Background: Previous studies have examined the relationship between patient resilience and functional outcome scores after anterior cruciate ligament reconstruction (ACLR). However, past studies have failed to explore the longitudinal relationship between preoperative resilience and functional outcomes 2 years after ACLR.
Purpose: To evaluate the relationship between preoperative patient resilience and functional outcomes 2 years after ACLR.
Study design: Cohort study; Level of evidence, 3.
Methods: Patients were identified who underwent ACLR for anterior cruciate ligament tears between January and June 2020 at a single institution. Those who completed the Brief Resilience Scale preoperatively as part of routine patient questionnaires were considered for inclusion. Patients were contacted a minimum of 2 years after ACLR to complete the short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-JR), Single Assessment Numeric Evaluation (SANE), International Knee Documentation Committee (IKDC) Subjective Knee Form, and visual analog scale (VAS). Outcomes were compared among patients with low resilience (LR), normal resilience (NR), and high resilience (HR), as defined in a previous study.23.
Results: A total of 81 patients were included in the final analysis, with 14 patients in the low preoperative resilience group, 54 in normal, and 13 in high. The mean age of the cohort was 32.0 years, and there were no significant differences in age, sex, race, graft type, or psychiatric comorbidities among the resilience groups. Significantly increased postoperative KOOS-JR scores were observed in patients in the HR group as compared with those in the NR and LR groups (94.8, 86.7, and 79.6, respectively; P = .031). There were also significantly increased postoperative SANE scores in patients in the HR group versus those in the NR and LR groups (92.3, 83.5, and 69.2; P = .012). Patients with high preoperative resilience achieved the IKDC Patient Acceptable Symptom State at significantly higher rates (P = .003). No significant differences were observed in postoperative VAS (P = .364), IKDC (P = .072), or change in IKDC (P = .448) over time among resilience groups. Postoperatively, 30 patients (37.0%) changed resilience groups, with 13 moving down and 17 moving up in category (low, n = 12; normal, n = 55; high, n = 14).
Conclusion: Preoperative resilience correlated with KOOS-JR and SANE scores 2 years after ACLR but did not correlate with VAS, IKDC, or change in IKDC over the same period. Resilience was not static, with changes in resilience observed from initial to final evaluations. Resilience is not a strong predictor of postoperative patient-reported outcomes after ACLR.
Background: Treatment for osteochondritis dissecans (OCD) of the humeral capitellum has been predominantly guided by fragment stability and articular cartilage integrity. Nonoperative management is recommended for stable lesions, whereas surgical intervention is indicated for unstable lesions and those that fail nonoperative care. Several surgical options may be considered, although limited information is available regarding indications for specific surgical techniques and comparative postoperative results.
Purpose: To assess surgical outcomes of patients with capitellar OCD treated according to a decision-making approach focused on subchondral bone involvement.
Study design: Cohort study; Level of evidence, 3.
Methods: Patients diagnosed with capitellar OCD at a tertiary academic center were enrolled in a prospective longitudinal cohort study. Patient information was collected at the time of enrollment, and OCD lesions were classified according to the Nelson grade. Clinical and radiologic data were collected both pre- and postoperatively for those undergoing surgical treatment. Surgical procedures were performed based on an evolving treatment framework that included considerations specifically for lesion containment and depth of subchondral bone disease. Timmerman scores were obtained to assess patient functional outcomes.
Results: A total of 154 patients were prospectively enrolled, 19 of whom had bilateral disease. The mean age at presentation was 13.7 years; 39% were gymnasts and 28.5% were primary baseball or softball athletes. Surgery was performed on 145 elbows, including 43 drilling/microfracture procedures, 21 internal fixations, and 63 autologous osteochondral grafting (OG) procedures. Clinically, there were significant improvements in pain, elbow motion, and mechanical symptoms. Timmerman scores significantly improved after each type of surgical procedure. A total of 76% of patients returned to their primary sport. When stratified by the Nelson grade, patients with OG had lower revision surgery rates than those treated with drilling/microfracture and fixation. Furthermore, for Nelson grade 2 lesions, patients treated with OG had significantly better postoperative elbow motion and higher Timmerman scores compared with those treated with other procedures.
Conclusion: Using a treatment framework incorporating lesion containment and depth of subchondral bone disease, surgery for capitellar OCD provides clinical, radiologic, and functional improvements. Patients treated with OG may have lower revision rates and better functional outcomes compared with those treated with other surgical techniques, with OG warranting consideration even for lower-grade OCD lesions.
Background: The utilization of lateral extra-articular tenodesis (LET) augmentation for anterior cruciate ligament reconstruction has increased. Various fixation points have been recommended based on tactile and anatomic landmarks; however, there is limited reporting of the accuracy or precision of these techniques in clinical practice.
