Sports 75 ± 26.2, and Quality of Life 72.6 ± 25.7. The mean Norwich Patellar Instability score was 14.9% ± 17.4%. The mean Marx activity score was 6.0 ± 5.2. No recurrent dislocations were noted during the study period. Sixty-three percent of patients who underwent isolated MPFL reconstruction met PASS thresholds in at least 4 of 5 KOOS subscales. Conclusions: The use of a peroneus longus allograft in MPFL reconstruction in conjunction with other indicated procedures results in a low re-dislocation risk and a high proportion of patients meeting PASS criteria for patient-reported outcome scores 3 to 4 years postoperatively. Level of Evidence: IV, case series.

Athletes and Nonathletes Show No Difference in Symptoms or Function Prior to Knee Surgery, but Those With Chronic Symptoms Show Increased Pain Catastrophizing and Kinesiophobia.

PURPOSE: To determine whether preoperative psychological status before outpatient knee surgery is influenced by athletic status, symptom chronicity, or prior surgical history. METHODS: International Knee Documentation Committee subjective scores (IKDC-S), Tegner Activity Scale scores, and Marx Activity Rating Scale scores were collected. Psychological and pain surveys included the McGill pain scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia 11, Patient Health Questionnaire 9, Perceived Stress Scale, New General Self-Efficacy Scale, and Life Orientation Test-Revised for optimism. Linear regression was used to determine the effects of athlete status, symptom chronicity (>6 months or ≤6 months), and history of prior surgery on preoperative knee function, pain, and psychological status after matching for age, sex, and surgical procedure. RESULTS: In total, 497 knee surgery patients (247 athletes, 250 nonathletes) completed a preoperative electronic survey. All patients were age 14 years and older and had knee pathology requiring surgical treatment. Athletes were younger than nonathletes on average (mean [SD], 27.7 [11.4] vs 41.6 [13.5] years; P < .001). The most frequently reported level of play among athletes was intramural or recreational (n = 110, 44.5%). Athletes had higher preoperative IKDC-S scores (mean [SE], 2.5 [1.0] points higher; P = .015) and lower McGill pain scores compared to nonathletes (mean [SE] 2.0 [0.85] points lower; P = .017). After matching for age, sex, athlete status, prior surgery, and procedure type, having chronic symptoms resulted in higher preoperative IKDC-S (P < .001), pain catastrophizing (P < .001), and kinesiophobia scores (P = .044). CONCLUSIONS: Athletes demonstrate no difference in symptom/pain and function scores preoperatively when compared to nonathletes of similar age, sex, and knee pathology, as well as no difference in multiple psychological distress outcomes measures. Patients with chronic symptoms have more pain catastrophizing and kinesiophobia, while those who have had prior knee surgeries have slightly higher preoperative McGill pain score. LEVEL OF EVIDENCE: Level III, cross-sectional analysis of prospective cohort study data.

Surgical Hip Dislocation in Pediatric and Adolescent Patients.

LEVEL OF EVIDENCE: V, Expert opinion.

Biologic Augmentation during Meniscal Repair.

