Eric J. Cotter

Failure of Bone Marrow Stimulation Techniques

Marrow stimulation techniques, including microfracture, are among the most commonly performed cartilage restoration procedures for symptomatic chondral defects of the knee. For the vast majority of patients, marrow stimulation results in reduced pain and improved function, providing overall satisfactory outcomes. In some cases, however, marrow stimulation fails, resulting in symptom recurrence and often, the need for repeat surgery. This review will describe the indications and outcomes of microfracture as a primary surgical treatment for focal chondral defects of the knee, identify patient and procedure-specific factors associated with poor clinical outcomes, and will discuss treatment options and their respective outcomes for patients with a failed prior microfracture surgery.

Bone Marrow Aspirate Concentrate for Cartilage Defects of the Knee: From Bench to Bedside Evidence:

Objective To critically evaluate the current basic science, translational, and clinical data regarding bone marrow aspirate concentrate (BMAC) in the setting of focal cartilage defects of the knee and describe clinical indications and future research questions surrounding the clinical utility of BMAC for treatment of these lesions. Design A literature search was performed using the PubMed and Ovid MEDLINE databases for studies in English (1980-2017) using keywords, including [“bone marrow aspirate” and “cartilage”], [“mesenchymal stem cells” and “cartilage”], and [“bone marrow aspirate” and “mesenchymal stem cells” and “orthopedics”]. A total of 1832 articles were reviewed by 2 independent authors and additional literature found through scanning references of cited articles. Results BMAC has demonstrated promising results in the clinical application for repair of chondral defects as an adjuvant procedure or as an independent management technique. A subcomponent of BMAC, bone marrow derived–mesenchymal stem cells (MSCs) possess the ability to differentiate into cells important for osteogenesis and chondrogenesis. Modulation of paracrine signaling is perhaps the most important function of BM-MSCs in this setting. In an effort to increase the cellular yield, authors have shown the ability to expand BM-MSCs in culture while maintaining phenotype. Conclusions Translational studies have demonstrated good clinical efficacy of BMAC both concomitant with cartilage restoration procedures, at defined time points after surgery, and as isolated injections. Early clinical data suggests BMAC may help stimulate a more robust hyaline cartilage repair tissue response. Numerous questions remain regarding BMAC usage, including cell source, cell expansion, optimal pathology, and injection timing and quantity.

Patient Understanding, Expectations, Outcomes, and Satisfaction Regarding Anterior Cruciate Ligament Injuries and Surgical Management

Patient satisfaction has become an increasingly important outcome metric in orthopaedics and medicine in general as many initiatives at both the state and national levels aim to improve the efficiency and quality of health care. Anterior cruciate ligament injuries are among the most common injuries in orthopaedics, with anterior cruciate ligament reconstruction (ACLR) surgery consistently reported as one of the most frequently performed procedures by orthopaedic surgeons. Patient-reported outcomes are frequently used to evaluate outcomes from the patients perspective, and many physicians also ask patients about their satisfaction with treatment. A growing volume of literature has investigated the relation between preoperative patient expectations and postoperative patient satisfaction. The quality of online resources, patient expectations for ACLR, and factors associated with and/or predictive of either poor or good to excellent outcomes after surgery are described. This article critically reviews the orthopaedic literature on this important topic and identifies variables that influence patient expectations and satisfaction to help treating physicians better counsel and evaluate patients and ultimately improve outcomes of and satisfaction with ACLR surgery.

The Utility of Biologics, Osteotomy, and Cartilage Restoration in the Knee

The management of complex cartilage and meniscal pathology in young, athletic patients is extremely challenging. Joint preservation surgery is most difficult in patients with concomitant knee pathologies, including cartilage defects, meniscal deficiency, malalignment, and/or ligamentous insufficiency. Clinical decision making for these patients is further complicated by articular cartilage lesions, which often are incidental findings; therefore, treatment decisions must be based on the confirmed contribution of articular cartilage lesions to symptomatology. Surgical management of any of the aforementioned knee pathologies that is performed in isolation typically results in acceptable patient outcomes; however, concomitant procedures for the management of concomitant knee pathologies often are essential to the success of any single procedure. The use of biologic therapy as an alternative to or to augment more conventional surgical management has increased in popularity in the past decade, and indications for biologic therapy continue to evolve. Orthopaedic surgeons should understand knee joint preservation techniques, including biologic and reconstructive approaches in young, high-demand patients.

