ACL Graft Selection Is Best Tailored to Individual Patient Sport and Activity Level.

ACL reconstruction graft choice is a topic of ever ongoing debate. Literature shows allograft should be avoided in younger patients, and given that result, there has been a general trend toward increased use of autograft reconstruction in recent years, regardless of age. Almost concurrently, there has been an increased trend toward the use of quadriceps tendon (QT) as a primary or revision graft. In addition to these trends, more and more patients are remaining active at later ages, resulting in increased numbers of patients requiring ACL surgery at later ages (>50 yrs). In this population, recent research shows equal outcomes with hamstring tendon and quadriceps tendon autografts, and lower return to skiing with hamstring grafts (showing that graft choice should be tailored to the individual patient and their sport or activity level). Allografts (and any graft choice) may also show good outcomes in this age group.

Subacromial Surgery for Irreparable Posterosuperior Rotator Cuff Tears.

The irreparable posterosuperior rotator cuff tear describes a tear of the supraspinatus and/or infraspinatus tendon that is massive, contracted, and immobile in both the anterior-posterior and medial-lateral directions. Patients with an intact subscapularis and preserved forward elevation are challenging to treat because there is not a consensus treatment algorithm. For low-demand, elderly patients, several subacromial surgical options are available that can provide pain relief without the risks or burden of rehabilitation posed by reverse total shoulder arthroplasty or a complex soft-tissue reconstruction (e.g., superior capsular reconstruction, tendon transfer, bridging grafts). Debridement, more specifically the "smooth-and-move" procedure, offers a reliable outcome with documented improvements in pain and function at long-term follow-up. Similarly, the biodegradable subacromial balloon spacer (InSpace; Stryker, Kalamazoo, MI) has been shown to significantly improve pain and function in patients who are not responsive to nonoperative treatment. Disease progression with these options is possible, with a small percentage of patients progressing to rotator cuff arthropathy. Biologic tuberoplasty and bursal acromial reconstruction are conceptually similar to the balloon spacer but instead use biologic grafts to prevent bone-to-bone contact between the humeral head and the acromion. Although there is no single gold standard treatment, the variety of surgical techniques allows patients and surgeons to effectively manage these challenging situations.

Osteochondral Allograft Transplantation in the Knee.

Osteochondral injuries of the knee can be a frequent source of debilitating pain and dysfunction. Significant chondral (>1.5-2 cm2) lesions of the femoral condyles can be especially difficult to manage with nonsurgical measures. Fresh osteochondral allograft (OCA) transplantation has been shown to be a reliable surgical procedure to manage a wide array of high-grade focal chondral lesions, with or without subchondral bone involvement. OCA transplantation affords the transfer of a size-matched allograft of mature hyaline cartilage with its associated subchondral bony scaffold. Indications include primary or secondary management of large, high-grade chondral or osteochondral defects secondary to trauma, developmental malformation, osteonecrosis, or other focal degenerative disease. Contraindications include end-stage osteoarthritis, uncorrected malalignment, ligament or meniscus deficiency, and inflammatory joint disease. Improvements in surgical technique, allograft storage, and tissue availability have created more reproducible clinical results and increased chondrocyte viability. Long-term (>10 year) graft survival rates have been shown to be between 70% and 91%, and the procedure has been shown to be cost-effective based on cost per quality-adjusted life year. Finally, OCA transplantation has been shown to provide excellent return to play rate for athletes with medium-to-large cartilage lesions. OCA transplantation is therefore an important option in the treatment algorithm of articular cartilage injuries.

All-Inside Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed knee operations. An "all-inside" technique creates bone sockets for ACL graft passage, as opposed to more traditional full bone tunnels, and typically incorporates suspensory fixation instead of screw fixation to secure the graft. This technique may be indicated for any ACL reconstruction surgery, where adequate bone stock exists to drill sockets and to use cortical fixation. The technique may be used with all soft tissue, as well as bone plug ACL grafts and autograft hamstring or quadriceps tendon; most allograft tendon options may be performed with an all-inside technique. Advantages include anatomic tunnel/socket placement, decreased postoperative pain and swelling, minimal hardware, appropriate graft tensioning and retensioning, and circumferential graft to bone healing. Tips for successful all-inside surgery include matching graft diameter to socket diameter, drilling appropriate length sockets based on individual graft length, so as not to "bottom out" the graft and confirming cortical button fixation intraoperatively. Potential complications include graft-socket mismatch, full-tunnel reaming, and loss of cortical fixation. Multiple studies have shown the all-inside technique to have similar or superior biomechanical properties and clinical outcomes compared to the more traditional full-tunnel ACL reconstruction techniques.

