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Schneider JG, Ormseth B, DiBartola AC, Magnussen RA, Duerr RA, Stoodley P, Flanigan DC. Incidence, Common Pathogens, and Risk Factors for Infection after Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review. J Knee Surg 2024; 37:470-481. [PMID: 37734405 DOI: 10.1055/a-2179-3678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis, and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction.
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Affiliation(s)
| | | | - Alex C DiBartola
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Duerr
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Paul Stoodley
- Department of Microbial Infection and Immunity and the Department of Orthopaedics, The Ohio State University School of Medicine, The Ohio State University, Columbus, Ohio
| | - David C Flanigan
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Oosten JD, DiBartola AC, Wright JC, Cavendish PA, Milliron EM, Magnussen RA, Duerr RA, Kaeding CC, Flanigan DC. More Is Not Merrier: Increasing Numbers of All-Inside Implants Do Not Correlate with Higher Odds of Revision Surgery. J Knee Surg 2024; 37:361-367. [PMID: 37336501 DOI: 10.1055/a-2112-8158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The purpose of this study was to evaluate the relationship between the number of all-inside meniscal repair implants placed and the risk of repair failure. We hypothesized that the use of higher numbers of all-inside meniscus repair implants would be associated with increased failure risk. A retrospective chart review identified 351 patients who underwent all-inside meniscus repair between 2006 and 2013 by a sports medicine fellowship-trained orthopaedic surgeon at a single institution. Patient demographics (age, body mass index [BMI], sex) and surgical data (number of implants used, concomitant anterior cruciate ligament reconstruction [cACLR], and tear type/size/location) were recorded. Patients who received repairs in both menisci or who had follow-up < 1-year postoperatively were excluded. Repair failure was identified through chart review or patient interviews defined as a revision surgery on the index knee such as partial meniscectomy, total knee arthroplasty, meniscus transplant, or repeat repair. Logistic regression modeling was utilized to evaluate the relationship between the number of implants used and repair failure. A total of 227 all-inside meniscus repairs were included with a mean follow-up of 5.0 ± 3.0 years following surgery. Repair failure was noted in 68 knees (30.3%)-in 28.1% of knees with fewer than four implants and in 35.8% of knees with four or more implants (p = 0.31). No significant increase in failure was observed with increasing number of all-inside medial (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.79-1.7; p = 0.46) or lateral (OR: 0.86; 95% CI: 0.47-1.57; p = 0.63) implants after controlling for patient age, BMI, cACLR, tear type, or size. Tears of the lateral meniscus located in the red-white and white-white zones had lower odds of failure (OR: 0.14; 95% CI: 0.02-0.88; p = 0.036) than tears within the red-red zone, and patients with cACLR had lower odds of repair failure (OR: 0.40; 95% CI: 0.18-0.86, p = 0.024) than those without. The number of all-inside implants placed during meniscus tear repair did not affect the likelihood of repair failure leading to reoperation after controlling for BMI, age, tear type, size, location, and cACLR. LEVEL OF EVIDENCE: III.
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Affiliation(s)
- James D Oosten
- The Ohio State University College of Medicine, Wexner Medical Center, Columbus, Ohio
| | - Alex C DiBartola
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Jonathan C Wright
- The Ohio State University College of Medicine, Wexner Medical Center, Columbus, Ohio
| | - Parker A Cavendish
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Eric M Milliron
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Robert A Duerr
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Christopher C Kaeding
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio
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Bentkowski BN, Blunt KM, Milliron EM, Cavendish PA, Barnes RH, Kaeding CC, Magnussen RA, Stoodley P, Flanigan DC. Tobramycin and Vancomycin in an In Vitro Model of Anterior Cruciate Ligament Allograft Decontamination. Am J Sports Med 2024; 52:956-960. [PMID: 38305039 DOI: 10.1177/03635465231223138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Approximately 100,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) occur annually in the United States, and postoperative surgical-site infection is a relatively rare but devastating complication, often leading to graft failure or septic arthritis of the knee, necessitating repeat surgery. Wrapping allografts in vancomycin-soaked gauze has been adopted as a common sterilization technique in the operating room to reduce surgical-site infection; however, identifying effective alternatives to vancomycin has not been extensively pursued. HYPOTHESIS Tobramycin would be as effective as vancomycin in reducing the concentrations of Staphylococcus epidermidis bacteria on tendon allografts. STUDY DESIGN Controlled laboratory study. METHODS S. epidermidis strain ATCC 12228 was inoculated onto the human cadaveric gracilis tendon. The tendons were wrapped in sterile gauze saturated with tobramycin or vancomycin at various experimental concentrations. Bacteria remaining on the tendon were dislodged, serially diluted, and plated for colony counting. Statistical analysis was performed utilizing 2-way analysis of variance testing. Results were considered statistically significant when P < .05. RESULTS Vancomycin (P = .0001) and tobramycin (P < .0001) reduced bacterial concentration. Tobramycin was found to produce a statistically significant reduction in bacterial concentration at concentrations as low as 0.1 mg/mL (P < .0001 and P = .01 at 10 and 20 minutes), while vancomycin produced a statistically significant reduction at a concentration as low as 2.5 mg/mL (P < .0001 at both 10 and 20 minutes). CONCLUSION This study demonstrates that tobramycin is as effective as vancomycin in bacterial concentration reduction but can achieve this reduction level at lower doses. Further studies clarifying the biomechanical and cytotoxic effects of tobramycin on tendon tissue are indicated to solidify its use as a clinical alternative to vancomycin in ACLR. CLINICAL RELEVANCE These results will begin establishing tobramycin as an alternative to vancomycin in ACL graft decontamination. Because of relatively frequent shortages of vancomycin, establishing tobramycin as an alternative agent is a useful option for the orthopaedic surgeon.
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Walla N, Moore T, Harangody S, Fitzpatrick S, Flanigan DC, Duerr RA, Siston R, Magnussen RA. Qualitative visual assessment of the J-sign demonstrates high inter-rater reliability. J ISAKOS 2023; 8:420-424. [PMID: 37499874 DOI: 10.1016/j.jisako.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES To assess the inter- and intra-rater reliability of the classification of the J-sign as "large" versus "small or none" as compared to another two-level system ("present" versus "absent") and a three-level system ("large," "small," or "none") and to identify anatomical and patient factors associated with the presence of a large J-sign. METHODS Forty patients (40 knees) with recurrent patellar instability were prospectively enrolled and recorded on video actively extending their knee while seating. Four raters classified patellar tracking on two separate occasions using three systems: 1) two groups: J-sign versus no J-sign; 2) three groups: large J-sign, small J-sign, or no J-sign; and 3) two groups: large J-sign versus small or no J-sign. The intra- and inter-rater reliability of each system was assessed using kappa statistics. Anatomical (trochlear dysplasia, tibial tubercle-trochlear groove (TT-TG) distance, patellar height) and patient (Beighton score) factors as well as Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were compared between patients with a large J-sign and patients with a small or no J-sign. RESULTS Inter- and intra-rater reliability were found to be highest with the two-level classification system of a large J-sign versus a small or no J-sign (inter-rater kappa = 0.76, intra-rater kappa = 0.75). Patients with a large J-sign had more severe trochlear dysplasia as assessed with the sulcus angle (p = 0.042) and were more likely to have a tight lateral retinaculum (p = 0.032) and an elevated Beighton score (p = 0.009). No significant differences in KOOS subscales were noted based on the presence of a large J-sign versus a small J-sign or no J-sign. CONCLUSION Qualitative visual assessment of patellar tracking with the J-sign demonstrates substantial inter- and intra-rater reliability, particularly when utilizing a two-group classification system to identify knees with a large J-sign. Patients with a large J-sign demonstrate an increased incidence of a tight lateral retinaculum, generalized ligamentous laxity, and trochlear dysplasia. LEVEL OF EVIDENCE Level III - cross-sectional study.
