Chaitu S. Malempati

Allograft Augmentation of Hamstring Autograft for Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction: Clinical and Cost-Effectiveness Analyses:

Background: Younger patients and those with smaller hamstring autograft diameters have been shown to be at significantly greater risk of graft failure after anterior cruciate ligament (ACL) reconstruction. To date, there is no information in the literature about the clinical success and/or cost-effectiveness of increasing graft diameter by augmenting with semitendinosus allograft tissue for younger patients. Hypothesis: Hybrid hamstring grafts are a cost-effective treatment option because of a reduced rate of graft failure. Study Design: Cohort study (economic and decision analysis); Level of evidence, 3. Methods: We retrospectively identified patients younger than 18 years who had undergone ACL reconstruction by a single surgeon between 2010 and 2015. During this period, the operating surgeon’s graft selection algorithm included the use of bone–patellar tendon–bone (BTB) autografts for the majority of patients younger than 18 years. However, hamstring autografts (hamstring) or hybrid hamstring autografts with allograft augment (hybrid) were used in skeletally immature patients and in those whom the surgeon felt might have greater difficulty with postoperative rehabilitation after BTB graft harvest. Patient demographics, graft type, graft diameter, the time the patient was cleared to return to activity, and the need for secondary surgical procedures were compared between the hamstring and hybrid groups. The clinical results were then used to assess the potential cost-effectiveness of hybrid grafts in this select group of young patients with an ACL injury or reconstruction. Results: This study comprised 88 patients (hamstring group, n = 46; hybrid group, n = 42). The 2 groups did not differ in terms of age, sex, timing of return to activity, or prevalence of skeletally immature patients. Graft diameters were significantly smaller in the hamstring group (7.8 vs 9.9 mm; P < .001), which corresponded with a significantly greater rate of graft failure (13 of 46 [28.3%] vs 5 of 42 [11.9%]; P = .049). As a result of the reduced revision rate, the hybrid graft demonstrated incremental cost savings of US

Current Rehabilitation Concepts for Anterior Cruciate Ligament Surgery in Athletes.

2765 compared with the hamstring graft, and the hybrid graft was the preferred strategy in 89% of cases. Conclusion: Driven by increased graft diameters and the reduced risk of revision, hybrid grafts appear to be a more cost-effective treatment option in a subset of younger patients with an ACL injury.

Anatomic Femoral and Tibial Tunnel Placement During Anterior Cruciate Ligament Reconstruction: Anteromedial Portal All-Inside and Outside-In Techniques

The anterior cruciate ligament is the most commonly disrupted ligament in the knee in high-performance athletes. Most recently, advancements in surgical technique and graft fixation have enabled athletes to participate in early postoperative rehabilitation, focusing on range of motion and progressing to patellar mobilization, strengthening, and neuromuscular control. Several rehabilitation protocols exist with variations in specific exercises, progression through phases, and key components. The ultimate goal of rehabilitation is to return the athlete to preinjury performance level, including motion and strength, without injuring or elongating the graft. Each athlete is unique; thus, safe return to play should be individualized rather than follow a particular postoperative month or time line. This article provides an overview of the application and the scientific basis for formulating a rehabilitation protocol prior to and following anterior cruciate ligament surgery.

Single-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: Surgical Technique Pearls and Pitfalls

Tunnel malposition is one of the most common technical reasons for anterior cruciate ligament reconstruction failure. Small changes in tunnel placement can result in significant differences in outcome. More anatomic placement of the tunnels can lead to greater knee stability and a more accurate reproduction of native knee kinematics. This Technical Note describes 2 tibial tunnel-independent methods to obtain anatomic femoral tunnel placement. The all-inside anteromedial portal technique requires only minimal surgical incisions but allows precise femoral tunnel placement. However, hyperflexion of the knee is required, adequate surgical assistance is necessary, and this technique may be susceptible to graft-tunnel mismatch. The outside-in technique may be more beneficial in obese patients, skeletally immature patients, or revision cases. On the downside, it does require an additional 2-cm surgical incision. This article also provides surgical pearls to fine-tune tibial tunnel placement.

Current Arthroscopic Concepts in Repairing Posterior Cruciate Ligament Tibial-Sided Avulsions.

Anterior cruciate ligament (ACL) ruptures are some of the most common sports-related injuries. Treatment of these injuries with ACL reconstruction has evolved over the last several decades. Anatomic single-bundle ACL reconstruction offers an accurate and reproducible method to reproduce native knee anatomy, restore knee kinematics, and ultimately restore function and decrease long-term degenerative effects. The importance of adequate arthroscopic visualization and a thorough understanding of the native anatomic ACL landmarks are discussed in this article. Furthermore, surgical technique, pearls, pitfalls, potential complications, rehabilitation, and outcomes are reviewed.