Subpectoral Biceps Tenodesis of the Shoulder: Indications and Technique Options.

Subpectoral biceps tenodesis of the shoulder may be a useful tool that can address a wide range of disorders in the setting of pathology of the long head of the biceps tendon. Primary indications include (1) zone 2 or zone 3 tendon pathology and (2) failed previous proximal tendon tenodesis. Secondary indications include (1) an overhead athlete or thrower, (2) chronic tendinopathy, and (3) surgeon preference. A subpectoral technique allows tendon fixation directly posterior (deep) to the pectoralis tendon high in the bicipital fossa or in the mid fossa or fixation low in the fossa inferior to the pectoralis tendon (infrapectoral). Fixation technique options include an onlay suture anchor, onlay unicortical button, inlay bicortical button, or inlay interference screw. Potential surgical complications include humeral fracture, loss of fixation, tendon pullout or rupture, and neurovascular injury. Regardless of the specific location or technique used, subpectoral tenodesis is a valuable tool for the treatment of proximal biceps tendon pathology.

Editorial Commentary: Biceps Tendon Tenderness Is It Enough to Guide Surgical Management?

Pathology of the long head of the biceps tendon is often encountered concurrently with rotator cuff tears. Although both preoperative and intraoperative evaluations may play a role in the decision-making process of when and how to treat the biceps, it can still be a conundrum. The more straightforward tests and reliable evaluation methods we have in our repertoire, the more likely the appropriate treatment choice to address the pathology will be made. The subpectoral biceps test is a helpful examination maneuver as part of the preoperative biceps evaluation.

Editorial Commentary: The Search for the Perfect Fixation Method in Anterior Cruciate Ligament Reconstruction Continues.

Anterior cruciate ligament reconstruction fixation methods have long been the subject of frequent debate. The ability to optimize tendon-to-bone or bone-to-bone healing with secure graft fixation in a manner that can be performed as minimally invasively as possible is the goal. As we continue to develop and understand various graft fixation methods, our ability to achieve this goal continues to improve.

Radiologic and Histologic Evaluation of Proximal Bicep Pathology in Patients With Chronic Biceps Tendinopathy Undergoing Open Subpectoral Biceps Tenodesis.

PURPOSE: To correlate preoperative magnetic resonance imaging (MRI) and intraoperative anatomic findings within the proximal long head biceps tendon to histologic evaluation of 3 separate zones of the tendon in patients with chronic biceps tendinopathy. METHODS: Sixteen patients with chronic biceps tendinopathy were treated with open subpectoral biceps tenodesis. Preoperative MRI tendon grading was as follows: normal tendon, increased signal, tendon splitting, incomplete/complete tear. The removed portion of the biceps tendon was split into 3 segments: zone 1, 0-3.5 cm from the labral insertion; zone 2, 3.5-6.5 cm; and zone 3, 6.5-9 cm, and was histologically evaluated using the Bonar score. Tenosynovium adjacent to the tendon was assessed histologically using the Osteoarthritis Research Society International score. CD31, CD3, and CD79a immunohistochemistries were conducted to determine vascularization, T-cell infiltrates, and B-cell infiltrates, respectively. Analysis of variance and Pearson correlations were performed for statistical analysis. RESULTS: Preoperative MRI showed no significant differences in tendon appearance between zones 1-3. Intraoperative findings included nonspecific degenerative SLAP tears or mild/moderate biceps tenosynovitis in all cases. Significantly (P < .001) higher Bonar scores were noted for tendon in zones 1 (7.9 ± 1.8) and 2 (7.3 ± 1.5) compared with zone 3 (5.0 ± 1.1). Cell morphology scores in zone 1 (1.9 ± 0.4) and zone 2 (1.5 ± 0.6) were significantly higher than that in zone 3 (0.8 ± 0.3) (P < .05). Inflammatory tenosynovium showed weak correlation with tendon changes in zone 1 (r = 0.08), zone 2 (r = 0.03), or zone 3 (r = 0.1). CONCLUSIONS: In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon. CLINICAL RELEVANCE: Proximal versus distal biceps tenodesis is a subject of frequent debate. This study contributes to the ongoing evaluation of the characteristics of the proximal biceps in this type of pathologic condition.

Posterior single-incision semitendinosus harvest for a quadrupled anterior cruciate ligament graft construct: determination of graft length and diameter based on patient sex, height, weight, and body mass index.

