Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis.

PURPOSE: To identify trends in anterior cruciate ligament reconstruction (ACLR), including graft choice, femoral tunnel drilling techniques, and augmentation techniques, and to assess how various surgeon factors impact these trends. METHODS: A retrospective review of primary ACLRs performed between 2014 and 2022 was completed using a multicenter institutional database. Patient demographic characteristics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports trained vs non-sports trained), experience (high [minimum of 15 years in practice] vs low), and volume (high [minimum of 15 ACLRs/year] vs low) were used to stratify technique utilization. The z test for proportions was used to compare categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as P < .05. RESULTS: Our cohort consisted of 2,032 ACLRs performed in 2,006 patients. The average patient age was 28.3 ± 11.6 years, with more procedures performed in male patients (67.3%). The average length of surgeon experience was 19.7 ± 11.4 years, with an average annual procedural volume of 4.0 ± 5.4 ACLRs. Most surgeons were sports trained (n = 55, 64.7%), high experience (n = 44, 57.1%), and low volume (n = 80, 94.1%). There was an increasing annual proportion of ACLRs performed by sports-trained surgeons (R = 0.748, P = .020) and low-experience surgeons (R = 0.940, P < .001). Autograft reconstructions were most often performed by sports-trained (71.2%), low-experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLRs that used quadriceps tendon among sports-trained (R = 0.739, P = .023), high-experience (R = 0.768, P = .016), and low-volume (R = 0.785, P = .012) surgeons. Independent drilling techniques were used in an increasing proportion of ACLRs performed by non-sports-trained (R = 0.860, P = .003) and high-volume (R = 0.864, P = .003) surgeons. Augmentation of ACLR with concomitant suture augmentation (n = 24, 1.2%) or extra-articular tenodesis (n = 6, 0.3%) was rarely performed. CONCLUSIONS: In our multicenter institution, the quadriceps tendon autograft has been increasingly used in ACLR by sports-trained, low-volume, and high-experience surgeons. Independent drilling techniques have been increasingly used by non-sports-trained and high-volume surgeons. CLINICAL RELEVANCE: Surgeons must stay current with the literature that affects their procedures to ensure that evidence-based medicine is being practiced.

Prospective Randomized Trial of Biologic Augmentation With Bone Marrow Aspirate Concentrate in Patients Undergoing Arthroscopic Rotator Cuff Repair.

BACKGROUND: Although initial studies have demonstrated that concentrated bone marrow aspirate (cBMA) injections promote rotator cuff repair (RCR) healing, there are no randomized prospective studies investigating clinical efficacy. HYPOTHESIS/PURPOSE: To compare outcomes after arthroscopic RCR (aRCR) with and without cBMA augmentation. It was hypothesized that cBMA augmentation would result in statistically significant improvements in clinical outcomes and rotator cuff structural integrity. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients indicated for aRCR of isolated 1- to 3-cm supraspinatus tendon tears were randomized to receive adjunctive cBMA injection or sham incision. Bone marrow was aspirated from the iliac crest, concentrated using a commercially available system, and injected at the aRCR site after repair. Patients were assessed preoperatively and serially until 2 years postoperatively via the following functional indices: American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test, 12-Item Short Form Health Survey, and Veterans RAND 12-Item Health Survey. Magnetic resonance imaging (MRI) was performed at 1 year to assess rotator cuff structural integrity according to Sugaya classification. Treatment failure was defined as decreased 1- or 2-year ASES or SANE scores as compared with preoperative baseline, the need for revision RCR, or conversion to total shoulder arthroplasty. RESULTS: An overall 91 patients were enrolled (control, n = 45; cBMA, n = 46): 82 (90%) completed 2-year clinical follow-up and 75 (82%) completed 1-year MRI. Functional indices significantly improved in both groups by 6 months and were sustained at 1 and 2 years (all P < .05). The control group showed significantly greater evidence of rotator cuff retear according to Sugaya classification on 1-year MRI (57% vs 18%; P < .001). Treatment failed for 7 patients in each group (control, 16%; cBMA, 15%). CONCLUSION: cBMA-augmented aRCR of isolated supraspinatus tendon tears may result in a structurally superior repair but largely fails to significantly improve treatment failure rates and patient-reported clinical outcomes when compared with aRCR alone. Additional study is warranted to investigate the long-term benefits of improved repair quality on clinical outcomes and repair failure rates. REGISTRATION: NCT02484950 (ClinicalTrials.gov identifier).

Technical Note: Arthroscopic Rotator Cuff Repair with Patch Augmentation with Acellular Dermal Allograft.