Purpose/hypothesis: The purpose of this study was to evaluate whether LET fixation points identified using anatomic landmarks and tactile techniques would fall within a predefined radiographic zone. It was hypothesized that the majority of LET fixation points would be inside the radiographic zone.
Study design: Cross-sectional study; Level of evidence, 4.
Methods: Postoperative lateral knee radiographs of patients who underwent anterior cruciate ligament reconstruction with LET using a landmark-based technique without fluoroscopy between January 2018 and September 2023 were reviewed. Fixation points were measured by 2 raters based on their distance from an extension of the posterior femoral cortex line (PFCL) distally and a line perpendicular to the PFCL at the posterior condylar flare (PCF). Patients were excluded if the tunnel position could not be identified or if postoperative radiographs were malrotated. The mean LET position and percentage of points within the radiographic isometric zone, defined as 4 ± 4 mm posterior and 4 ± 3 mm anterior to the PFCL and 6 ± 4 mm distal and 20 ± 5 mm proximal to the PCF were calculated.
Results: Complete data sets were obtained for 47 cases. The mean LET position was 6.4 ± 7.1 mm (range, -9 to 27.3 mm) anterior to the PFCL and 1.8 ± 7.6 mm (range, -16.7 to 12.6 mm) proximal to the PCF. Overall, 53% of LET fixation points were within the predefined radiographic zone. Of the malpositioned tunnels (n = 22), their locations relative to the radiographic zone were anterior (n = 18), posterior (n = 2), proximal (n = 1), and anterior and distal (n = 1).
Conclusion: This study found large variation in the location of LET fixation points, and almost half of fixation points were outside the predefined radiographic zone. Accurate and precise tunnel placement is one of multiple factors that may be important to minimize the risk of lateral compartment overconstraint, anterior cruciate ligament graft failure, and anisometry leading to LET graft loosening.
Background: Osteochondritis dissecans (OCD) of the knee is a focal idiopathic alteration of subchondral bone and/or its precursor with risk for instability and disruption of adjacent cartilage. Treatment options focused on preventing premature osteoarthritis vary depending on multiple patient and lesion characteristics, including lesion mobility.
Purpose: To differentiate lesion mobility before arthroscopy using a multivariable model that includes patient demographic characteristics and physical examination findings.
Study design: Cohort study (Diagnosis); Level of evidence, 2.
Methods: Demographic, preoperative physical examination, and radiographic data were collected from a multicenter national prospective cohort of patients with OCD of the knee. Inclusion criteria included patients <19 years of age and patients with arthroscopically confirmed mobility status based on the Research on Osteochondritis Dissecans of the Knee arthroscopy classification. Multivariable logistic regression analysis using stepwise model selection was used to determine factors associated with the likelihood of a mobile versus an immobile lesion. A 75% partition of the data was used for model training, and 25% was used as a validation cohort. Quantitative model fit statistics were computed using the holdout data, including sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC), along with the corresponding 95% CI.
Results: A total of 407 patients in the prospective cohort met inclusion criteria, and 62% were male. The mean ± SD age was 13.7 ± 2.2 years, height 161.8 ± 5.3 cm, and weight 59.2 ± 42.2 kg. Arthroscopic evaluation yielded 235 immobile and 172 mobile lesions. Multivariable analysis determined that the best model to predict lesion mobility included chronologic age ≥14 years (P < .001), effusion on physical examination (P < .001), and any loss of range of motion on physical examination (P = .07), while controlling for male sex (P = .38) and weight >54.4 kg (P = .12). In the 25% holdout validation sample (n = 102), a sensitivity of 83%, a specificity of 82%, and an AUC of 0.89 (95% CI, 0.82-0.95) were achieved with these predictive factors.
Conclusion: Age, effusion, and loss of motion can predict knee OCD lesion mobility at the time of arthroscopy. Education about lesion mobility can help with surgical planning and patient and family counseling.
Background: Latissimus dorsi tendon transfer (LDTT) leads to good clinical outcomes and recovery of function. A previous study have evaluated the outcomes of LDTT at a minimum 10-year follow-up and found durable improvements in shoulder function and pain relief but observed that shoulders with fatty infiltration of the teres minor muscle and insufficiency of the subscapularis muscle tended to have inferior results.
Purpose: To evaluate the outcomes of LDTT with a minimum follow-up of 10 years in a sizeable cohort for the treatment of irreparable posterosuperior massive rotator cuff tears (mRCTs).
Study design: Case series; Level of evidence, 4.
Methods: Patients who underwent LDTT for irreparable mRCTs between 2004 and 2013, performed by the same senior surgeon, were included in this study. All intraoperative and postoperative complications, as well as whether patients required conversion to reverse shoulder arthroplasty (RSA), were noted. At a minimum follow-up of 10 years, an independent observer collected range of motion measurements and clinical scores, including those for the Constant score, the Subjective Shoulder Value, and a visual analog scale for pain; the subacromial space was also assessed.