PURPOSE: This study aimed to determine final graft length and diameter for a quadrupled semitendinosus anterior cruciate ligament (ACL) construct harvested from a single-incision posterior approach with correlation to preoperative patient variables of sex, height, weight, and body mass index (BMI). METHODS: This was a retrospective review of data collected prospectively on 60 patients undergoing all-inside quadrupled semitendinosus autograft ACL reconstruction. RESULTS: The mean values of the final quadrupled constructs were a length of 70.3 mm and a diameter of 9.0 mm. Separated based on sex, female versus male final mean graft length was 68.1 mm versus 71.7 mm, and final mean graft diameter was 8.6 mm and 9.3 mm, respectively. In both sexes, patient height and weight were strongly correlated to final construct diameter (r = 0.60 and r = 0.56) and length (r = 0.47 and r = 0.44), respectively. CONCLUSIONS: A single-incision posterior harvest approach allowed for retrieval of semitendinosis tendon autografts of sufficient dimension to allow for construction of quadrupled ACL grafts of a diameter of 8 mm or more in 95% of cases. In addition, desired graft length was achieved in all cases. Graft dimensions had moderately strong direct correlations to patient height and weight, with significant size differences noted between the sexes. We believe this to be helpful data for surgeons who might consider performing a quadrupled semitendinosus autograft ACL reconstruction. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Impacts of Knee Arthroplasty on Activity Level and Knee Function in Young Patients: A Systematic Review.

The annual demand for knee arthroplasty has been steadily rising, particularly in younger patients. The primary objective of this systematic review was to determine the impact of knee arthroplasties on knee function and activity levels in young (≤55 years) patients. A PubMed search from inception (1977) to March 2022 to identify eligible studies produced 640 peer-reviewed studies for consideration. A total of 18 studies including 4,186 knee arthroplasties in 3,200 patients (mean patient age at the time of surgery: 47.4 years, range: 18-55 years) were ultimately included for analysis. Mean final follow-up (FFU) duration was 5.8 years (range: 2-25.1 years). Mean FFU improvement in Knee Society Clinical Score was 48.0 (1,625 knees, range: 20.9-69.0), Knee Society Function Score was 37.4 (1,284 knees, range: 20-65). Mean FFU for the Tegner and Lysholm activity scale was 2.8 (4 studies, 548 knees, range: 0.7-4.2); University of California Los Angeles Physical Activity Questionnaire score was 2.8 (3 studies, 387 knees, range: 1.2-5); lower extremity activity scale was 1.84 (529 knees). The available evidence suggest that young patients typically realize sustained improvements in knee function compared to preoperative levels; however, these improvements do not typically translate into a return to desired activity levels or quality of life, and this patient population should expect a higher and earlier risk for revision than their older counterparts. Further research, including robust registry data, is needed to establish evidence-based indications, expectations, and prognoses for outcomes after knee arthroplasty in young and active patients.

Two-Portal Arthroscopic Knotless All-Suture Anchor Posterior Labral Repair.

Isolated posterior shoulder instability accounts for approximately 10% of shoulder instability cases. Patients may present after an acute trauma or with insidious onset and associated posterior shoulder pain. Knotless and all-suture anchor devices have become increasing popular and are often used in arthroscopic shoulder instability cases to avoid knot stacks and allow for the ability to re-tension the fixation. This technical note describes our technique for 2-portal posterior labral repair using knotless all-suture anchors with the patient in the lateral decubitus position.

Prospective Assessment of Outcomes After Femoral Condyle Osteochondral Allograft Transplantation With Concurrent Meniscus Allograft Transplantation.