The Responsiveness of Patient- Reported Outcome Tools in Shoulder Surgery Is Dependent on the Underlying Pathological Condition:

Posterior cruciate ligament (PCL) injuries are extremely rare and most commonly occur in the trauma setting. They can lead to instability, pain, diminished function, and eventual arthrosis. Several techniques of arthroscopic PCL repair for tibial-sided bony avulsions have been described in the literature; however, no single technique has emerged as the gold standard to predictably restore posterior knee stability, PCL function, and knee biomechanics. The authors believe that the best results will come from procedures that re-create the normal human anatomy and knee kinematics. In this article, 3 arthroscopic methods of PCL avulsion repairs performed at 2 academic institutions are analyzed. The techniques described here provide good options for the treatment of these injuries.

Responsiveness of Patient-Reported Outcome Measures After Shoulder Instability Surgery: A Systematic Review and Meta-Analysis

Background: Given the high number of available patient-reported outcome (PRO) tools for patients undergoing shoulder surgery, comparative information is necessary to determine the most relevant forms to incorporate into clinical practice. Purpose: To determine the utilization and responsiveness of common PRO tools in studies involving patients undergoing arthroscopic rotator cuff repair or operative management of glenohumeral instability. Study Design: Systematic review. Methods: A systematic review of rotator cuff and instability studies from multiple databases was performed according to PRISMA guidelines. Means and SDs of each PRO tool utilized, study sample sizes, and follow-up durations were collected. The responsiveness of each PRO tool compared with other PRO tools was determined by calculating the effect size and relative efficiency (RE). Results: After a full-text review of 238 rotator cuff articles and 110 instability articles, 81 studies and 29 studies met the criteria for final inclusion, respectively. In the rotator cuff studies, 25 different PRO tools were utilized. The most commonly utilized PRO tools were the Constant (50 studies), visual analog scale (VAS) for pain (44 studies), American Shoulder and Elbow Surgeons (ASES; 39 studies), University of California, Los Angeles (UCLA; 20 studies), and Disabilities of the Arm, Shoulder and Hand (DASH; 13 studies) scores. The ASES score was found to be more responsive than all scores including the Constant (RE, 1.94), VAS for pain (RE, 1.54), UCLA (RE, 1.46), and DASH (RE, 1.35) scores. In the instability studies, 16 different PRO tools were utilized. The most commonly used PRO tools were the ASES (13 studies), Rowe (10 studies), Western Ontario Shoulder Instability Index (WOSI; 8 studies), VAS for pain (7 studies), UCLA (7 studies), and Constant (6 studies) scores. The Rowe score was much more responsive than both the ASES (RE, 22.84) and the Constant (RE, 33.17) scores; however, the ASES score remained more responsive than the Constant (RE, 1.93), VAS for pain (RE, 1.75), and WOSI (RE, 0.97) scores. Conclusion: Despite being frequently used in the research community, the Constant score may be less clinically useful as it was less responsive. Additionally, it is a greater burden on the provider because it requires objective strength and range of motion data to be gathered by the clinician. In contrast, the ASES score was highly responsive after rotator cuff repair and requires only subjective patient input. Furthermore, separate PRO scoring methods appear to be necessary for patients undergoing rotator cuff repair and surgery for instability as the instability-specific Rowe score was much more responsive than the ASES score.

Lower Mental Component Scores are Associated with Lower Return-to-Work Rates after Patellofemoral Autologous Chondrocyte Implantation

Objectives: Patient reported outcomes (PROs) are increasingly used in orthopaedics as a tool to objectively assess subjective data and provide a sense of responsiveness to treatment. Unfortunately, there are several PROs and little data as to which outcome scores are most useful. The purpose of this study was to evaluate the utilization and responsiveness of PROs reported in the literature after shoulder instability surgery. Methods: We performed a systematic review of the PubMed, SportDiscus, Cochrane, and CINHAHL databases according to PRISMA guidelines to identify studies published in the last 10 years which reported PROs after shoulder instability surgery. Articles were excluded if they were not primary research (case reports and review articles), were published only in abstract form, were not available in English, or did not report pre- and post-operative mean PRO values. The specific PROs utilized, number of patients, mean follow-up time, and preoperative and postoperative means and standard deviations were recorded for each article, For studies including preoperative and postoperative means and standard deviations of two or more PROs, and the comparative responsiveness (CR) of each PRO was assessed (CR was calculated by squaring PRO change score t-value ratio). Results: Abstracts from 112 studies were identified for full text review, and 29 studies ultimately met inclusion criteria. Sixteen different PROs were reported in various combinations in the included studies. Mean follow-up was 25.17 months (SD = 15.01) and mean sample size was 47.34 (SD = 59.06). The majority of studies (72.4%) utilized more than one PRO. The most commonly used PROs were the ASES (13 studies, 44.8%), Rowe (10, 34.5%), WOSI (8, 27.6%), VAS-pain (7, 24.1%), UCLA (7, 24.1%), and Constant (6, 20.7%). The remaining PRO tools appeared in 3 or fewer studies. Responsiveness of the different PRO tools was evaluated with a subset of 4 articles that included sample size, pre- and postoperative means, and pre- and post-operative standard deviations for PROs reported in this subset were the ASES, Rowe, WOSI, VAS-pain, and Constant scores. The Rowe score was much more responsive than both the ASES (RE = 22.8) and Constant scores (RE = 33.17). On the contrary, the VAS-pain was the least responsive, with RE = 0.57 when compared to the ASES, and RE = 0.32 when compared to the WOSI. ASES remained more responsive than the Constant (RE = 1.75), VAS-pain (RE = 1.75), and WOSI (RE = 0.97). Conclusion: Despite being less frequently utilized, the Rowe score was considerably more responsive than the ASES and Constant scores. ASES, Constant, and WOSI were similar to each other in terms of responsiveness, and the shoulder-specific scores were more responsive than the VAS-pain score. When assessing patient outcomes related to shoulder instability surgery, surgeons may want to consider employing the more sensitive, and instability-specific, Rowe score rather than other commonly used shoulder PROs.