Male Sex, Decreased Activity Level, and Higher BMI Associated With Lower Completion of Patient-Reported Outcome Measures Following ACL Reconstruction

Background: Patient-reported outcome (PRO) surveys have become increasingly important in both improving patient care and assessing outcomes. Purpose/Hypothesis: The purpose of this study was to evaluate which variables are associated with compliance with completing PRO surveys in patients who have undergone anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that older patient age and longer time since ACLR would be associated with lower completion rates of PRO surveys preoperatively and at postoperative time points. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent ACLR by a sports medicine fellowship–trained orthopaedic surgeon at a single institution and were electronically assigned PRO surveys through a data collection system preoperatively between December 2013 and March 2015 were included. Postoperatively, PRO surveys were sent to patients’ email addresses at 6, 12, and 24 months. Demographics, history, and operative and postoperative information were evaluated for an association with survey completion rates. Results: A total of 256 patients met the inclusion criteria. There were 140 (54.7%) male and 116 (45.3%) female patients, with an overall mean age of 28.6 ± 11.9 years. Only 19 (7.4%) patients completed all preoperative and postoperative surveys at all time points. Less than half of the patients (n = 104; 40.6%) completed both the preoperative survey and at least 1 postoperative survey. There was a steady decrease in the completion rate of PRO surveys postoperatively over time (Pearson r = –0.995, P = .005). Male patients had significantly worse compliance with completing PRO surveys preoperatively and at a minimum of 1 time point postoperatively (P = .044). Patients who did not identify as athletes or report frequent exercise (≥3 times/wk) had significantly worse compliance with completing any PRO surveys (P = .046). Lower body mass index was associated with greater odds of compliance with completing the preoperative survey and 24-month postoperative survey (odds ratio, 0.902; P = .029). Conclusion: An inverse relationship was found between the surgery-to-survey period and percentage of those completing PRO surveys, with poor overall compliance. Male sex and not self-identifying as an athlete or performing frequent physical exercise were associated with lower completion rates of PRO surveys, while lower body mass index was associated with a greater rate of completion.

Effect of Vertical or Beveled Chondral Defect Creation on Rim Deformation and Contact

Objective To determine biomechanical effects of knee cartilage defect perimeter morphology based on cartilage strain and opposing subchondral bone contact. Design Articular cartilage defects were created in 5 bovine femoral condyles: group 1, 45° inner bevel with 8-mm rim; group 2, vertical with 8-mm rim; and group 3, 45° outer bevel with 8-mm base. Samples were placed into a custom-machined micro–computed tomography tube and subjected to 800 N of axial loading. DICOM data were used to calculate cartilage thickness 4 and 6 mm from the center, distance between tibial cartilage surface and femoral subchondral bone, and contact width between tibial cartilage and subchondral bone. Strain 4 mm from the center and both absolute and change in distance (mm) to subchondral bone were compared between groups 1 and 2 using paired t tests. Strain at 6 mm and distance changed, loaded distance, and contact width (mm) were compared between groups using the Friedman test with post hoc analysis using Wilcoxon signed rank test. Results No significant differences in rim strain were noted between groups 1 and 2 at 4 mm (P = 0.10) and between groups 1, 2, and 3 at 6 mm (P = 0.247) from the defect center. The loaded distance was significantly different between groups 1 and 3 (P = 0.013). No significant change in distance to the subchondral bone was found between groups (P = 0.156). The difference in subchondral bone contact area approached but did not reach significance (P = 0.074). Conclusion When debriding focal articular cartilage defects, establishment of an inner bevel decreases tissue deformation and contact with opposing subchondral bone.