Background: Osteochondral allograft transplantation (OCAT) and meniscus allograft transplantation (MAT) have each become more commonly implemented for the treatment of young to middle-aged patients with complex knee pathology. Evidence regarding tibiofemoral OCAT in the setting of concurrent MAT is limited. Purpose/Hypothesis: The purpose of this study was to characterize outcomes for femoral condyle OCAT with concurrent MAT (OCAT+MAT) in the ipsilateral compartment of patients after evidence-based shifts in practice. It was hypothesized that OCAT+MAT would be associated with successful outcomes characterized by statistically significant and clinically meaningful improvements in patient-reported outcome measures (PROMs) of knee pain and function in >80% of patients for at least 2 years after transplantation. Study Design: Case series; Level of evidence, 4. Methods: With institutional review board approval and documented informed consent, patients who underwent primary OCAT+MAT between 2016 and 2020 and enrolled in a lifelong registry for prospective collection of outcomes after OCAT were included. Patients with minimum 2-year follow-up data regarding complications, failures, adherence, and PROMs were analyzed. Patients who required OCAT and/or MAT revision or conversion to arthroplasty were defined as experiencing treatment failures. Results: A total of 23 consecutive patients (mean age, 37.1 years; mean body mass index, 28 kg/m2; 14 men) met the inclusion criteria, with a mean follow-up of 51 months (range, 24-86 months). The initial treatment success rate was 78% based on 5 initial treatment failures, and the overall success rate was 83% based on a successful revision OCAT. All failures occurred in the medial compartment. Older patient age (42.2 vs 32.1 years; P = .046) and nonadherence to postoperative restriction and rehabilitation protocols (P = .033; odds ratio, 14) were significant risk factors for treatment failure. All measured PROMs achieved significant improvements (P < .001) and minimum clinically important differences at a minimum of 2 years postoperatively. Conclusion: OCAT+MAT was associated with successful short- to mid-term outcomes in 83% of cases. Evidence-based shifts in practice were implemented before the enrollment of this patient cohort. Older patients and those who were not adherent to postoperative restriction and rehabilitation protocols had a significantly higher risk for treatment failure and subsequent conversion to arthroplasty.

Comparison of Outcomes After Primary Versus Salvage Osteochondral Allograft Transplantation for Femoral Condyle Osteochondritis Dissecans Lesions.

Background: Osteochondral allograft transplantation (OCAT) allows the restoration of femoral condyle osteochondritis dissecans (OCD) lesions using an osteochondral unit. When OCD lesions are irreparable, or treatments have failed, OCAT is an appropriate approach for revision or salvage surgery. Based on its relative availability, cost-effectiveness, lack of donor site morbidity, and advances in preservation methods, OCAT is also an attractive option for primary surgical treatment for femoral condyle OCD. Hypothesis: OCAT for large femoral condyle OCD lesions would be highly successful (>90%) based on significant improvements in knee pain and function, with no significant differences between primary and salvage procedure outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were enrolled into a registry for assessing outcomes after OCAT. Those patients who underwent OCAT for femoral condyle OCD and had a minimum of 2-year follow-up were included. Reoperations, treatment failures, and patient-reported outcomes were compared between primary and salvage OCAT cohorts. Results: A total of 22 consecutive patients were included for analysis, with none lost to the 2-year follow-up (mean, 40.3 months; range, 24-82 months). OCD lesions of the medial femoral condyle (n = 17), lateral femoral condyle (n = 4), or both condyles (n = 1) were analyzed. The mean patient age was 25.3 years (range, 12-50 years), and the mean body mass index was 25.2 kg/m2 (range, 17-42 kg/m2). No statistically significant differences were observed between the primary (n = 11) and salvage (n = 11) OCAT cohorts in patient and surgical characteristics. Also, 91% of patients had successful outcomes at a mean of >3 years after OCAT with 1 revision in the primary OCAT cohort and 1 conversion to total knee arthroplasty in the salvage OCAT cohort. For both primary and salvage OCATs, patient-reported measures of pain and function significantly improved at the 1-year and final follow-up, and >90% of patients reported that they were satisfied and would choose OCAT again for treatment. Conclusion: Based on the low treatment failure rates in conjunction with statistically significant and clinically meaningful improvements in patient-reported outcomes, OCAT can be considered an appropriate option for both primary and salvage surgical treatment in patients with irreparable OCD lesions of the femoral condyles.

Optimizing Socket-Tunnel Position for Meniscal Allograft Transplantation Combined With ACL Reconstruction: A 3D Model Analysis.