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Affiliation(s)
- Nicholas Walla
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Toren Moore
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Sarah Harangody
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Sean Fitzpatrick
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Robert A Duerr
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Robert Siston
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University, Columbus, OH, 43202, USA.
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Pappa N, Good L, DiBartola A, Martin K, Flanigan DC, Magnussen RA. Patella alta and increased TT-TG distance do not adversely affect patient-reported outcomes following isolated MPFL reconstruction: A systematic review. J ISAKOS 2023; 8:352-363. [PMID: 37562573 DOI: 10.1016/j.jisako.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/19/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVES To analyze the effect of patellofemoral anatomical variations (patella alta, increased tibial tubercle-trochlear groove [TT-TG] distance, and trochlear dysplasia) on clinical outcomes after isolated medial patellofemoral ligament (MPFL) reconstruction. METHODS A comprehensive search from PubMed, Embase, and the Cochrane Library databases was conducted to identify studies that compared outcomes based on the presence or absence of patella alta, elevated tibial tubercle-trochlear groove (TT-TG) distance, and/or trochlear dysplasia. Exclusion criteria included reviews and meta-analyses, studies that included patients who underwent associated bony procedures, and those reporting outcomes after isolated MPFL reconstruction with no comparison between varying anatomical groups. RESULTS After application of selection criteria, 19 studies were included. Patella alta was not predictive of failure or poorer outcomes among 13 studies; however, 2 studies demonstrated poorer patient-reported outcome scores and/or higher failure rates with increasing patellar height. Increasing TT-TG distance demonstrated a statistically significant correlation with poorer outcomes in only one study, whereas 12 other studies showed no association. Trochlear dysplasia resulted in worse outcomes and greater failure rates in 6 studies, while 10 studies showed no statistically significant correlation between trochlear dysplasia and postoperative outcomes. CONCLUSION Patella alta and increased TT-TG distance did not adversely affect outcomes following isolated MPFL reconstruction in the preponderance of reviewed studies. Data are mixed regarding the impact of trochlear dysplasia on the outcomes of isolated MPFL reconstruction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Nicholas Pappa
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Logan Good
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Alex DiBartola
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Kyle Martin
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA.
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Zwolski CM, Paterno MV, Magnussen RA, Thomas SM, Goodway JD, Hand BN, Quatman-Yates CC, Schmitt LC. The Association of Physical Competence With Psychological Response Among Young Athletes at Time of Return to Sport After ACL Reconstruction. Am J Sports Med 2023; 51:2908-2917. [PMID: 37551704 DOI: 10.1177/03635465231188448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND The traditional index of return-to-sport (RTS) readiness after anterior cruciate ligament reconstruction (ACLR) is the achievement of physical competence criteria. Emerging research indicates that psychological response and self-perceptions of physical competence may be critical mechanisms for successful RTS among young athletes. HYPOTHESIS Young athletes with higher actual physical competence (APC) and perceived physical competence (PPC) will demonstrate a more positive psychological response at the time of RTS after ACLR. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 41 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. APC was measured with isokinetic knee extension strength, single-limb crossover hop for distance, and the Knee injury and Osteoarthritis Outcome Score. PPC was measured with the Athletic Competence subscale of the Self-Perception Profile. Criteria for APC and PPC were based on established age- and activity-relevant cutoff scores. Different constructs of psychological response were assessed with the adapted Sport Motivation Scale, Brief Resilience Scale, and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) total and subscale scores (Emotions, Confidence, and Risk Appraisal). Multiple linear regression analyses were used to determine differences in measures of psychological response based on achievement of APC and PPC, while adjusting for age and sex. RESULTS Of the 41 participants, 10 (24.4%) met all criteria for APC and 22 (53.7%) met the PPC criteria. The regression models estimating the ACL-RSI score (P < .001; adjusted R2 = 0.331), ACL-RSI Emotions score (P < .001; adjusted R2 = 0.427), and ACL-RSI Risk Appraisal score (P = .013; adjusted R2 = 0.212) were statistically significant. Although APC was not associated with any measure of psychological response, meeting PPC criteria, younger age, and male sex were found to be associated with a more positive psychological readiness to RTS, but not with motivation or resilience. CONCLUSION Meeting PPC criteria was associated with higher psychological readiness to RTS among young athletes after ACLR, while meeting APC criteria was not associated with any construct of psychological response.
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Affiliation(s)
- Christin M Zwolski
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mark V Paterno
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Robert A Magnussen
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Staci M Thomas
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Brittany N Hand
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Catherine C Quatman-Yates
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Laura C Schmitt
- Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
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Mallory N, Qin C, Gibbs D, Milliron E, Cavendish P, Magnussen RA, Flanigan DC. Horizontal Cleavage Meniscus Tears: Biomechanics, Indications, Techniques, and Outcomes. JBJS Rev 2023; 11:01874474-202308000-00006. [PMID: 37561839 DOI: 10.2106/jbjs.rvw.23.00042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
» Accounting for up to 24% of all meniscus tears, horizontal cleavage tears (HCTs) are a common pathology orthopaedic practitioners should be comfortable managing.» Historically, HCTs were treated with partial meniscectomy; however, recent studies have demonstrated that these procedures have an adverse biomechanical effect, while HCT repairs restore the knee's natural biomechanics.» Indications for the surgical repair of HCTs remain disputed, but surgery is generally considered for young, active patients and older patients without significant concomitant osteoarthritis.» Early clinical findings surrounding HCT repair are promising. They suggest that this treatment adequately restores meniscus mechanics, leads to good knee functional outcomes, and results in a high likelihood of return to preinjury activity levels.
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Affiliation(s)
- Noah Mallory
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Charles Qin
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David Gibbs
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Eric Milliron
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Parker Cavendish
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Blunt KM, Bentkowski BN, Milliron E, Cavendish P, Qin C, Magnussen RA, Stoodley P, Flanigan DC. Influence of Staphylococcus epidermidis on Collagen Crimp Patterns of Soft Tissue Allograft. Am J Sports Med 2023:3635465231181649. [PMID: 37449681 DOI: 10.1177/03635465231181649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Postoperative infections, commonly from Staphylococcus epidermidis, may result in anterior cruciate ligament graft failure and necessitate revision surgery. In biomechanical studies, S. epidermidis has been shown to establish biofilms on tendons and reduce graft strength. PURPOSE/HYPOTHESIS The goal of this study was to determine the effect of bacterial bioburden on the collagen structure of tendon. It was hypothesized that an increase in S. epidermidis biofilm would compromise tendon crimp, a pattern necessary for mechanical integrity, of soft tissue allografts. STUDY DESIGN Controlled laboratory study. METHODS Cultures of S. epidermidis were used to inoculate tibialis anterior cadaveric tendons. Conditions assessed included 5 × 105 colony-forming units or concentrated spent media from culture (no living bacteria). Incubation times of 30 minutes, 3 hours, 6 hours, and 24 hours were utilized. Second-harmonic generation imaging allowed for visualization of collagen autofluorescence. Crimp lengths were determined using ImageJ and compared based on incubation time. RESULTS Incubation time positively correlated with increasing S. epidermidis bioburden. Both fine and coarse crimp patterns lengthened with increasing incubation time. Significant coarse crimp changes were observed after only 30-minute incubations (P < .029), whereas significant fine crimp lengthening occurred after 6 hours (P < .0001). No changes in crimp length were identified after incubation in media lacking living bacteria. CONCLUSION The results of this study demonstrate that exposure to S. epidermidis negatively affects collagen crimp structure. Structural alterations at the collagen fiber level occur within 30 minutes of exposure to media containing S. epidermidis. CLINICAL RELEVANCE Our study highlights the need for antimicrobial precautions to prevent graft colonization and maximize graft mechanical strength.