The Early Osteoarthritic Knee : Implications for Cartilage Repair

Objectives: Autologous chondrocyte implantation (ACI) is a well established treatment for articular cartilage defects of the knee. However, few studies have examined return-to-work rates among ACI patients, and even fewer have investigated the effect of mental health on postoperative outcomes. The purpose of this study was to examine the effect of preoperative mental health on return to work and patient-reported outcomes. Methods: From our IRB-approved prospective outcomes registry, we identified 109 ACI patients (mean age = 34.5 years, mean follow-up = 2.8 years) with pre- and postoperative clinical data. Patients were stratified into those with preoperative VR-12 Mental Component Scores in the bottom quartile (LOW MCS) and in the top 3 quartiles (HIGH MCS) based on normative values. Patients with patellar and/or trochlear lesions were placed in the patellofemoral (PF) group, and all other patients were placed in the tibiofemoral (TF) group. Return to work, IKDC scores, and Lysholm scores were individually compared between the LOW MCS and HIGH MCS groups that had undergone either PF or TF ACI. Fisher’s exact tests were used to compare the return to work rates and frequency of IKDC and Lysholm improvements greater than the minimal clinically important difference. One-way ANOVAs were used to examine magnitude of change of IKDC and Lysholm scores. Results: Preoperatively, 14/55 (25.5%) TF patients and 17/54 (31.5%) PF patients were included in the LOW MCS group. For PF patients, return to work rates were significantly lower for the LOW MCS group (p=.0005). Return to work rates did not differ in the TF group (p>0.99). Changes in IKDC and Lysholm scores did not differ between the LOW MCS and HIGH MCS groups in TF or PF patients (Table 1). Conclusion: Lower preoperative mental component scores were more common in PF ACI patients and were associated with decreased return to work rates in PF ACI patients. The results of this study underscore the need to preoperatively quantify mental health status for this specific patient group in order to set realistic postoperative expectations. Table 1. Comparison of postoterative outcomes between patients with either low or high preoperative VR-12 mental component scores (MCS), separated by the location of the lesion (patellofemoral or tibiofemoral). *MCID: Minimal Clinically Important Difference Patellofemoral ACI Tibiofemoral ACI LOW MCS HIGH MCS P LOW MCS HIGH MCS P Number of patients 17 37 - 14 37 - Return to Work (%) 29.4% 81.1% 0.0005 57.1% 60.9% >0.99 IKDC change > MDIC (%) 73.3% 45.7% 0.12 35% 43.9% 0.76 Mean IKDC Improvement 14.12 21.87 0.917 10.13 5.77 0.35 Lysholm Change > MDIC (%) 81.3% 62.9% 0.33 14.3% 46.2% 0.53 Mean Lysholm Improvement 16.71% 19.06 0.719 11.92 0.65 0.631

Return to Sport Following Arthroscopic Treatment of Acetabular Labral Tears in Competitive Athletes: A Systematic Review

Patients with early osteoarthritis (OA) have been reported to have inferior outcomes with an increased prevalence of early failure after cartilage procedures. The underlying reasons for this failure are likely multifactorial, including a chronic synovial and chondrogenic process, which is confounded by persistent muscle weakness and altered pain processing for those with increased preoperative symptom duration. Pain, radiographic changes, patient-reported outcomes, and macroscopic changes on arthroscopic evaluation or MRI can assist clinicians in identifying the early OA knee to both aid in clinical decision making and create realistic postoperative expectations for patients.