Background: Socket-tunnel overlap during meniscal allograft transplantation (MAT) combined with anterior cruciate ligament reconstruction (ACLR) may compromise graft integrity and lead to impaired fixation and treatment failure. Purpose/Hypothesis: The purpose of this study was to determine optimal socket-tunnel drilling parameters for medial and lateral MAT with concurrent ACLR using artificial tibias and computed tomography (CT) scans for 3-dimensional (3D) modeling. It was hypothesized that clinically relevant socket tunnels could be created to allow for concurrent medial or lateral MAT and ACLR without significant risk for overlap at varying tunnel guide angles. Study Design: Descriptive laboratory study. Methods: A total of 27 artificial right tibias (3 per subgroup) were allocated to 9 experimental groups based on the inclination of the socket tunnels (55°, 60°, and 65°) created for simulating medial and lateral MAT and ACLR. Five standardized socket tunnels were created for each tibia using arthroscopic guides: one for the ACL tibial insertion and one for each meniscus root insertion. CT scans were performed for all specimens and sequentially processed using computer software to produce 3D models for quantitative assessment of socket-tunnel overlap risk. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests. Results: No subgroup consistently presented significantly safer distances than other subgroups for all distances measured. Three cases (11%) and 24 cases (~90%) of tunnel overlap occurred between the ACL tunnel and tunnels for medial and lateral MAT, respectively. Most socket-tunnel overlap (25 of 27; 92.6%) occurred between sockets at depths ranging between 6.3 and 10 mm from the articular surface. For ACLR and posterior root of the lateral meniscus setting, the guide set at 65° increased socket-tunnel distances. Conclusion: When combined ACLR and MAT using socket tunnels for graft fixation is performed, the highest risk for tibial socket-tunnel overlap involves the ACLR tibial socket and the lateral meniscus anterior root socket at a depth of 6 to 10 mm from the tibial articular surface. Clinical Relevance: Setting tibial guides at 65° to the tibial articular surface with the tunnel entry point anteromedial and socket aperture location within the designated anatomic "footprint" will minimize the risk for socket-tunnel overlap.

Tunnel Overlap Occurs 25% of the Time With Simultaneous Anterior Cruciate Ligament Reconstruction and Lateral Meniscal Root Repair.

Purpose: To assess the risk of socket-tunnel overlap for posterior medial or lateral meniscal root repair combined with anterior cruciate ligament reconstruction (ACLR) using artificial tibias and computed tomography scans for 3-dimensional modeling. Methods: Artificial tibias (n = 27; n = 3/subgroup) were allocated to groups based on inclination of socket-tunnels (55°, 60°, 65°) created for posterior root of the medial meniscus (MMPR) and lateral meniscus posterior root (LMPR) repair, and ACLR. Three standardized socket-tunnels were created: one for the ACL and one for each posterior meniscal root insertion. Computed tomography scans were performed and sequentially processed using computer software to produce 3-dimensional models for assessment of socket-tunnel overlap. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests. Significance was set at P < .05. Results: The present study found no significant risk of tunnel overlap when drilling for combined ACLR and MMPR repair, whereas 7 cases of tunnel overlap occurred between ACL tunnels and LMPR (25.9% of cases). No subgroup or specific pattern of angulation consistently presented significantly safer distances than other subgroups for all distances measured. Conclusions: This study demonstrated 25.9% rate of overlap for combined LMPR repair and ACLR, compared with 0% for MMPR repair with ACLR. Lower ACL drilling angle (55 or 60°) combined with greater lateral meniscus drilling angle (65°) produced no socket-tunnel overlap. Clinical Relevance: Socket-tunnel overlap during meniscal root repair combined with ACLR may compromise graft integrity and lead to impaired fixation and treatment failure of either the ACL, the meniscus, or both. Despite this, risk for socket-tunnel overlap has not been well characterized.

Initial Outcomes following Fresh Meniscus Allograft Transplantation in the Knee.

Based on recent evidence-based advances in meniscus allograft transplantation (MAT), fresh (viable) meniscus allografts have potential for mitigating key risk factors associated with MAT failure, and preclinical and clinical data have verified the safety of fresh meniscus allografts as well as possible efficacy advantages compared with fresh-frozen meniscus allografts. The objective of this study was to prospectively assess clinical outcomes for the initial cohort of patients undergoing MAT using fresh meniscus allografts at our center. Patients who were prospectively enrolled in a dedicated registry were included for analyses when they had undergone primary MAT using a fresh meniscus allograft for treatment of medial and/or lateral meniscus deficiency with at least 1-year follow-up data recorded. Forty-five patients with a mean final follow-up of 47.8 months (range = 12-90 months) were analyzed. The mean patient age was 30.7 years (range = 15-60 years), mean body mass index (BMI) was 29.7 kg/m2 (range = 19-48 kg/m2), and 14 patients (31%) were females. In total, 28 medial, 13 lateral, and 4 combined medial and lateral MATs with 23 concurrent ligament reconstructions and 2 concurrent osteotomies were included. No local or systemic adverse events or complications related to MAT were reported for any patient in the study. Treatment success rate for all patients combined was 91.1% with three patients requiring MAT revision and one patient requiring arthroplasty. Treatment failures occurred 8 to 34 months after MAT and all involved the medial meniscus. None of the variables assessed were significantly different between treatment success and treatment failure cohorts. Taken together, the data suggest that the use of fresh (viable) meniscus allografts can be considered a safe and effective option for medial and lateral MAT. When transplanted using double bone plug suspensory fixation with meniscotibial ligament reconstruction, fresh MATs were associated with a 91% success rate, absence of local or systemic adverse events or complications, and statistically significant and clinically meaningful improvements in patient-reported measures of pain and function at a mean of 4 years postoperatively.