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Affiliation(s)
- Koral M Blunt
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Eric Milliron
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Parker Cavendish
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Charles Qin
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- The Ohio State University Sports Medicine Research Institute, Columbus, Ohio, USA
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, USA
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- The Ohio State University Sports Medicine Research Institute, Columbus, Ohio, USA
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Sheean AJ, Jin Y, Huston LJ, Brophy RH, Cox CL, Flanigan DC, Jones MH, Kaeding CC, Magnussen RA, Marx RG, Matava MJ, McCarty EC, Parker RD, Wolcott ML, Wolf BR, Wright RW, Spindler KP. Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients With High Preinjury Marx Activity Scores: A MOON Prospective Cohort Study. Am J Sports Med 2023; 51:2313-2323. [PMID: 37724692 DOI: 10.1177/03635465231172769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Predictors of return to activity after anterior cruciate ligament reconstruction (ACLR) among patients with relatively high preinjury activity levels remain poorly understood. PURPOSE/HYPOTHESIS The purpose of this study was to identify predictors of return to preinjury levels of activity after ACLR, defined as achieving a Marx activity score within 2 points of the preinjury value, among patients with Marx activity scores of 12 to 16 who had been prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) cohort. We hypothesized that age, sex, preinjury activity level, meniscal injuries and/or procedures, and concurrent articular cartilage injuries would predict return to preinjury activity levels at 2 years after ACLR. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS All unilateral ACLR procedures from 2002 to 2008 performed in patients enrolled in the MOON, with preinjury Marx activity scores ranging from 12 to 16, were evaluated with a specific focus on return to preinjury activity levels at 2 years postoperatively. Return to activity was defined as a Marx activity score within 2 points of the preinjury value. The proportion of patients able to return to preinjury activity levels was calculated, and multivariable modeling was performed to identify risk factors for patients' inability to return to preinjury activity levels. RESULTS A total of 1188 patients were included in the final analysis. The median preinjury Marx activity score was 16 (interquartile range, 12-16). Overall, 466 patients (39.2%) were able to return to preinjury levels of activity, and 722 patients (60.8%) were not able to return to preinjury levels of activity. Female sex, smoking at the time of ACLR, fewer years of education, lower 36-Item Short Form Health Survey Mental Component Summary scores, and higher preinjury Marx activity scores were predictive of patients' inability to return to preinjury activity levels. Graft type, revision ACLR, the presence of medial and/or lateral meniscal injuries, a history of meniscal surgery, the presence of articular cartilage injuries, a history of articular cartilage treatment, and the presence of high-grade knee laxity were not predictive of a patient's ability to return to preinjury activity level. CONCLUSION At 2 years after ACLR, most patients with high preinjury Marx activity scores did not return to their preinjury level of activity. The higher the preinjury Marx activity score that a patient reported at the time of enrollment, the less likely he/she was able to return to preinjury activity level. Smoking and lower mental health at the time of ACLR were the only modifiable risk factors in this cohort that predicted an inability to return to preinjury activity levels. Continued effort and investigation are required to maximize functional recovery after ACLR in patients with high preinjury levels of activity.
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Affiliation(s)
- Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Yuxuan Jin
- Cleveland Clinic, Cleveland, Ohio, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura J Huston
- Vanderbilt University, Nashville, Tennessee, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert H Brophy
- Washington University in St Louis, St Louis, Missouri, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles L Cox
- Vanderbilt University, Nashville, Tennessee, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - David C Flanigan
- The Ohio State University, Columbus, Ohio, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Morgan H Jones
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher C Kaeding
- The Ohio State University, Columbus, Ohio, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert A Magnussen
- The Ohio State University, Columbus, Ohio, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert G Marx
- Hospital for Special Surgery, New York, New York, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew J Matava
- Washington University in St Louis, St Louis, Missouri, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric C McCarty
- University of Colorado, Denver, Colorado, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard D Parker
- Cleveland Clinic, Cleveland, Ohio, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Michelle L Wolcott
- University of Colorado, Denver, Colorado, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian R Wolf
- University of Iowa, Iowa City, Iowa, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Rick W Wright
- Vanderbilt University, Nashville, Tennessee, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt P Spindler
- Cleveland Clinic, Cleveland, Ohio, USA
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA, and Cleveland Clinic, Cleveland, Ohio, USA
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10
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DiBartola AC, Magnussen RA, Everhart JS, Milliron E, Emery CF, Schiele SE, Harris KM, Schmitt L, Flanigan DC. Athletes and Nonathletes Show No Difference in Symptoms or Function Prior to Knee Surgery, but Those With Chronic Symptoms Show Increased Pain Catastrophizing and Kinesiophobia. Arthroscopy 2023; 39:1028-1034. [PMID: 36872027 DOI: 10.1016/j.arthro.2022.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 10/09/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE To determine whether preoperative psychological status before outpatient knee surgery is influenced by athletic status, symptom chronicity, or prior surgical history. METHODS International Knee Documentation Committee subjective scores (IKDC-S), Tegner Activity Scale scores, and Marx Activity Rating Scale scores were collected. Psychological and pain surveys included the McGill pain scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia 11, Patient Health Questionnaire 9, Perceived Stress Scale, New General Self-Efficacy Scale, and Life Orientation Test-Revised for optimism. Linear regression was used to determine the effects of athlete status, symptom chronicity (>6 months or ≤6 months), and history of prior surgery on preoperative knee function, pain, and psychological status after matching for age, sex, and surgical procedure. RESULTS In total, 497 knee surgery patients (247 athletes, 250 nonathletes) completed a preoperative electronic survey. All patients were age 14 years and older and had knee pathology requiring surgical treatment. Athletes were younger than nonathletes on average (mean [SD], 27.7 [11.4] vs 41.6 [13.5] years; P < .001). The most frequently reported level of play among athletes was intramural or recreational (n = 110, 44.5%). Athletes had higher preoperative IKDC-S scores (mean [SE], 2.5 [1.0] points higher; P = .015) and lower McGill pain scores compared to nonathletes (mean [SE] 2.0 [0.85] points lower; P = .017). After matching for age, sex, athlete status, prior surgery, and procedure type, having chronic symptoms resulted in higher preoperative IKDC-S (P < .001), pain catastrophizing (P < .001), and kinesiophobia scores (P = .044). CONCLUSIONS Athletes demonstrate no difference in symptom/pain and function scores preoperatively when compared to nonathletes of similar age, sex, and knee pathology, as well as no difference in multiple psychological distress outcomes measures. Patients with chronic symptoms have more pain catastrophizing and kinesiophobia, while those who have had prior knee surgeries have slightly higher preoperative McGill pain score. LEVEL OF EVIDENCE Level III, cross-sectional analysis of prospective cohort study data.
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Affiliation(s)
- Alex C DiBartola
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A; Department of Orthopaedics Sports Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | | | - Eric Milliron
- The Ohio State University College of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Charles F Emery
- Department of Psychology, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Steve E Schiele
- Department of Psychology, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Kristie M Harris
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Laura Schmitt
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, Ohio State University and Jameson Crane Sports Medicine Research Institute, Ohio State University, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A; Department of Orthopaedics Sports Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A; Cartilage Restoration Program, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.