Do Outcomes of Osteochondral Allograft Transplantation Differ Based on Age and Sex? A Comparative Matched Group Analysis

Background: The effect of patient age or sex on outcomes after osteochondral allograft transplantation (OCA) has not been assessed. Purpose: To determine clinical outcomes for male and female patients aged ≥40 years undergoing OCA compared with a group of patients aged <40 years. Study Design: Cohort study; Level of evidence, 3. Methods: A review of prospectively collected data of consecutive patients who underwent OCA by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, failure rate, and patient-reported outcome scores were reviewed. All outcomes were compared between patients aged <40 or ≥40 years, with subgroup analyses conducted based on patient sex. Failure was defined as revision OCA, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery. Descriptive statistics, Fisher exact or chi-square testing, and Mann-Whitney U testing were performed, with P < .05 set as significant. Results: A total of 170 patients (of 212 eligible patients; 80.2% follow-up) who underwent OCA with a mean follow-up of 5.0 ± 2.7 years (range, 2.0-15.1 years) were included, with 115 patients aged <40 years (mean age, 27.6 ± 7.3 years; 58 male, 57 female) and 55 patients aged ≥40 years (mean age, 44.9 ± 4.0 years; 33 male, 22 female). There were no differences in the number of pre-OCA procedures between the groups (P = .085). There were no differences in the reoperation rate (<40 years: 38%; ≥40 years: 36%; P = .867), time to reoperation (<40 years: 2.12 ± 1.90 years; ≥40 years: 3.43 ± 3.43 years; P = .126), or failure rate (<40 years: 13%; ≥40 years: 16%; P = .639) between the older and younger groups. Patients in both groups demonstrated significant improvement in Lysholm (both: P < .001), International Knee Documentation Committee (IKDC) (both: P < .001), Knee Injury and Osteoarthritis Outcome Score (KOOS) (both: P < .001), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (both: P < .001), and Short Form–12 (SF-12) physical (both: P < .001) scores compared with preoperative values. Patients aged ≥40 years demonstrated significantly higher KOOS symptom (P = .015) subscores compared with patients aged <40 years. There were no significant differences in the number of complications, outcome scores, or time to failure between the sexes. In patients aged <40 years, female patients experienced failure significantly more quickly than male patients (P = .039). In contrast, in patients aged ≥40 years, male patients experienced failure significantly more quickly than female patients (P = .046). Conclusion: This study provides evidence that OCA is a safe and reliable treatment option for osteochondral defects in patients aged ≥40 years. Male and female patients had similar outcomes. Patients aged <40 years demonstrated lower KOOS symptom subscores postoperatively compared with older patients, potentially attributable to higher expectations of return to function postoperatively as compared with older patients.

Preoperative Tibial Subchondral Bone Marrow Lesion Patterns and Associations With Outcomes After Isolated Meniscus Allograft Transplantation