Donor-recipient age- or sex-mismatched osteochondral allografts do not adversely affect cumulative graft survival rates after transplantation in the knee.

BACKGROUND: Osteochondral allograft transplantation (OCAT) can be performed without the need for blood-type matching or anti-rejection medications. However, other donor-recipient mismatch variables could influence outcomes. Therefore, it is critical to examine the impacts of sex and age mismatching on functional OCA survival. METHODS: Prospectively collected data for patients undergoing primary knee OCAT enrolled in a lifelong outcomes registry were analyzed for functional OCA survival based on sex- and age-matched and -mismatched cohorts. Treatment failure was defined as the need for OCAT revision surgery or knee arthroplasty. RESULTS: 162 donor-recipient pairs were analyzed; 57 (35.2%) were sex-mismatched and 89 (54.9%) were age-mismatched. Sex-mismatched OCATs were not associated with a significantly different cumulative graft survival rate when compared to sex-matched OCATs (78.9% vs 75.2% p = 0.324). Age-mismatched OCATs were not associated with a significantly different cumulative graft survival rate when compared to age-matched OCATs (71.6% vs 81.5% p = 0.398). When adjusting for sex, BMI, concomitant procedures, and surgery type, age-mismatched and sex-mismatched OCATs were not significantly associated with higher likelihood for treatment failure. CONCLUSION: By analyzing functional graft survival rates for donor-recipient sex- or age-mismatched OCAs following primary OCAT, the results of the present study support current donor-recipient matching protocols for OCA transplantation in the knee. Based on current evidence, donor-recipient blood-type, sex-, and age-matching are not required for safe and effective primary OCAT in the knee. However, further studies are imperative for defining modifiable variables that further optimize safety and outcomes while maximizing donor tissue quality, availability, access, and use.

Enrollment in a Behavioral Health Program Positively Impacts 2-Year Cumulative Survival Rates in Osteochondral Allograft Transplant Patients.

Emerging evidence suggests that patients' behavioral health may influence outcomes after osteochondral allograft transplantation (OCAT). A comprehensive behavioral health program (BHP) including preoperative screening and education, and postoperative counseling and support, led by a health behavior psychologist was implemented for patients considering OCAT. We hypothesized that patients undergoing knee OCAT and enrolled in the BHP would have a significantly higher 2-year graft survival rate than those not enrolled. Prospectively collected data for patients undergoing knee OCAT enrolled in the lifelong outcomes registry were analyzed. Based on the timing of implementation of a comprehensive BHP to provide preoperative screening and education followed by postoperative counseling and support, BHP and no-BHP cohorts were compared. Treatment failure was defined as the need for either OCAT revision surgery or knee arthroplasty. The Kaplan-Meier method using log-rank tests compared cumulative survival rates. Multivariable Cox regression analysis was used to determine the effects of confounding variables on the influence of BHP enrollment on graft survival. A total of 301 patients were analyzed (no-BHP = 220 and BHP = 81). At 2-year follow-up, a significantly lower cumulative graft survival rate was observed for patients not enrolled in the BHP (68.2 vs. 91.4%; p = 0.00347). Adjusting for sex, age, body mass index, tobacco use, tibiofemoral bipolar OCAT type surgery, and nonadherence, patients not enrolled in the BHP were 2.8 times more likely to experience OCAT treatment failure by 2 years after primary OCAT compared with patients in the BHP (95% confidence interval, 1.02-4.98; p = 0.01). A comprehensive BHP contributes to significant improvements in 2-year graft survival rates following OCAT in the knee. Preoperative mental and behavioral health screening and support for shared decision-making regarding treatment options, in conjunction with patient and caregiver education and assistance through integrated health care team engagement, are beneficial to patients pursuing complex joint preservation surgeries. Level of evidence is 2, prospective cohort study.

The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions.

CONTEXT: Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed. EVIDENCE ACQUISITION: Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR. CONCLUSION: The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT): B.