We reviewed the literature regarding utility of biologic augmentation in meniscal repair. We hypothesized that the addition of biologic augmentation during meniscal repair improves postoperative knee function and reduces risk of repair failure. PubMed and Embase databases were systematically searched. Included studies were clinical studies in humans, published in English, and reported use of biologic augmentation techniques in addition to meniscal repair (including platelet-rich plasma [PRP], fibrin clot, bone marrow stimulation, meniscal wrapping, and bioscaffolds) for treatment of knee meniscal tears. Outcome measures included repair failure, repeat knee arthroscopic surgery, and magnetic resonance imaging), visual analog scale for pain, the International Knee Documentation Committee questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index Lysholm's Knee Scoring Scale, and the Knee Injury and Osteoarthritis Outcome Score. Study quality was assessed using the modified Coleman methodology score. Nineteen studies reported repair of 1,092 menisci including six studies that investigated fibrin clot augmentation, five studies that investigated PRP augmentation, three studies that investigated bone marrow stimulation augmentation, two studies that used meniscal wrapping augmentation, and three studies that used other techniques. The level of evidence ranged from I to IV and mean modified Coleman methodology score was 43 (range: 17-69), with higher scores noted in studies completed in recent years. PRP and bone marrow stimulation augmentation appear to decrease risk of failure in patients undergoing isolated meniscal repair but do not improve knee symptom scores. Fibrin clot and trephination augmentation techniques do not have sufficient evidence to support decreased failure risk at this time. Meniscal wrapping augmentation and scaffold implantation augmentation appear to be an attractive option to meniscectomy in complicated tears that are not candidates for repair alone, but further confirmatory studies are needed to support initial data. Evidence supporting augmentation of meniscal repair is limited at this time but suggests that the highest likelihood for effectiveness of augmentation is in the settings of isolated meniscal repair or meniscal repairs that would normally not be amenable to repair.

Influence of Staphylococcus epidermidis biofilm on the mechanical strength of soft tissue allograft.

We sought to determine the impact of bacterial inoculation and length of exposure on the mechanical integrity of soft tissue tendon grafts. Cultures of Staphylococcus epidermidis were inoculated on human tibialis posterior cadaveric tendon to grow biofilms. A low inoculum in 10% growth medium was incubated for 30 min to replicate conditions of clinical infection. Growth conditions assessed included inoculum concentrations of 100, 1000, 10,000 colony-forming units (CFUs). Tests using the MTS Bionix system were performed to assess the influence of bacterial biofilms on tendon strength. Load-to-failure testing was performed on the tendons, and the ultimate tensile strength was obtained from the maximal force and the cross-sectional area. Displacements of tendon origin to maximal displacement were normalized to tendon length to obtain strain values. Tendon force-displacement and stress-strain relationships were calculated, and Young's modulus was determined. Elastic modulus and ultimate tensile strength decreased with increasing bioburden. Young's modulus was greater in uninoculated controls compared to tendons inoculated at 10,000 CFU (p = 0.0011) but unaffected by bacterial concentrations of 100 and 1000 CFU (p = 0.054, p = 0.078). Increasing bioburden was associated with decreased peak load to failure (p = 0.043) but was most significant compared to the control under the 10,000 and 1000 CFU growth conditions (p = 0.0005, p = 0.049). The presence of S. epidermidis increased elasticity and decreased ultimate tensile stress of human cadaveric tendons, with increasing effect noted with increasing bioburden.

Patellofemoral articular cartilage damage is associated with poorer patient-reported outcomes following isolated medial patellofemoral ligament reconstruction.

PURPOSE: The purpose of this study was to investigate the impact of articular cartilage damage on outcomes following medial patellofemoral ligament (MPFL) reconstruction. METHODS: Record review identified 160 patients who underwent isolated MPFL reconstruction at a single institution between 2008 and 2016. Patient demographics, patellofemoral articular cartilage status at surgery, and patient anatomical measures from imaging were obtained via chart review. Patients were contacted and outcomes assessed through collection of Norwich Patellar Instability (NPI) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity score as well as an assessment for recurrent patellar dislocation. Outcomes of patients with grade 0-II patellofemoral cartilage damage were compared to those of patients with grade III-IV cartilage damage. RESULTS: One hundred twenty-two patients (76%) with a minimum of one year follow-up were contacted at a mean of 4.8 years post-operatively. A total of 63 patients (52%) had grade III or IV patellofemoral chondral damage at the time of surgery. The majority of the defects was on the medial patella (46 patients-72%) and the mean patellar defect size was 2.8 cm2. Among 93 patients who completed patient-reported outcome scores, the 52 with grade III or IV chondral damage reported a significantly poorer KOOS Quality of Life than the 44 patients with grade 0 to II chondral damage (p = 0.041), controlling for patient age, sex, BMI, and anatomical factors. CONCLUSION: Patients with grade III or IV articular cartilage damage of the patellofemoral joint at the time of MPFL reconstruction demonstrated poorer KOOS knee-related quality of life than patients without grade III or IV articular cartilage damage at a mean of 4.8 years following isolated MPFL reconstruction. LEVEL OF EVIDENCE: Level II.