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11
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Sorensen HH, Magnussen RA, DiBartola AC, Mallory NT, Litsky AS, Stoodley P, Swinehart SD, Duerr RA, Kaeding CC, Flanigan DC. Influence of Staphylococcus epidermidis biofilm on the mechanical strength of soft tissue allograft. J Orthop Res 2023; 41:466-472. [PMID: 35526143 PMCID: PMC9640764 DOI: 10.1002/jor.25360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
We sought to determine the impact of bacterial inoculation and length of exposure on the mechanical integrity of soft tissue tendon grafts. Cultures of Staphylococcus epidermidis were inoculated on human tibialis posterior cadaveric tendon to grow biofilms. A low inoculum in 10% growth medium was incubated for 30 min to replicate conditions of clinical infection. Growth conditions assessed included inoculum concentrations of 100, 1000, 10,000 colony-forming units (CFUs). Tests using the MTS Bionix system were performed to assess the influence of bacterial biofilms on tendon strength. Load-to-failure testing was performed on the tendons, and the ultimate tensile strength was obtained from the maximal force and the cross-sectional area. Displacements of tendon origin to maximal displacement were normalized to tendon length to obtain strain values. Tendon force-displacement and stress-strain relationships were calculated, and Young's modulus was determined. Elastic modulus and ultimate tensile strength decreased with increasing bioburden. Young's modulus was greater in uninoculated controls compared to tendons inoculated at 10,000 CFU (p = 0.0011) but unaffected by bacterial concentrations of 100 and 1000 CFU (p = 0.054, p = 0.078). Increasing bioburden was associated with decreased peak load to failure (p = 0.043) but was most significant compared to the control under the 10,000 and 1000 CFU growth conditions (p = 0.0005, p = 0.049). The presence of S. epidermidis increased elasticity and decreased ultimate tensile stress of human cadaveric tendons, with increasing effect noted with increasing bioburden.
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Affiliation(s)
- Hanna H. Sorensen
- The Ohio State University College of Medicine Medical Student Research Program,The Ohio State University Department of Microbial Infection and Immunity
| | | | | | - Noah T. Mallory
- The Ohio State University College of Medicine Medical Student Research Program
| | - Alan S. Litsky
- The Ohio State University Department of Orthopaedics,Ohio State University Department of Biomedical Engineering
| | - Paul Stoodley
- The Ohio State University Department of Microbial Infection and Immunity,The Ohio State University Department of Orthopaedics,National Centre for Advanced Tribology at Southampton (nCATS) and National Biofilm Innovation Centre (NBIC), Dept. Mechanical Engineering, University of Southampton, UK
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12
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Duerr RA, Ormseth B, DiBartola A, Geers K, Kaeding CC, Siston R, Flanigan DC, Magnussen RA. Association of Elevated Posterior Tibial Slope With Revision Anterior Cruciate Ligament Graft Failure in a Matched Cohort Analysis. Am J Sports Med 2023; 51:38-48. [PMID: 36412535 DOI: 10.1177/03635465221134806] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Elevated posterior tibial slope (PTS) has been identified as an important risk factor in anterior cruciate ligament (ACL) injuries and ACL graft failures. The cutoff value to recommend treatment with slope-reducing osteotomy remains unclear and is based on expert opinion and small case series. PURPOSE (1) To determine whether there is a difference in PTS shown on lateral knee radiographs and magnetic resonance imaging (MRI) scans in a group of patients who experienced revision ACL graft failure versus a control group of patients who underwent successful revision ACL reconstruction, (2) to identify cutoff values of PTS measurements that predict risk of revision ACL graft failure, and (3) to examine whether there is a correlation between radiographic and MRI measurements of PTS. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A total of 38 patients who experienced revision ACL graft failure were identified from a revision ACL database. These patients were matched 1:1 by age, sex, and graft type to a group of 38 control patients who underwent revision ACL reconstruction with no evidence of graft failure at a minimum 2 years of follow-up. Medial and lateral PTS were measured by lateral knee radiographs and MRI scans of the affected limb. Demographics, surgical characteristics, and PTS were compared between the groups. The optimal cutoff values of medial and lateral PTS per radiographs and MRI scans for predicting increased risk of revision ACL graft failure were determined by receiver operating characteristic curves. Conditional multivariable logistic regression was used to assess the relative contribution of PTS cutoff values as a predictor of revision graft failure. RESULTS The mean PTS values in the failure group were significantly higher than those in the control group on radiographs (medial, 13.2°± 2.9° vs 10.3°± 2.9°; P < .001; lateral, 12.9°± 3.0° vs 9.8°± 2.8°; P < .001) and MRI scans (medial, 7.2°± 3.1° vs 4.8°± 2.9°; P < .001; lateral, 8.4 ± 3.1° vs 5.9 ± 3.0°; P < .001). A radiographic medial PTS ≥14° had the highest increased risk of revision ACL graft failure with sensitivity equal to 50% and specificity to 92.1% (odds ratio, 18.71; 95% CI, 2.0-174.9; P = .01). CONCLUSION Elevated PTS was a significant risk factor for revision ACL graft failure. Patients with radiographic medial PTS ≥14° had 18.7-times increased risk of revision ACL failure.
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Affiliation(s)
- Robert A Duerr
- Department of Orthopedic Surgery, Mercy Clinic Sports Medicine, St. Louis, Missouri, USA
| | - Benjamin Ormseth
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alex DiBartola
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Katie Geers
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA. Presented at the annual meeting of the AOSSM, Nashville, Tennessee, July 2021
| | - Christopher C Kaeding
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert Siston
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA. Presented at the annual meeting of the AOSSM, Nashville, Tennessee, July 2021
| | - David C Flanigan
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert A Magnussen
- Jameson Crane Sports Medicine Institute, Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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13
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Long J, Pappa N, Stitgen M, Flanigan DC, Fowler B, DiBartola AC, Magnussen RA. Patient-Reported Outcomes Following Medial Patellofemoral Reconstruction With Peroneus Longus Allografts Demonstrate Good Results. Arthrosc Sports Med Rehabil 2022; 5:e201-e206. [PMID: 36866312 PMCID: PMC9971893 DOI: 10.1016/j.asmr.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To evaluate the recurrent dislocation risk and patient-reported outcomes of peroneus longus allograft tissue for medial patellofemoral ligament (MPFL) reconstruction. Methods Patients who underwent MPFL reconstruction with peroneus longus allograft at an academic center between 2008 and 2016 were identified. Record review and patient contact were used to identify any cases of recurrent patellar dislocation and collect patient-reported outcomes scores (Knee injury and Osteoarthritis Outcome Score [KOOS], Norwich Patellar Instability score, Marx activity scale). Patients with 1-year minimum follow-up were included. Outcomes were quantified and the proportion of patients reaching a previously defined patient acceptable symptom state (PASS) for patellar instability was determined. Results Sixty-one patients (42 female and 19 male) underwent MPFL reconstruction with peroneus longus allograft during the study period. Forty-six patients (76%) with 1-year minimum follow up were contacted at a mean of 3.5 years postoperative. The mean age at time of surgery was 22 ± 7.2 years. Patient-reported outcomes data were available in 34 patients. Mean KOOS subscale scores were as follows: Symptoms 83.2 ± 19.1, Pain 85.2 ± 17.6, Activities of Daily Living 89.9 ± 14.8, Sports 75 ± 26.2, and Quality of Life 72.6 ± 25.7. The mean Norwich Patellar Instability score was 14.9% ± 17.4%. The mean Marx activity score was 6.0 ± 5.2. No recurrent dislocations were noted during the study period. Sixty-three percent of patients who underwent isolated MPFL reconstruction met PASS thresholds in at least 4 of 5 KOOS subscales. Conclusions The use of a peroneus longus allograft in MPFL reconstruction in conjunction with other indicated procedures results in a low re-dislocation risk and a high proportion of patients meeting PASS criteria for patient-reported outcome scores 3 to 4 years postoperatively. Level of Evidence IV, case series.