Background: The association between preoperative tibial subchondral bone marrow lesion (BML) patterns and outcomes after isolated meniscus allograft transplantation (MAT) are unknown. Purpose: To determine (1) if a superior classification means exists (ie, high interrater reliability [IRR]) for grading tibial subchondral BML before isolated MAT and (2) whether quality and/or severity of preoperative tibial subchondral BML patterns was associated with clinical outcomes and/or failure rates after isolated MAT. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent isolated MAT with a single surgeon between October 2006 and February 2017 were identified. Three means were evaluated to quantify the degree of subchondral BML in the affected tibial-sided compartment: Welsch et al, based on maximum diameter of the lesion; Costa-Paz et al, based on appearance and location of the lesion; and Filardo et al, based on severity of findings. IRR was generated and compared among the 3 classifications. The preoperative magnetic resonance imaging (MRI) subchondral BML grading scheme with the highest IRR was then used to assess for associations with postoperative outcomes for those patients with >2-year follow-up, per a Spearman correlation matrix with each reviewer’s grades. Results: In total, 60 MRI scans were available for subchondral BML grading. Grader 1 identified the presence of subchondral BML in the tibia of the affected compartment in 40 (66.7%) of the available MRI scans, as compared with 38 (63.3%) for grader 2. The calculated IRRs with the Welsch et al and Costa-Paz et al classifications were rated “strong/almost perfect” agreement. A significant correlation was demonstrated between grader 1 with the Welsch et al grading scheme and outcome measures of KOOS pain (Knee injury and Osteoarthritis Outcome Score; negative correlation, P = .05), WOMAC pain (Western Ontario and McMaster Universities Osteoarthritis Index; positive correlation, P = .026), and Marx Activity Rating Scale (negative correlation, P = .019). A significant correlation was demonstrated between grader 2 with the Costa-Paz et al grading scheme and postoperative satisfaction (positive correlation, P = .018). There were no significant differences in survivorship based on gradings. Conclusion: Nearly two-thirds of patients who undergo isolated MAT have subchondral BML on preoperative MRI. Our findings suggest that increasing BML size (Welsch et al) is correlated with worse postoperative pain measures (KOOS pain, WOMAC pain) and worse activity ratings (Marx Activity Rating Scale). Additionally, increasing disruption or depression of the normal contour of the cortical surface, with or without lesion contiguity with the subjacent articular surface (Costa-Paz et al), is correlated with greater postoperative satisfaction.

Clinical Outcomes of Patellofemoral Osteochondral Allograft Transplantation: A Prospective Analysis

Objectives: The use of osteochondral allograft transplantation (OAG) for chondral defects of the knee is increasing, particularly for defects involving the femoral condyles. The purpose of this study was to prospectively evaluate the clinical outcomes for patients undergoing patellofemoral OAG for symptomatic chondral lesions. Methods: Consecutive patients undergoing OAG for full-thickness patella and trochlear lesions between 2007 and 2014 by two senior surgeons were analyzed. Pre- and post-operative patient reported outcomes scores were collected, with a minimum 21-month follow-up. Patient demographics, preoperative clinical data including information on prior ipsilateral knee surgeries, and intraoperative details were analyzed for all patients. Complications, reoperations, and conversion to total knee or patellofemoral arthroplasty were recorded. Statistical analysis was conducted with student’s T-tests, with P<0.05 considered significant. Results: A total of 14 patients (10 females, 4 males) with an average age of 32.8±7.5 years (range, 20-48) were identified for inclusion with an average follow-up of 3.6±1.8 years (range, 1.8-7.8) (Table 1). The average body mass index was 27.5±6.9 kg/m2. Patients experienced an average 5.4±4.2 years of symptoms prior to OAG and 100% of patients had undergone previous ipsilateral knee surgery with an average 4.1±3.5 prior procedures before undergoing patellofemoral OAG. The average defect size on the patella was 855mm2 while that on the trochlea was 322mm2. At the time of OAG, 6 (43%) patients received trochlear grafts, 6 (43%) received patellar grafts, and 2 (14%) received bipolar grafts. Nine patients (64%) received a single allograft, 3 (21%) received 2 allografts to 2 separate lesions, and 2 (14%) received grafts to 4 separate lesions. At final follow-up, there were significant improvements in Lysholm, IKDC, KOOS, WOMAC, and SF-12 Physical outcomes scores; no significant improvements were found in the SF-12 Mental subscale (Figure 1). Two patients (both female, ages 27 and 41) were considered failures as they had converted to knee arthroplasty at an average 2.7 years following OAG. Both of these patients had received allografts to the patella with lesion sizes of 506mm2 and 1800mm2, respectively. Conclusion: Osteochondral allograft transplantation of the patellofemoral joint can be considered a viable restoration procedure for patients with symptomatic chondral lesions to the trochlea and patella. At an average follow-up of 3.6 years, the majority of patients will experience significant improvements in nearly all outcomes scores, with an arthroplasty conversion rate of 14%. Additional information on this difficult-to-treat patient population, including a better understanding of risk factors for failure, prognostic factors for success, and long-term outcomes, is needed. Table 1 Patient information Case Body Mass Index (kg/m2) Symptom Duration(yrs.) History of Failed Prior Articular Cartilage Procedure Type of Previous Cartilage Procedure # OA Grafts Location of Grafts Lesion Area (mm) Failed to TKA/PFA Time to Failure (Yrs.) 1 (36yo M) 33.22 5 No N/A 2 Trochlea, MFC 400, 225 No N/A 2 (27yo M) 27.12 3 Yes ACI 1 Patella 324 No N/A 3 (48yo F) 23.40 2 No 1 Trochlea 400, 225 No N/A 4 (24yo M) 27.60 9 No 4 Trochlea, MFC (x2), LFC 625, 324, 225, 625 No N/A 5 (34yo M) 28.32 2 Yes MFX 1 Trochlea/MFC Junction 225 No N/A 6 (24yo F) 19.58 3.5 Yes 1 Trochlea 225 No N/A 7 (30yo F) 26.62 3 No 2 Trochlea, MFC 324, 225 No N/A 8 (34yo F) 33.6 1 Yes MFX 4 patella, trochlea, MFC x2 1500,254, 254, 201 No N/A 9 (41yo F) 20.8 10 No 1 Patella 506 Yes 2.9 10 (27yo F) 42.6 2.5 Yes TruFit Plug, DeNovo 1 Patella 1800 Yes 2.4 11 (37yo F) 35.7 2 Yes DeNovo 1 Patella 988 No N/A 12 (33yo F) 17.3 11 Yes OA Graft 2 Patella, Trochlea 375, 300 No N/A 13 (20yo F) 25.1 6 Yes DeNovo, ACI 1 Patella 975 No N/A 14 (38yo F) 24.4 15 No 1 Patella 375 No N/A