Smaller Iatrogenic Defects Created by Inside-Out Compared With All-Inside Meniscus Repair Devices in Human Cadaveric Model.

PURPOSE: (1) To investigate the pattern and diameter of the iatrogenic defect that meniscal repair devices impose on meniscal tissue and (2) to determine whether repair-induced defect patterns or diameters differ across devices. METHODS: Sixty-one fresh frozen human cadaveric menisci were used (n = 9; eliminated). All-inside devices (n = 9) included ULTRA FAST-FIX, FAST-FIX 360, Depuy Mitek 0° and 12° TRUESPAN, ConMed Sequent, Zimmer Biomet JuggerStitch, Stryker IvyAIR, Arthrex FiberStitch and Meniscal Cinch II. Inside-out needles (n = 4) included ConMed HiFi, Depuy Mitek ORTHOCORD, Arthrex-2-0 FiberWire, and Stryker SharpShooter. Following India Ink staining, implant devices were inserted into cadaveric menisci. Samples were fixed in formalin solution and imaged with a high-resolution camera. Defects were classified by qualitative evaluation. Defect and needle diameter were quantified with software assistance. Statistical analysis was performed using analysis of variance testing. RESULTS: We analyzed 644 iatrogenic defects with mean defect diameter of 1.96 mm (standard deviation 0.86). For all-inside devices, defect patterns (n = 436) were 15.6% linear, 38.1% semilunar, 46.3% stellate, while inside-out devices (n = 208) were 95.7% stellate, 4.3% linear, and 0.0% semilunar. All-inside devices had mean defect diameter of 2.46 mm, while inside-out meniscus needles had mean 0.90 mm defect diameter (P < .001). FasT-FIX 360, ULTRA-FAST-FIX, and Arthrex Meniscal Cinch II induced smaller diameter defects than other all-inside devices (F = 20.2, P < .05). Strong positive correlation was found comparing outer needle diameter and mean defect diameters across all devices (R2 = 0.9447). CONCLUSIONS: Needles utilized in meniscal implant systems produce the following basic defect patterns: stellate (62.3%), semilunar (25.8%), and linear (11.9%). A strong positive correlation was found between mean defect size and outer needle diameter across all devices. Inside-out double-armed flexible needles produced significantly smaller defects than all-inside devices. Of the all-inside devices, ULTRA FAST-FIX, FAST-FIX 360, and Arthrex Meniscal Cinch II produced smaller defects on average. CLINICAL RELEVANCE: While the true clinical impact of these findings cannot be drawn from the present study, this investigation provides necessary context to better understand reported similarities and differences in healing rates and outcomes between inside-out and all-inside repair techniques.

Influence of Patellofemoral Anatomy on Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability.