Rotator cuff tears are one of the most common causes of shoulder pain and dysfunction seen by orthopaedic surgeons. Although rotator cuff repair (RCR) has been shown to provide optimal outcomes, retear rates average roughly 60% and have been reported to exceed 90%. Retear after RCR is especially prevalent in patients with large, multitendon tears with poor tissue quality. Allograft augmentation of RCR may reinforce anatomically reparable tears, particularly in patients with poor tissue quality. Although various techniques of patch augmented RCR have been described, the procedure remains challenging. This Technical Note describes RCR augmented with acellular dermal allograft using the CuffMend system (Arthrex Inc, Naples, FL), which significantly decreases surgeon demand and helps avoid the pitfalls common with this procedure.

Osteochondral Allograft Transplant for Focal Cartilage Defects of the Femoral Condyles: Clinically Significant Outcomes, Failures, and Survival at a Minimum 5-Year Follow-up.

BACKGROUND: Osteochondral allograft (OCA) transplant for symptomatic focal cartilage defects in the knee has demonstrated favorable short- to midterm outcomes. However, the reoperation rate is high, and literature on mid- to long-term outcomes is limited. PURPOSE: To analyze clinically significant outcomes (CSOs), failures, and graft survival rates after OCA transplant of the femoral condyles at a minimum 5-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Review of a prospectively maintained database of 205 consecutive patients who had primary OCA transplant was performed to identify patients with a minimum of 5 years of follow-up. Outcomes including patient-reported outcomes (PROs), CSOs, complications, reoperation rate, and failures were evaluated. Failure was defined as revision cartilage procedure, conversion to knee arthroplasty, or macroscopic graft failure confirmed using second-look arthroscopy. Patient preoperative and surgical factors were assessed for their association with outcomes. RESULTS: A total of 160 patients (78.0% follow-up) underwent OCA transplant with a mean follow-up of 7.7 ± 2.7 years (range, 5.0-16.3 years). Mean age at the time of surgery was 31.9 ± 10.7 years, with a mean symptom duration of 5.8 ± 6.3 years. All mean PRO scores significantly improved, with 75.0% of patients achieving minimal clinically important difference (MCID), and 58.9% of patients achieving significant clinical benefit for the International Knee Documentation Committee score at final follow-up. The reoperation rate was 39.4% and was associated with a lower probability of achieving MCID. However, most patients undergoing reoperation did not proceed to failure at final follow-up (63.4% of total reoperations). A total of 34 (21.3%) patients had failures overall, and the 5- and 10-year survival rates were 86.2% and 81.8%, respectively. Failure was independently associated with greater body mass index, longer symptom duration, number of previous procedures, and previous failed cartilage debridement. Athletes were protected against failure. Survival rates over time were not affected by OCA site (P = .154), previous cartilage or meniscal procedure (P = .287 and P = .284, respectively), or concomitant procedures at the time of OCA transplant (P = .140). CONCLUSION: OCA transplant was associated with significant clinical improvement and durability at mid- to long-term follow-up, with 5- and 10-year survival rates of 86.2% and 81.8%, respectively. Maintenance of CSOs can be expected in the majority of patients at a mean of 7.7 years after OCA transplant. Although the reoperation rate was high (39.4%) and could have adversely affected chances of maintaining MCID, most patients did not have failure at long-term follow-up.

Outcomes of the Latarjet Procedure Versus Free Bone Block Procedures for Anterior Shoulder Instability: A Systematic Review and Meta-analysis.

BACKGROUND: Free bone block (FBB) procedures for anterior shoulder instability have been proposed as an alternative to or bail-out for the Latarjet procedure. However, studies comparing the outcomes of these treatment modalities are limited. PURPOSE: To systematically review and perform a meta-analysis comparing the clinical outcomes of patients undergoing anterior shoulder stabilization with a Latarjet or FBB procedure. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed, Embase, and the Cochrane Library databases were systematically searched from inception to 2019 for human-participants studies published in the English language. The search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement including studies reporting clinical outcomes of patients undergoing Latarjet or FBB procedures for anterior shoulder instability with minimum 2-year follow-up. Case reports and technique articles were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine the proportions of recurrent instability, other complications, progression of osteoarthritis, return to sports, and patient-reported outcome (PRO) improvement. RESULTS: A total of 2007 studies were screened; of these, 70 studies met the inclusion criteria and were included in the meta-analysis. These studies reported outcomes on a total of 4540 shoulders, of which 3917 were treated with a Latarjet procedure and 623 were treated with an FBB stabilization procedure. Weighted mean follow-up was 75.8 months (range, 24-420 months) for the Latarjet group and 92.3 months (range, 24-444 months) for the FBB group. No significant differences were found between the Latarjet and the FBB groups in the overall random pooled summary estimate of the rate of recurrent instability (5% vs 3%, respectively; P = .09), other complications (4% vs 5%, respectively; P = .892), progression of osteoarthritis (12% vs 4%, respectively; P = .077), and return to sports (73% vs 88%; respectively, P = .066). American Shoulder and Elbow Surgeons scores improved after both Latarjet and FBB, with a significantly greater increase after FBB procedures (10.44 for Latarjet vs 32.86 for FBB; P = .006). Other recorded PRO scores improved in all studies, with no significant difference between groups. CONCLUSION: Current evidence supports the safety and efficacy of both the Latarjet and FBB procedures for anterior shoulder stabilization in the presence of glenoid bone loss. We found no significant differences between the procedures in rates of recurrent instability, other complications, osteoarthritis progression, and return to sports. Significant improvement in PROs was demonstrated for both groups. Significant heterogeneity existed between studies on outcomes of the Latarjet and FBB procedures, warranting future high-quality, comparative studies.