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Affiliation(s)
| | | | | | | | | | | | - Robert A. Magnussen
- Address correspondence to Robert A. Magnussen, M.D., Sports Medicine Research Institute, 2835 Fred Taylor Dr., Columbus, OH, 43202.
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14
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Gonzalez RC, Ryskamp DJ, Swinehart SD, Cavendish PA, Milliron E, DiBartola AC, Duerr RA, Flanigan DC, Magnussen RA. Patellofemoral articular cartilage damage is associated with poorer patient-reported outcomes following isolated medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07221-x. [PMID: 36383223 DOI: 10.1007/s00167-022-07221-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to investigate the impact of articular cartilage damage on outcomes following medial patellofemoral ligament (MPFL) reconstruction. METHODS Record review identified 160 patients who underwent isolated MPFL reconstruction at a single institution between 2008 and 2016. Patient demographics, patellofemoral articular cartilage status at surgery, and patient anatomical measures from imaging were obtained via chart review. Patients were contacted and outcomes assessed through collection of Norwich Patellar Instability (NPI) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity score as well as an assessment for recurrent patellar dislocation. Outcomes of patients with grade 0-II patellofemoral cartilage damage were compared to those of patients with grade III-IV cartilage damage. RESULTS One hundred twenty-two patients (76%) with a minimum of one year follow-up were contacted at a mean of 4.8 years post-operatively. A total of 63 patients (52%) had grade III or IV patellofemoral chondral damage at the time of surgery. The majority of the defects was on the medial patella (46 patients-72%) and the mean patellar defect size was 2.8 cm2. Among 93 patients who completed patient-reported outcome scores, the 52 with grade III or IV chondral damage reported a significantly poorer KOOS Quality of Life than the 44 patients with grade 0 to II chondral damage (p = 0.041), controlling for patient age, sex, BMI, and anatomical factors. CONCLUSION Patients with grade III or IV articular cartilage damage of the patellofemoral joint at the time of MPFL reconstruction demonstrated poorer KOOS knee-related quality of life than patients without grade III or IV articular cartilage damage at a mean of 4.8 years following isolated MPFL reconstruction. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - David J Ryskamp
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Steven D Swinehart
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Parker A Cavendish
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Eric Milliron
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Alex C DiBartola
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Robert A Duerr
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Jameson Crane Institute of Sports Medicine, Sports Medicine Research Institute, 2835 Fred Taylor Drive, Columbus, OH, 43202, USA.
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15
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Calafiore DA, Magnussen RA, Everhart JS, DiBartola AC, Milliron EM, Kaeding CC, Flanigan DC. Smaller Iatrogenic Defects Created by Inside-Out Compared With All-Inside Meniscus Repair Devices in Human Cadaveric Model. Arthroscopy 2022; 38:3070-3079.e3. [PMID: 36344063 DOI: 10.1016/j.arthro.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/04/2022] [Accepted: 05/13/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE (1) To investigate the pattern and diameter of the iatrogenic defect that meniscal repair devices impose on meniscal tissue and (2) to determine whether repair-induced defect patterns or diameters differ across devices. METHODS Sixty-one fresh frozen human cadaveric menisci were used (n = 9; eliminated). All-inside devices (n = 9) included ULTRA FAST-FIX, FAST-FIX 360, Depuy Mitek 0° and 12° TRUESPAN, ConMed Sequent, Zimmer Biomet JuggerStitch, Stryker IvyAIR, Arthrex FiberStitch and Meniscal Cinch II. Inside-out needles (n = 4) included ConMed HiFi, Depuy Mitek ORTHOCORD, Arthrex-2-0 FiberWire, and Stryker SharpShooter. Following India Ink staining, implant devices were inserted into cadaveric menisci. Samples were fixed in formalin solution and imaged with a high-resolution camera. Defects were classified by qualitative evaluation. Defect and needle diameter were quantified with software assistance. Statistical analysis was performed using analysis of variance testing. RESULTS We analyzed 644 iatrogenic defects with mean defect diameter of 1.96 mm (standard deviation 0.86). For all-inside devices, defect patterns (n = 436) were 15.6% linear, 38.1% semilunar, 46.3% stellate, while inside-out devices (n = 208) were 95.7% stellate, 4.3% linear, and 0.0% semilunar. All-inside devices had mean defect diameter of 2.46 mm, while inside-out meniscus needles had mean 0.90 mm defect diameter (P < .001). FasT-FIX 360, ULTRA-FAST-FIX, and Arthrex Meniscal Cinch II induced smaller diameter defects than other all-inside devices (F = 20.2, P < .05). Strong positive correlation was found comparing outer needle diameter and mean defect diameters across all devices (R2 = 0.9447). CONCLUSIONS Needles utilized in meniscal implant systems produce the following basic defect patterns: stellate (62.3%), semilunar (25.8%), and linear (11.9%). A strong positive correlation was found between mean defect size and outer needle diameter across all devices. Inside-out double-armed flexible needles produced significantly smaller defects than all-inside devices. Of the all-inside devices, ULTRA FAST-FIX, FAST-FIX 360, and Arthrex Meniscal Cinch II produced smaller defects on average. CLINICAL RELEVANCE While the true clinical impact of these findings cannot be drawn from the present study, this investigation provides necessary context to better understand reported similarities and differences in healing rates and outcomes between inside-out and all-inside repair techniques.
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Affiliation(s)
- David A Calafiore
- College of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio; Sports Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Alex C DiBartola
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eric M Milliron
- College of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christopher C Kaeding
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio; Sports Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio; Sports Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Cartilage Restoration Program, U.S.A..
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16
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Magnussen RA, Peters NJ, Long J, Pappa N, Schmitt LC, Brunst CL, Kaeding CC, Flanigan DC. Accelerated rehabilitation program following medial patellofemoral ligament reconstruction does not increase risk of recurrent instability. Knee 2022; 38:178-183. [PMID: 36063612 DOI: 10.1016/j.knee.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/13/2021] [Accepted: 08/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rehabilitation protocols following medial patellofemoral ligament (MPFL) reconstruction were historically restrictive, with patients often immobilized and/or given weightbearing restrictions. However, more recently published protocols have been more aggressive. We compared patient-reported outcomes and recurrent dislocation risk between patients treated with a restrictive rehabilitation program (early post-operative bracing and weightbearing restrictions) and an accelerated rehabilitation protocol (no post-operative bracing or weightbearing restrictions) following MPFL reconstruction. METHODS Patients who underwent isolated MPFL reconstruction at an academic center between 2008 and 2016 were identified. Patient demographics, anatomical measurements, surgical details, and outcomes were collected. During this period, the rehabilitation protocol at the center transitioned from a restrictive to an accelerated rehabilitation protocol. Failure risk and patient-reported outcomes were compared based on rehabilitation protocol. RESULTS Of the163 isolated MPFL reconstructions performed during the study period, 123 (75%) were available for minimum one-year follow up at a mean of 4.0 years post-operative. Overall, 53 knees (43%) underwent the accelerated rehabilitation protocol and the remaining 70 knees (57%) underwent the restrictive protocol. There were 3 recurrent dislocations during the study period (2.4%), all of which occurred in the restrictive rehabilitation group. Multiple linear regression demonstrated that being in the accelerated rehabilitation group was not associated with poorer Knee injury and Osteoarthritis Outcome Score (KOOS) subscales controlling for age, sex, body mass index, Caton-Deschamps Index, tibial tubercle-trochlear groove distance, sulcus angle, MPFL graft choice, and length of follow-up. CONCLUSION An accelerated rehabilitation protocol without immobilization or weightbearing restrictions does not increase risk of recurrent patellar dislocation or poorer patient-reported outcome following isolated MPFL reconstruction.