Results: A total of 143 patients (147 shoulders) that underwent LDTT, with a minimum follow-up of 10 years, were included; of these, 24 patients (24 shoulders, 16%) were lost to follow-up, 1 patient (1 shoulder, 0.7%) died 9 years after the index procedure for reasons unrelated to shoulder surgery, and 18 patients (18 shoulders, 12%) required conversion to RSA, of which 6 underwent conversion at ≥6 years after LDTT. The remaining 101 patients (104 shoulders), including 3 patients who were scheduled to undergo RSA, were assessed at a mean time of 12.3 ± 2.2 years (range, 10-20 years) after index LDTT, comprised 52 men (53 shoulders) and 49 women (51 women) and had a mean age of 61.6 ± 8.0 years (range, 39-81 years) at the time of index surgery. Complications were noted in 14 shoulders, of which 4 required a reoperation. The Constant score improved by 34.2 ± 11.7 points, the adjusted Constant score by 43.5 ± 15.3 points, and the Subjective Shoulder Value score by 50.4 ± 16.4 points. The subacromial space decreased by 0.3 ± 2.0 mm.
Conclusion: At a minimum follow-up of 10 years, LDTT for the treatment of irreparable posterosuperior mRCTs led to satisfactory clinical scores. Of the 147 shoulders that underwent LDTT, 18 (12%) required conversion to RSA.
Background: If an increased posterior tibial slope (PTS) and concomitant unicompartmental osteoarthritis are present, a simultaneous sagittal (slope) and coronal correcting high tibial osteotomy has been recommended. However, no study has investigated the accuracy of such combined high tibial slope correction osteotomies.
Purpose: (1) To report the accuracy of navigated high tibial slope correction osteotomies using patient-specific instruments (PSI) and (2) to analyze the influence of an open wedge osteotomy (OWO) versus a closed wedge osteotomy (CWO) and the hinge axis angle (HAA) on the accuracy of the PTS correction.
Study design: Cohort study; Level of evidence, 3.
Methods: All PSI PTS-reducing osteotomies performed at 1 institution between 2019 and 2022 were reviewed. Three-dimensional (3D) accuracy was defined as the mean absolute 3D angular difference between the planned and achieved surgical correction (in degrees) in 3D models of computed tomography data. The influence of OWO versus CWO and the HAA on the reported accuracy was analyzed and a cutoff defined using receiver operating characteristic curve analysis.
Results: Eighteen patients who underwent a slope-reducing CWO (n = 9) or OWO (n = 9) were included. The 3D accuracy for PTS was 2.3°± 1.1° (mean ± SD), with CWO being more accurate than OWO (1.4°± 0.9° vs 3.1°± 0.6°; P < .01). Accuracy strongly correlated with the HAA (r = 0.788; P < .01). An HAA >38.9° predicted a PTS error >2° (odds ratio, 1.12 [95% CI, 1.04-1.20; P = .004]; area under the curve, 0.95 [95% CI, 0.89-1.00; P < .001]) corresponding to a coronal/sagittal correction of 0.8:1.
Conclusion: Slope-reducing osteotomy can accurately be achieved using PSI. CWO demonstrated an increased accuracy when compared with OWO, which strongly depended on the HAA. With an aim of combined PTS and coronal correction, CWO should be considered the primary choice for accurate slope reduction with a coronal/sagittal correction cutoff of 0.8:1 (HAA, 38.9°).
Background: Microfracture is one surgical treatment strategy for osteochondral lesions of the talus (OLTs) but results in fibrocartilage repair tissue, which has inferior mechanical properties to native hyaline cartilage. Biological regulation of microfracture has been suggested to improve the quality of cartilage repair in patients.
Purpose: To determine if administration of losartan, fisetin, or losartan and fisetin combined can enhance microfracture-mediated cartilage repair of OLTs in a rabbit model.
Study design: Controlled laboratory study.
Methods: Four-month-old female rabbits were divided into the following groups (8 rabbits per group): microfracture only (microfracture), microfracture plus losartan (losartan), microfracture plus fisetin (fisetin), and microfracture plus losartan and fisetin (losartan+fisetin). A 2.7-mm osteochondral defect and 4 microfracture holes were created in the talar dome cartilage. The rabbits were administered losartan (10 mg/kg/day), fisetin (20 mg/kg/day), or losartan and fisetin orally until euthanized 12 weeks after surgery. Gross evaluation, micro-computed tomography, histology, and immunohistochemistry evaluations of the osteochondral defects were performed as well as quantitative polymerase chain reaction of capsule tissue and enzyme-linked immunosorbent assay of serum.