Cartilage Restoration Using Dehydrated Allogeneic Cartilage, Platelet-Rich Plasma, and Autologous Cartilage Mixture Sealed With Activated Autologous Serum.

Articular cartilage injury is a common source of knee pain and dysfunction. Patients in whom conservative treatment fails may benefit from surgical intervention to restore function and alleviate pain. Autologous cartilage procedures are a viable treatment modality for cartilage repair, providing comparable outcomes to osteochondral allografts while leaving the subchondral bone intact. This article discusses the senior author's method of cartilage restoration using BioCartilage (Arthrex, Naples, FL), platelet-rich plasma, and autologous cartilage collected using a designated collection device sealed with activated autologous serum.

Meniscal Allograft Transplants.

Meniscus allograft transplantation is an established surgical treatment indicated in symptomatic meniscus-deficient patients with minimal to no arthritis. Treatment decision making should be individualized after a thorough history and physical examination, with diagnostic imaging and arthroscopy to assess the status of the meniscus. The senior author prefers to use a bridge-in-slot technique, where osseous fixation of the allograft is completed through passage of a bone bridge to a tibial slot. Outcomes in meniscus allograft transplantation are favorable, with reported significant improvements in clinical outcome and low failures in short- and midterm follow-up studies.

The Use of Platelet-Rich Plasma in Symptomatic Knee Osteoarthritis.

With average life expectancy and the rising prevalence of obesity, osteoarthritis (OA) is creating an increasingly large financial and physical burden on the U.S. population today. As the body ages and experiences trauma, articular cartilage surfaces in joints are gradually worn away, leading to OA. Traditionally, treatment options have included lifestyle modifications, pain management, and corticosteroid injections, with joint replacement reserved for those who have exhausted nonsurgical measures. More recently, hyaluronic acid, micronized dehydrated human amniotic/chorionic membrane tissue, and platelet-rich plasma (PRP) injections have started to gain traction. PRP has been shown to have both anti-inflammatory effects through growth factors such as transforming growth factor-ß and insulin-like growth factor 1, and stimulatory effects on mesenchymal stem cells and fibroblasts. Multiple studies have indicated that PRP is superior to hyaluronic acid and corticosteroids in terms of improving patient-reported pain and functionality scores. Unfortunately, there are many variations in PRP preparation, and lack of standardization in factors, such as speed and duration of centrifugation, leads to wide ranges of platelet and leukocyte concentrations. This review examines the current literature addressing the use of PRP in symptomatic knee OA and addresses suggestions for future studies in this area.

Use of Allografts in Orthopaedic Surgery: Safety, Procurement, Storage, and Outcomes.

The use of allografts has become a vital option for orthopaedic surgeons in the treatment of a variety of musculoskeletal lesions, ranging from osteochondral defects in the glenohumeral joint to meniscal deficiency in the young athlete. Nevertheless, barriers to treating a patient with an allograft-based procedure may arise from concerns over disease transmission, the navigation of tissue banks that supply allografts, the process of obtaining insurance approval, or optimal storage methods. This review serves to support orthopaedic surgeons in the incorporation of allografts into their practice by quelling these potential concerns. Fresh osteochondral allografts, fresh-frozen meniscal allografts, soft tissue allografts, and off-the-shelf cartilage products are the focus of this review amid broad overviews of allograft safety and tissue bank practices in the United States.

Preservation of Knee Articular Cartilage.

Hyaline articular cartilage is critical for the normal functioning of the knee joint. Untreated focal cartilage defects have the potential to rapidly progress to diffuse osteoarthritis. Over the last several decades, a variety of interventions aiming at preserving articular cartilage and preventing osteoarthritis have been investigated. Reparative cartilage procedures, such as microfracture, penetrate the subchondral bone plate in effort to fill focal cartilage defects with marrow elements and stimulate fibrocartilaginous repair. In contrast, restorative cartilage procedures aim to replace the defective articular surface with autologous or allogeneic hyaline cartilage. This review focuses on the preservation of articular cartilage, and discusses the current reparative and restorative surgical techniques available for treating focal cartilage defects.