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Affiliation(s)
- Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University, United States.
| | - Nicholas J Peters
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Joseph Long
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Nicholas Pappa
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Laura C Schmitt
- Sports Medicine Research Institute, The Ohio State University, United States
| | - Caroline L Brunst
- Sports Medicine Research Institute, The Ohio State University, United States
| | | | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University, United States
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Welder E, Magnussen RA, Fitzpatrick S, Duerr RA, Kaeding CC, Flanigan DC. Arthroscopic Bone Graft Technique for Two-Stage Revision Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2022; 11:e1667-e1674. [PMID: 36311315 PMCID: PMC9596458 DOI: 10.1016/j.eats.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/24/2022] [Indexed: 02/03/2023] Open
Abstract
Revision anterior cruciate ligament reconstruction is an increasingly common procedure, with 2-stage surgery often required to address large bone defects and malpositioned tunnels. The arthroscopic bone grafting technique described herein uses morselized allograft bone to provide reproducible fill of asymmetrical bone defects without autograft harvest or additional loss of native bone. The second stage of the anterior cruciate ligament reconstruction can typically proceed 6 months following bone grafting.
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Affiliation(s)
- Eric Welder
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A. Magnussen
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.,OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A
| | - Sean Fitzpatrick
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.,OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A. Duerr
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.,OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A
| | - Christopher C. Kaeding
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.,OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A
| | - David C. Flanigan
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.,OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, U.S.A.,Address correspondence to David C. Flanigan, M.D., Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr., Columbus, OH 43202.
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18
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Fabricant PD, Heath MR, Mintz DN, Emery K, Veerkamp M, Gruber S, Green DW, Strickland SM, Wall EJ, Shubin Stein BE, Parikh SN, Chambers CC, Ellis HB, Farr J, Heyworth BE, Koh JL, Kramer DE, Magnussen RA, Redler LH, Sherman SL, Tompkins MA, Wilson PL. Many Radiographic and Magnetic Resonance Imaging Assessments for Surgical Decision Making in Pediatric Patellofemoral Instability Patients Demonstrate Poor Interrater Reliability. Arthroscopy 2022; 38:2702-2713. [PMID: 35398485 DOI: 10.1016/j.arthro.2022.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the interrater reliability of several common radiologic parameters used for patellofemoral instability and to attempt to improve reliability for measurements demonstrating unacceptable interrater reliability through consensus training. METHODS Fifty patients with patellar instability between the ages of 10 and 19 years were selected from a prospectively enrolled cohort. For measurements demonstrating unacceptable interrater reliability (intraclass correlation coefficient [ICC]: <0.6), raters discussed consensus methods to improve reliability and re-examined a subset of 20 images from the previous set of images. If reliability was still low after the second round of assessment, the measure was considered unreliable. RESULTS Of the 50 included subjects, 22 (44%) were male and the mean age at the time of imaging was 14 ± 2 years. With 1 or fewer consensus training sessions, the interrater reliability of the following radiograph indices were found to be reliable: trochlea crossing sign (ICC: 0.625), congruence angle (ICC: 0.768), Caton-Deshamps index (ICC: 0.644), lateral patellofemoral angle (ICC: 0.768), and mechanical axis deviation on hip-to-ankle alignment radiographs (ICC: 0.665-0.777). Reliable magnetic resonance imaging (MRI) indices were trochlear depth (ICC: 0.743), trochlear bump (ICC: 0.861), sulcus angle (ICC: 0.684), patellar tilt (ICC: 0.841), tibial tubercle to trochlear groove distance (ICC: 0.706), effusion (ICC: 0.866), and bone marrow edema (ICC: 0.961). CONCLUSIONS With 1 or fewer consensus training sessions, the interrater reliability of the following patellofemoral indices were found to be reliable for trochlear morphology: trochlea crossing sign and congruence angle on radiograph and trochlear depth, trochlear bump, and sulcus angle on MRI. Reliable patellar position measurements included: Caton-Deshamps index and lateral patellofemoral angle on radiograph and patellar tilt and tibial tubercle to trochlear groove distance on MRI. Additional global measurements (e.g., mechanical axis deviation on standing radiographs) and MRI assessments demonstrated acceptable reliability. LEVEL OF EVIDENCE II, prospective diagnostic study.
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Affiliation(s)
| | | | | | | | | | - Simone Gruber
- Hospital for Special Surgery, New York, New York, U.S.A
| | | | | | - Eric J Wall
- Cincinnati Children's Hospital, Cincinnati, Ohio, U.S.A
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19
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Meynard P, Malatray M, Sappey-Marinier E, Magnussen RA, Bodiou V, Lustig S, Servien E. Medial patellofemoral ligament reconstruction for recurrent patellar dislocation allows a good rate to return to sport. Knee Surg Sports Traumatol Arthrosc 2022; 30:1865-1870. [PMID: 34846539 DOI: 10.1007/s00167-021-06815-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Recurrent patellar dislocation is a frequent knee disorders in young, active patients. Medial patellofemoral ligament reconstruction (MPFLR) can restore knee stability and function, but the rate of return to sports is less clear. The aim of this study was to evaluate rate of return to sport following treatment of recurrent patellar dislocation with isolated MPFLR. METHODS Between 2011 and 2018, 113 patients with recurrent patellar dislocation were treated with isolated MPFLR at an academic center. Pre-injury sports participation and Tegner score, pre-operative subjective IKDC score, time to return to sports, and post-operative Tegner and subjective IKDC scores were collected, with a minimum of follow-up of 2 years. RESULTS One hundred and three patients (91%) were evaluated at a mean of 4.5 ± 2.5-year post-operative. 92 patients (89%) participated in sports prior to onset of patellar instability. At final follow-up, 84 of these 92 patients (91%) were able to return to sports. The mean time from surgery to return to sports was 10.4 ± 8.6 months (range: 2-48 months). 62 patients (67%) returned to the same (50 patients) or higher (12 patients) level. 22 patients (26%) returned at a lower level. 19 of these patients attributed this decreased participation to ongoing knee problems. The median Tegner score was noted to decrease from 5 pre-injury to 4 post-operatively (p = 0.02). CONCLUSION Isolated MPFL reconstruction allowed return to pre-injury sports in 91% of patients, with 67% of patients returning to the same or higher level than pre-injury. Mean time to return to sports was 10 months and post-operative Tegner score was noted to be modestly decreased from pre-injury level. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Pierre Meynard
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France.