Background: Patella alta and elevated tibial tubercle-trochlear groove (TT-TG) distance can predispose patients to lateral patellar dislocations and recurrent instability. Their influence on patient-reported outcomes (PROs) after medial patellofemoral ligament (MPFL) reconstruction is less clear. Hypothesis: We hypothesized that neither moderately increased TT-TG distance nor patella alta would negatively affect PROs after isolated MPFL reconstruction in patients with relatively normal patellar tracking (no large J-sign). Study Design: Cohort study; Level of evidence, 3. Methods: We identified patients who underwent isolated MPFL reconstruction at a single institution between 2008 and 2016. The decision to perform an isolated MPFL reconstruction was at the discretion of the operating surgeon but was not performed in the setting of a large J-sign. Patient characteristics and surgical details were collected, and patients completed the Norwich Patellar Instability Score, Knee injury and Osteoarthritis Outcome Score, and Marx activity score. Patellar height (Caton-Deschamps Index [CDI]) was assessed on preoperative lateral radiographs, and TT-TG distance was measured on preoperative axial magnetic resonance imaging (MRI) scans. Patients were grouped based on CDI and TT-TG distance, and outcomes were compared. Linear regression modeling was performed to determine whether patella alta or elevated TT-TG distance was associated with poorer PRO scores. Results: Of 165 knees in 152 patients who underwent isolated MPFL reconstruction, 115 patients (125 knees; 76%) with minimum 1-year follow-up were contacted at a mean of 5.2 years after surgery. Recurrent dislocation occurred in 5 of 125 knees (4%). Preoperative radiographs were available in 111 knees (89%), and preoperative MRI scans were available in 89 knees (71%). Mean CDI was 1.13, and 35% had a CDI ≥1.20. Mean TT-TG distance was 17.5 mm, and 26% had a TT-TG distance >20 mm. After adjusting for patient age, sex, body mass index, and graft choice, we observed that neither patella alta nor elevated TT-TG distance were associated with poorer PROs. Conclusion: Isolated MPFL reconstruction in the setting of moderately elevated TT-TG distance or patella alta was not associated with worse PROs in this cohort with relatively normal patellar tracking (no large J-sign).

Editorial Commentary: Age-Appropriate Expectations Are Critical When Analyzing Knee Anterior Cruciate Ligament Reconstruction Outcomes: Age Is More Than Just a Number.

In patients undergoing anterior cruciate ligament (ACL) reconstruction, age affects treatment and postoperative recovery decisions, as well as failure rates and outcomes. However, how age affects postoperative patient-reported outcomes and the appropriateness of using the International Knee Documentation Committee patient acceptable symptoms state score in the >40-year-old patient population has received little attention. This study assesses commonly used patient-reported outcomes in older patients undergoing ACL reconstruction and aims to redefine a more suitable patient acceptable symptoms state score for this patient population. As our understanding of both the importance of ACL reconstruction on knee biomechanics and joint stability, as well as the increased rate of ACL reconstruction in older patients grows, having age-appropriate outcomes expectations is critical to both counseling patients and developing future research aims. Future application of outcomes scores in clinical practice and in the research, arena must take into account patient age and function after ACL reconstruction.

Time Matters: Knee Cartilage Defect Expansion and High-Grade Lesion Formation while Awaiting Autologous Chondrocyte Implantation.

OBJECTIVE: The objective of this study was to assess potential risk factors, including time delay until implantation, for knee cartilage defect expansion or new high-grade defect formation between biopsy and Autologous Chondrocyte Implantation (ACI) or Matrix Autologous Chondrocyte Implantation (MACI). STUDY DESIGN: Consecutive knee ACI and MACI cases by a single surgeon (n = 111) were reviewed. The relationship between time between biopsy and staged implantation and (1) progression in primary cartilage defect size and (2) development of a new high-grade (Outerbridge grade ≥3) cartilage defect were determined with adjustment for demographics, body mass index, smoking status, coronal alignment, initial cartilage status, and prior surgery. RESULTS: Average size of the primary defect at time of biopsy was 4.50 cm2. Mean time to chondrocyte implantation was 155 days. Defect expansion increased 0.11 cm2 (standard error = 0.03) per month delay to implantation (P = 0.001). Independent predictors of defect expansion were male sex, smaller initial defect size, and delay to implantation (adjusted mean = 0.15 cm2 expansion per month). A total of 16.2% of patients (n = 18/111) developed a new high-grade defect. Independent predictors of a new secondary defect were Outerbridge grade 2 changes (vs. 0-1) on the surface opposing the index defect and delayed implantation (per month increase, adjusted odds ratio = 1.21, 95% confidence interval: 1.01-1.44; P = 0.036). CONCLUSIONS: Patients undergoing 2-stage cell-based cartilage restoration with either ACI or MACI demonstrated long delays between stages of surgery, placing them at risk for expanding defects and development of new high-grade cartilage defects. Patients who were male, had smaller initial defect size, and longer time between surgeries were at greater risk for defect expansion. LEVEL OF EVIDENCE: III, retrospective comparative study.