Results: The losartan and fisetin groups had increased International Cartilage Regeneration & Joint Preservation Society macroscopic scores with improved cartilage repair and enhanced subchondral bone healing compared with the microfracture group. However, the losartan+fisetin group did not show a synergistic effect. O'Driscoll histology scores were higher in the losartan and fisetin groups compared with the microfracture group, while the losartan+fisetin group had a lower score than the losartan, fisetin, and microfracture groups. Collagen type 2 staining revealed organized chondrocytes in the losartan and fisetin groups, but the losartan+fisetin group did not show improvement when compared with other groups. Fisetin treatment decreased catalase and transforming growth factor-β1-activated kinase 1 expression in capsular tissue.
Conclusion: Concomitant microfracture and biological regulation, using oral administration of either losartan or fisetin, may improve cartilage healing of OLTs; however, losartan and fisetin combined in the current drug administration regimen does not appear to provide synergistic effects.
Clinical relevance: Oral intake of losartan or fisetin may result in beneficial effects on microfracture-mediated cartilage repair of OLTs.
Background: One-step cell-based techniques of cartilage repair that lead to restoration of durable chondral tissue and long-term maintenance of joint function are cost-effective and ideal for routine use.
Purposes: To examine the long-term clinical outcomes, after a mean follow-up duration of 14 years, of cartilage repair in the knee using a hyaluronic acid-based scaffold in association with bone marrow aspirate concentrate (HA-BMAC) and to evaluate the effect of age, lesion characteristics, and associated treatments on the outcome of this cartilage repair method.
Study design: Case series; Level of evidence, 4.
Methods: Patients were followed prospectively for a mean duration of 14.0 years after undergoing treatment of knee full-thickness articular cartilage injury using HA-BMAC. Clinical evaluation consisted of the patient-reported scoring tools of the visual analog scale and the Knee injury and Osteoarthritis Outcome Score, which were completed preoperatively and at the time of final follow-up.
Results: A total of 26 patients with a mean age of 48.3 years (17 male, 9 female) and median chondral lesion size of 6.6 cm2 (range, 1-27 cm2) were followed prospectively. There were 3 treatment failures, and 1 patient who underwent medial compartment unicompartmental arthroplasty 12 years after HA-BMAC treatment of patellar chondral injury. Of the 22 remaining patients, after a mean final follow-up duration of 14.0 years (range, 12-16 years), the median visual analog scale score of 0.6 was significantly decreased from the preoperative median score of 5.0 (P < .001). The median Knee injury and Osteoarthritis Outcome Score Pain (92), Symptoms (86), Activities of Daily Living (96), Sports (85), and Quality of Life (88) subscale values were all increased compared with the preoperative scores (P≤ .001). There was no correlation of clinical outcome score and body mass index.
Conclusion: One-step cartilage repair of full-thickness chondral defects in the knee using an HA-BMAC led to successful long-term clinical outcomes and maintenance of joint junction after a mean follow-up duration of 14 years. Long-term clinical success in active, nonobese patients has been uniformly demonstrated across a wide range of patient ages and lesion types, including cases of multicompartment involvement, treatment of associated conditions, and large or bipolar chondral lesions.
Background: Repair of rotator cuff tear is not always feasible, depending on the severity. Although several studies have investigated factors related to reparability and various methods to predict it, inconsistent scoring methods and a lack of validation have hindered the utility of these methods.
Purpose: To develop machine learning models to predict the reparability of rotator cuff tears, compare them with previous scoring systems, and provide an accessible online model.
Study design: Cohort study; Level of evidence, 3.
Methods: Arthroscopic rotator cuff repairs for tears with both anteroposterior and mediolateral diameters >1 cm on preoperative magnetic resonance imaging were included and divided into a training set (70%) and an internal validation set (30%). For external validation, rotator cuff repairs performed by 2 different surgeons were included in a test set. Machine learning models and a newly adjusted scoring system were developed using the training set. The performance of the models including the adjusted scoring system and 2 previous scoring systems were compared using the test set. The performance was assessed using metrics such as the area under the receiver operating characteristic curve (AUROC) and compared using the net reclassification improvement based on the adjusted scoring system.
Results: A total of 429 patients were included for the training and internal validation set, and 112 patients were included for the test set. An elastic-net logistic regression demonstrated the best performance, with an AUROC of 0.847 and net reclassification improvement of 0.071, compared with the adjusted scoring system in the test set. The AUROC of the adjusted scoring system was 0.786, and the AUROCs of the previous scoring systems were 0.757 and 0.687. The elastic-net logistic regression was transformed into an accessible online model.
Conclusion: The performance of the machine learning model, which provides a probability estimation for rotator cuff reparability, is comparable with that of the adjusted scoring system. Nevertheless, when deploying prediction models beyond the original cohort, regardless of whether they rely on machine learning or scoring systems, clinicians should exercise caution and not rely solely on the output of the model.
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