| | - Matthieu Malatray
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France
| | - Elliot Sappey-Marinier
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France
| | - Robert A Magnussen
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, OH, USA
| | - Victor Bodiou
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France
| | - Sébastien Lustig
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France.,LBMC UMR T 9406, Laboratory of Chock Mechanics and Biomechanics, Claude Bernard Lyon 1 University, 69100, Villeurbanne, France
| | - Elvire Servien
- Department of Orthopedic Surgery and Sports Medicine, Croix Rousse Hospital, Civil Hospices of Lyon, FIFA Medical Center of Excellence, 103 bvd de la croix-rousse, 69004, Lyon, France.,LIBM-EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, 69100, Villeurbanne, France
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20
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Pappa N, Flanigan DC, Long J, Dorweiler M, Fowler B, Duerr R, Dibartola AC, Kaeding CK, Magnussen RA. Influence of Patellofemoral Anatomy on Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability. Orthop J Sports Med 2022; 10:23259671221104414. [PMID: 35783469 PMCID: PMC9247377 DOI: 10.1177/23259671221104414] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Patella alta and elevated tibial tubercle–trochlear groove (TT-TG) distance
can predispose patients to lateral patellar dislocations and recurrent
instability. Their influence on patient-reported outcomes (PROs) after
medial patellofemoral ligament (MPFL) reconstruction is less clear. Hypothesis: We hypothesized that neither moderately increased TT-TG distance nor patella
alta would negatively affect PROs after isolated MPFL reconstruction in
patients with relatively normal patellar tracking (no large J-sign). Study Design: Cohort study; Level of evidence, 3. Methods: We identified patients who underwent isolated MPFL reconstruction at a single
institution between 2008 and 2016. The decision to perform an isolated MPFL
reconstruction was at the discretion of the operating surgeon but was not
performed in the setting of a large J-sign. Patient characteristics and
surgical details were collected, and patients completed the Norwich Patellar
Instability Score, Knee injury and Osteoarthritis Outcome Score, and Marx
activity score. Patellar height (Caton-Deschamps Index [CDI]) was assessed
on preoperative lateral radiographs, and TT-TG distance was measured on
preoperative axial magnetic resonance imaging (MRI) scans. Patients were
grouped based on CDI and TT-TG distance, and outcomes were compared. Linear
regression modeling was performed to determine whether patella alta or
elevated TT-TG distance was associated with poorer PRO scores. Results: Of 165 knees in 152 patients who underwent isolated MPFL reconstruction, 115
patients (125 knees; 76%) with minimum 1-year follow-up were contacted at a
mean of 5.2 years after surgery. Recurrent dislocation occurred in 5 of 125
knees (4%). Preoperative radiographs were available in 111 knees (89%), and
preoperative MRI scans were available in 89 knees (71%). Mean CDI was 1.13,
and 35% had a CDI ≥1.20. Mean TT-TG distance was 17.5 mm, and 26% had a
TT-TG distance >20 mm. After adjusting for patient age, sex, body mass
index, and graft choice, we observed that neither patella alta nor elevated
TT-TG distance were associated with poorer PROs. Conclusion: Isolated MPFL reconstruction in the setting of moderately elevated TT-TG
distance or patella alta was not associated with worse PROs in this cohort
with relatively normal patellar tracking (no large J-sign).
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Affiliation(s)
- Nicholas Pappa
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Joseph Long
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Matthew Dorweiler
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Brian Fowler
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Robert Duerr
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Alex C Dibartola
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | | | - Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
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21
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Leon J, Flanigan DC, Colatruglio M, Ormseth B, Fitzpatrick S, Duerr RA, Kaeding CC, Magnussen RA. Larger Prior Tibial Tunnel Size Is Associated with Increased Failure Risk following Revision Anterior Cruciate Ligament Reconstruction. J Knee Surg 2022. [PMID: 35240716 DOI: 10.1055/s-0042-1743234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We hypothesize that larger prior tunnel size is associated with an increased risk of failure of single-stage revision anterior cruciate ligament reconstruction (ACLR) as defined by the performance of a re-revision (third) ACLR on the index knee. Retrospective review identified 244 patients who underwent single-stage revision ACLR at a single center with available preoperative radiographs. Patient and surgical factors were extracted by chart review. The maximum diameter of the tibial tunnel was measured on lateral radiographs and the maximum diameter of the femoral tunnel was measured on anteroposterior radiographs. Record review and follow-up phone calls were used to identify failure of the revision surgery as defined by re-revision ACLR on the index knee. One hundred and seventy-one patients (70%) were reviewed with a mean of 3.9 years follow-up. Overall, 23 patients (13.4%) underwent re-revision surgery. Mean tibial tunnel size was 12.6 ± 2.8 mm (range: 5.7-26.9 mm) and mean femoral tunnel size was 11.7 ± 2.8 mm (range: 6.0-23.0 mm). Re-revision risk increased with tibial tunnel size. Tibial tunnels 11 mm and under had a re-revision risk of 4.2%, while tunnels > 11 mm had a risk of 17.1% (relative risk: 4.1, p = 0.025). No significant association between femoral tunnel size and re-revision risk was noted. Patients with prior tibial tunnels > 11mm in diameter at revision surgery had significantly increased risk of re-revision ACLR. Further studies are needed to explore the relationship between prior tunnel size and outcomes of revision ACLR.
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Affiliation(s)
- Jacy Leon
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Matthew Colatruglio
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Benjamin Ormseth
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Sean Fitzpatrick
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Robert A Duerr
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Christopher C Kaeding
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
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22
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Fitzpatrick S, Magnussen RA, Léger-St-Jean B, Gorica Z, Vasileff WK, Kaeding CC. Treatment of Chronic Proximal Hamstring Tendinopathy with Surgical Debridement and Suture Anchor Repair. J Surg Orthop Adv 2022; 31:61-64. [PMID: 35377311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We evaluated outcomes following surgical debridement and suture anchor repair of chronic proximal hamstring tendinopathy without sciatic nerve decompression. Chart review identified eight patients (one bilateral) who met study requirements. All eight patients were available for follow-up at a mean of 6.7 years and none underwent re-operation on the index hip during the follow-up period. Seven patients completed patient-reported outcome scores. The mean LEFS score was 81.1, and the mean SANE score was 74.9. The mean Marx activity score was 2.8, and the mean Custom Marx score was 23.3. Pain relief was excellent. The mean numeric pain score at rest was 0.6, while the mean numeric pain score with activity was 4.0. Treatment of chronic, recalcitrant proximal hamstring tendinopathy with surgical debridement and suture anchor repair without exploration of the sciatic nerve results in excellent pain relief, good function, and low re-operation risk. (Journal of Surgical Orthopaedic Advances 31(1):061-064, 2022).
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Affiliation(s)
- Sean Fitzpatrick
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; OSU Sports Medicine Research Institute, The Ohio State University Columbus, Ohio
| | - Benjamin Léger-St-Jean
- Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Est Montréal, Québec; Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Zylyftar Gorica
- Department of Orthopaedic Surgery, Virginia Commonwealth University Richmond, Virgina
| | - W Kelton Vasileff
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; OSU Sports Medicine Research Institute, The Ohio State University Columbus, Ohio
| | - Christopher C Kaeding
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; OSU Sports Medicine Research Institute, The Ohio State University Columbus, Ohio
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23
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Baria MR, Vasileff WK, Borchers J, DiBartola A, Flanigan DC, Plunkett E, Magnussen RA. Treating Knee Osteoarthritis With Platelet-Rich Plasma and Hyaluronic Acid Combination Therapy: A Systematic Review. Am J Sports Med 2022; 50:273-281. [PMID: 33831332 DOI: 10.1177/0363546521998010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect. PURPOSE To systematically review the clinical literature examining the combined use of PRP + HA. DESIGN Systematic review. METHODS A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs). RESULTS A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone. CONCLUSION Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.