Predictors of poor pre-operative psychological status among patients with cartilage defects.

BACKGROUND: We evaluated the risk factors for pain catastrophizing, kinesiophobia, and elevated depressive symptoms among patients undergoing high-grade cartilage defect surgery. We hypothesized that cartilage patients would demonstrate high scores on pain catastrophizing, kinesiophobia, and depression testing prior to surgery. METHODS: Two hundred and ten patients undergoing surgery for high-grade cartilage defects (56% chondroplasty, 36% microfracture, 22% autologous chondrocyte implantation) completed a preoperative survey before undergoing surgery. Outcome scores assessed were: International Knee Documentation Committee-Symptom (IKDC-S) score, Tegner activity score, Pain catastrophizing scale (PCS), Tampa scale for kinesiophobia (TSK-11), and Patient Health Questionnaire depression scale (PHQ-9). Multivariate logistic regression was used to determine what pre-operative factors predicted pain catastrophizing, kinesiophobia, and elevated depressive symptoms. RESULTS: The mean pre-operative Tegner score was 5.8 (SD 2.4) and IKDC-S score was 44.7 (SD 11.1). Prior to surgery, 19% had abnormal pain catastrophizing (PCS ≥ 20 points), 14.4% had moderate-severe depression (PHQ ≥ 10), and 49.0% had high kinesiophobia (TSK-11 ≥ 25). Lower pre-operative Tegner scores predicted moderate-severe depressive symptoms (per point decrease, OR 1.36, 95% CI 1.06, 1.76; p = 0.008). Predictors of elevated pain catastrophizing were lower pre-operative IKDC-S scores (per 5-point decrease, OR 1.28, 95% CI 1.08, 1.51; p = 0.002) and symptom duration >6 months (OR 2.20 CI 1.14, 4.32; p = 0.02). A lower pre-operative IKDC-S score (per 5-point decrease, OR 1.17, CI 1.03, 1.33; p = 0.02) predicted elevated kinesiophobia. CONCLUSION: Low self-reported function, low activity level and symptom duration greater than six months are associated with poor preoperative psychological status.

Repair of Radial Meniscus Tears Results in Improved Patient-Reported Outcome Scores: A Systematic Review.

PURPOSE: To quantify healing rates and patient-reported outcome scores following repair of radial meniscus tears. METHODS: PubMed, Scopus, and Embase databases were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria included: human subjects with meniscal tears, full-text English language, average follow-up of at 1 year, and publication after the 2000. Exclusion criteria included technical, biomechanical, and cadaveric studies. Study quality was assessed using Coleman Methodology Scores and Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: Twelve studies reported on the repair of 243 radial tears in 241 patients. The mean Modified Coleman Methodology Score was 46.8, range 26-60, with a mean level of evidence of 3.5. Arthroscopic techniques were used in all studies, with 1 study using an arthroscopic-assisted 2-tunnel trans-tibial pullout technique. The mean patient age was 32 years (11-71). The mean follow-up was 35 months (12 to 75.6). The average time to surgery was 10.9 months (0.5-22.4). Eight of the 12 studies reported concomitant anterior cruciate ligament (ACL) reconstruction, with 64% having concomitant ACL injury. The most common outcome measure was the Lysholm score, which improved from 47-68.9 preoperatively to 86.4-95.6 postoperatively. Tegner Activity Scale improved from 2.5-3.1 preoperatively to 4.7-6.7 postoperatively. Healing rates were reported via magnetic resonance imaging and second-look arthroscopy. Second-look arthroscopy was performed for a variety of indications, including removal of screw, washers or plates, dissatisfaction with original procedure, partial healing found on magnetic resonance imaging, or desire of the patient to know the true healing status before return to sport. Of those assessed, 62.0% had complete healing, 30.0% partial healing, and 8.0% failure to heal. CONCLUSIONS: Patient-reported outcomes of radial meniscus repair with and without ACL reconstruction are encouraging, with high patient-reported outcomes reported at final follow-up when compared with preoperative scores. Among all meniscus repairs assessed for healing, the majority demonstrated at least some healing with an overall low rate of failure. LEVEL OF EVIDENCE: IV; systematic review of level III-IV studies.