Factors Influencing Patient Selection of an Orthopaedic Sports Medicine Physician

Background: The rise in consumer-centric health insurance plans has increased the importance of the patient in choosing a provider. There is a paucity of studies that examine how patients select an orthopaedic sports medicine physician. Purpose: To evaluate factors that patients consider when choosing an orthopaedic sports medicine physician. Study Design: Case series; Level of evidence, 4. Methods: A total of 1077 patients who sought treatment by 3 sports medicine physicians were administered an anonymous questionnaire. The questionnaire included 19 questions asking respondents to rate the importance of specific factors regarding the selection of orthopaedic sports medicine physicians on a scale of 1 (not important at all) to 10 (very important). The remaining 6 questions were multiple-choice and regarded the following criteria: preferred physician age, appointment availability, clinic waiting room times, travel distance, and medical student/resident involvement. Results: Of the 1077 consecutive patients administered the survey, 382 (35%) responded. Of these, 59% (n = 224) were male, and 41% (n = 158) were female. In ranking the 19 criteria in terms of importance, patients rated board certification (9.12 ± 1.88), being well known for a specific area of expertise (8.27 ± 2.39), and in-network provider status (8.13 ± 2.94) as the 3 most important factors in selecting an orthopaedic sports medicine physician. Radio, television, and Internet advertisements were rated the least important. Regarding physician age, 63% of patients would consider seeking a physician who is ≤65 years old. Approximately 78% of patients would consider seeking a different physician if no appointments were available within 4 weeks. Conclusion: The study results suggest that board certification, being well known for a specific area of expertise, and health insurance in-network providers may be the most important factors influencing patient selection of an orthopaedic sports medicine physician. Advertisements were least important to patients. Patient preferences varied regarding ideal physician age, clinic appointment availability, medical student/resident involvement, and travel distance in choosing an orthopaedic sports medicine physician. In the context of health care delivery and as reimbursement becomes increasingly consumer centered, understanding the process of provider selection is important.