Positive reframing: An important but underutilized coping strategy in youth athletes undergoing sports-related knee surgery.

CONTEXT: It is unknown how specific coping strategies are associated with the short-term outcomes among athletes following knee surgery. OBJECTIVE: 1) To determine whether specific coping strategies are associated with satisfaction, return to sport, self-reported knee function, or kinesiophobia following sports-related knee surgery. 2) To determine whether these associations vary by age, sex, or surgical procedure. STUDY DESIGN: Case series. METHODS: Athletes (n=184 total; n=104 men, n=80 women; n=38 age <20 years, n=35 age 20-25, n=36 age 26-31, n=36 age 32-40, n=39 age >40) who underwent outpatient knee surgery were enrolled from a single center. Utilization of specific coping strategies (self-distraction, use of emotional or instrumental support, venting, positive reframing, and acceptance) was assessed pre-operatively with the Brief-COPE inventory. Relationship between coping strategies and post-operative satisfaction, return to sport, International Knee Documentation Committee-subjective (IKDC-S) and Tampa Scale for Kinesiophobia scores at median 10.7 months follow-up were determined with consideration for age, sex, and surgical procedure. RESULTS: Return to prior level of sport was 72%, and satisfaction was 86%. Most coping strategies had age-specific utilization rates; positive reframing was utilized least frequently in ages <20 years. Satisfaction increased with greater positive reframing among ages <20 years and decreased with greater self-distraction among men. Return to sport was higher with greater positive reframing in ages <32 years. No coping strategies predicted IKDC-S scores. Greater positive reframing correlated with lower kinesiophobia in ages <20 years. Greater instrumental support correlated with lower kinesiophobia in ages >40 years. No other coping strategies were associated with outcomes. Surgical procedure was not related to association between coping strategies and outcomes. CONCLUSION: Coping strategies have age-specific associations with outcomes after knee surgery in athletes. Positive reframing is infrequently utilized in younger athletes. Greater use of positive reframing in this group may improve satisfaction, return to sport, and lower fear of re-injury.

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

BACKGROUND: Nearly 1 in 5 American children are obese. The primary purpose of this study is to evaluate the relationship between childhood obesity and perioperative complications, patient-reported outcomes (PRO), and functional recovery after closed reduction and percutaneous pinning (CRPP) of type II and III supracondylar humerus fractures. METHODS: Retrospective review of patients treated operatively with CRPP of Wilkins modification of the Gartland classification type II and III supracondylar humerus fractures was performed over a 1-year timeframe (July 1, 2016 to July 1, 2017). One hundred forty-four patients under the age of 16 treated were identified. Obesity was defined as body mass index (BMI) at or above the 95th percentile for age. Obesity as a risk factor for poor outcomes was assessed. The primary outcome measure was postoperative PRO [quick-DASH, Patient Reported Outcomes Measurement Information System (PROMIS)-UE, PROMIS Global Health, and PROMIS Pain scores]. RESULTS: Mean age at surgery was 5.9 years (SD=2.1, 1.07 to 12.2) and mean age at final follow-up (3.3 y) was 8.8 (SD=2.14, 4 to 16). Mean patient BMI was 17.2 (SD=4.48, 12.4 to 56.2). Sixty-six patients were female (45.8%) and 78 patients were male (54.2%). In all, 31 of 144 patients (21.5%) met criteria for obesity. Obesity (95th percentile for BMI or above) was not associated with a higher rate of complications overall (χ2=1.29, P=0.256), range of motion loss (χ2=0.2, P=0.655) or requirement of postoperative physical therapy (χ2=0.17, P=0.678). Seventy-five patients were available and willing to participate in the outcomes score assessments. Mean follow-up for this cohort of 75 patients was 3.3 years (SD=0.31, 2.85 to 3.88). There were no differences in PROMIS pain, PROMIS upper extremity function, PROMIS general health, or quick-DASH scores when comparing obese with nonobese patients. CONCLUSIONS: Obesity is a growing concern in the United States and its effect on long-term outcomes after CRPP of supracondylar humerus fractures is unknown. The present study demonstrates no difference in complications or PRO among obese patients compared with nonobese patients. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Room Traffic in Orthopedic Surgery: A Prospective Clinical Observational Study of Time of Day.

OBJECTIVE: High rates of operating room (OR) traffic may contribute to surgical air contamination and surgical site infections (SSIs). The purpose of this study was to evaluate room traffic patterns in orthopedic implant procedures to determine the frequency of door openings and if time of day had an effect on room traffic. METHODS: In 2015, OR traffic was assessed in orthopedic implant cases. Room traffic was reported as the number of door openings per minute. Counts of how many people were present in the operating room were noted in 5-minute intervals from the time of sterile case opening to dressing placement. Operative cases were observed and categorized into 3 periods (6:00-9:59, 10:00-13:59, and 14:00-17:59) to assess if time of day affected room traffic. RESULTS: Forty-six cases were observed for the present study. Among all cases, the mean room traffic rate was 35.2 openings per hour (SD, 10; range, 13.2-60.8). One-way analysis of variance revealed no statistically significant difference among groups (6:00-9:59 [n = 29], 10:00-13:59 [n = 10], and 14:00-17:59 [n = 7]) as it relates door openings per minute (room traffic rate) (P = 0.9237) or mean number of people in the OR (P = 0.3560). Pearson correlation revealed no correlation between case start time and room traffic rates (P = 0.6129, r2 = 0.0059) or between case start time and mean number of people in the OR (P = 0.3435, r2 = 0.0214). CONCLUSIONS: Room traffic rates and mean number of people in the OR do not correlate with time of day of case in orthopedic implant procedures.

Knee Cartilage Defect Characteristics Vary among Symptomatic Recreational and Competitive Scholastic Athletes Eligible for Cartilage Restoration Surgery.

OBJECTIVE: To determine whether there are differences by sport or competitive level in symptomatic knee cartilage defects among recreational, high school, or collegiate competitive athletes undergoing initial arthroscopic knee surgery who meet criteria for cartilage restoration surgery. DESIGN: Three hundred recreational (n = 172) and high school or collegiate competitive athletes (n = 128) younger than 40 years and body mass index (BMI) <35 kg/m2 (63% male, mean age 24.3 years, SD 7.1; mean BMI 25.7 kg/m2, SD 3.7) with Outerbridge grade 2 or higher symptomatic cartilage defects who underwent arthroscopic knee surgery were identified. The independent relationship between sporting activity or competitive level and cartilage defect location, size, severity, and symptom chronicity were assessed by multivariate regression analysis. RESULTS: Full-thickness defects were present in 24% of competitive athletes and 31% of recreational athletes (P = 0.21). There was a trend toward an independent association with competitive level and high-grade (3 or 4) multicompartment disease (adjusted odds ratio [aOR] 3.99, 95% confidence interval 0.84-18.8; P = 0.08) or isolated anterior compartment defects (aOR 2.00, 95% CI 0.86-4.62, P = 0.10) but not isolated medial or lateral defects. High-grade defect size was similar among recreational and competitive athletes (P = 0.71). High-grade lateral defect prevalence differed by sport (running 24%, basketball 23%, soccer 18%, football 5%; P = 0.02) but not medial or anterior defect prevalence. CONCLUSIONS: Among recreational and high school or collegiate competitive athletes with symptomatic cartilage defects who meet criteria for cartilage restoration, competitive athletes may have higher risk of high-grade anterior and multicompartment defects but no difference in defect size.