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Affiliation(s)
- Michael R Baria
- Department of Physical Medicine and Rehabilitation, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - W Kelton Vasileff
- Department of Orthopaedics, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - James Borchers
- Department of Family Medicine, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Alex DiBartola
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - David C Flanigan
- Department of Orthopaedics, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Evan Plunkett
- Department of Physical Medicine and Rehabilitation, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Robert A Magnussen
- Department of Orthopaedics, Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
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24
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DiBartola AC, Magnussen RA, Wiet M, Everhart JS, Emery CF, Schmitt L, Flanigan DC. Predictors of poor pre-operative psychological status among patients with cartilage defects. Knee 2021; 33:11-16. [PMID: 34537536 DOI: 10.1016/j.knee.2021.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/02/2021] [Accepted: 08/25/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND We evaluated the risk factors for pain catastrophizing, kinesiophobia, and elevated depressive symptoms among patients undergoing high-grade cartilage defect surgery. We hypothesized that cartilage patients would demonstrate high scores on pain catastrophizing, kinesiophobia, and depression testing prior to surgery. METHODS Two hundred and ten patients undergoing surgery for high-grade cartilage defects (56% chondroplasty, 36% microfracture, 22% autologous chondrocyte implantation) completed a preoperative survey before undergoing surgery. Outcome scores assessed were: International Knee Documentation Committee-Symptom (IKDC-S) score, Tegner activity score, Pain catastrophizing scale (PCS), Tampa scale for kinesiophobia (TSK-11), and Patient Health Questionnaire depression scale (PHQ-9). Multivariate logistic regression was used to determine what pre-operative factors predicted pain catastrophizing, kinesiophobia, and elevated depressive symptoms. RESULTS The mean pre-operative Tegner score was 5.8 (SD 2.4) and IKDC-S score was 44.7 (SD 11.1). Prior to surgery, 19% had abnormal pain catastrophizing (PCS ≥ 20 points), 14.4% had moderate-severe depression (PHQ ≥ 10), and 49.0% had high kinesiophobia (TSK-11 ≥ 25). Lower pre-operative Tegner scores predicted moderate-severe depressive symptoms (per point decrease, OR 1.36, 95% CI 1.06, 1.76; p = 0.008). Predictors of elevated pain catastrophizing were lower pre-operative IKDC-S scores (per 5-point decrease, OR 1.28, 95% CI 1.08, 1.51; p = 0.002) and symptom duration >6 months (OR 2.20 CI 1.14, 4.32; p = 0.02). A lower pre-operative IKDC-S score (per 5-point decrease, OR 1.17, CI 1.03, 1.33; p = 0.02) predicted elevated kinesiophobia. CONCLUSION Low self-reported function, low activity level and symptom duration greater than six months are associated with poor preoperative psychological status.
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Affiliation(s)
- Alex C DiBartola
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Robert A Magnussen
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, OH, United States; Department of Orthopaedics, Sports Medicine, Ohio State University, Wexner Medical Center, United States
| | - Matthew Wiet
- The Ohio State University College of Medicine, Ohio State University, Wexner Medical Center, United States
| | | | - Charles F Emery
- Department of Psychology, Ohio State University, Columbus, OH, United States
| | - Laura Schmitt
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, Ohio State University and Jameson Crane Sports Medicine Research Institute, Ohio State University, United States
| | - David C Flanigan
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, OH, United States; Department of Orthopaedics, Sports Medicine, Ohio State University, Wexner Medical Center, United States; Cartilage Restoration Program, Ohio State University, Wexner Medical Center, United States.
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25
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Abstract
We reviewed the literature regarding utility of biologic augmentation in meniscal repair. We hypothesized that the addition of biologic augmentation during meniscal repair improves postoperative knee function and reduces risk of repair failure. PubMed and Embase databases were systematically searched. Included studies were clinical studies in humans, published in English, and reported use of biologic augmentation techniques in addition to meniscal repair (including platelet-rich plasma [PRP], fibrin clot, bone marrow stimulation, meniscal wrapping, and bioscaffolds) for treatment of knee meniscal tears. Outcome measures included repair failure, repeat knee arthroscopic surgery, and magnetic resonance imaging), visual analog scale for pain, the International Knee Documentation Committee questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index Lysholm's Knee Scoring Scale, and the Knee Injury and Osteoarthritis Outcome Score. Study quality was assessed using the modified Coleman methodology score. Nineteen studies reported repair of 1,092 menisci including six studies that investigated fibrin clot augmentation, five studies that investigated PRP augmentation, three studies that investigated bone marrow stimulation augmentation, two studies that used meniscal wrapping augmentation, and three studies that used other techniques. The level of evidence ranged from I to IV and mean modified Coleman methodology score was 43 (range: 17-69), with higher scores noted in studies completed in recent years. PRP and bone marrow stimulation augmentation appear to decrease risk of failure in patients undergoing isolated meniscal repair but do not improve knee symptom scores. Fibrin clot and trephination augmentation techniques do not have sufficient evidence to support decreased failure risk at this time. Meniscal wrapping augmentation and scaffold implantation augmentation appear to be an attractive option to meniscectomy in complicated tears that are not candidates for repair alone, but further confirmatory studies are needed to support initial data. Evidence supporting augmentation of meniscal repair is limited at this time but suggests that the highest likelihood for effectiveness of augmentation is in the settings of isolated meniscal repair or meniscal repairs that would normally not be amenable to repair.
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Affiliation(s)
- Christian L Blough
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Alex C DiBartola
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua S Everhart
- Sports Medicine, Department of Orthopaedic Surgery, Indiana University, Indianapolis, Indiana
| | - Robert A Magnussen
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio.,Sports Medicine, The Ohio State University, Columbus, Ohio
| | - Christopher Kaeding
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio.,Sports Medicine, The Ohio State University, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio.,Sports Medicine, The Ohio State University, Columbus, Ohio.,Cartilage Restoration Program, The Ohio State University, Columbus, Ohio
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26
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Arnold MP, Calcei JG, Vogel N, Magnussen RA, Clatworthy M, Spalding T, Campbell JD, Bergfeld JA, Sherman SL. ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades. Knee Surg Sports Traumatol Arthrosc 2021; 29:3871-3876. [PMID: 33486558 DOI: 10.1007/s00167-021-06443-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/11/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Anterior cruciate ligament reconstruction (ACLR) aims to restore knee function and stability, allowing patients to return to the activities they enjoy and minimize further injury to the meniscus and cartilage and their ultimate progression to osteoarthritis. This study aims to present the evolution of graft choice over the last three decades according to members of the ACL Study Group (SG). METHODS Prior to the January 2020 ACL SG biannual meeting, a survey was administered consisting of 87 questions and 16 categories, including ACLR graft choice. A similar questionnaire has been administered prior to each meeting and survey results from the past 14 meetings (1992 through 2020, excluding 1994) are included in this work. Survey responses are reported as frequencies in percentages to quantify changes in practice over the surgery period. RESULTS In 1992, the most frequent graft choice for primary ACLR was bone-patellar tendon-bone (BTB) autograft, at nearly 90%. Hamstring tendon (HT) autografts have increased in popularity, currently over 50%, followed by just under 40% BTB autograft. Recently, quadriceps tendon (QT) autograft has increased in popularity since 2014. CONCLUSION Autograft (HT, BTB, QT) is an overwhelming favorite for primary ACLR over allograft. The preference for HT autograft increased over the study period relative to BTB autograft, with QT autograft gaining in popularity in recent years. Graft selection should be individualized for each patient and understanding the global trends in graft choice can help orthopaedic surgeons discuss graft options with their patients and determine the appropriate graft for each case. LEVEL OF EVIDENCE Level V, Expert Opinion.
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Affiliation(s)
- Markus P Arnold
- Practice LEONARDO, Hirslanden Clinic Birshof, Münchenstein, Switzerland
| | - Jacob G Calcei
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
| | - Nicole Vogel
- Practice LEONARDO, Hirslanden Clinic Birshof, Münchenstein, Switzerland
| | - Robert A Magnussen
- Department of Orthopaedic Surgery, The Ohio State University, Columbus, OH, USA
| | - Mark Clatworthy
- Department of Orthopaedics, Middlemore Hospital, Otahuhu, Auckland, New Zealand
| | - Tim Spalding
- Department of Orthopaedics, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - John D Campbell
- Bridger Orthopedics and Sports Medicine, PC, Montana State University, Bozeman, MT, USA
| | - John A Bergfeld
- Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA, USA.
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27
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Sherman SL, Calcei J, Ray T, Magnussen RA, Musahl V, Kaeding CC, Clatworthy M, Bergfeld JA, Arnold MP. ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group. J ISAKOS 2021; 6:322-328. [PMID: 34272329 DOI: 10.1136/jisakos-2020-000567] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The primary objective of this survey was to gauge the current global trends in anterior cruciate ligament reconstruction (ACLR) as reported by the members of the Anterior Cruciate Ligament (ACL) Study Group (SG). METHODS A survey was created and distributed among the members of the ACL SG consisting of 87 questions and 16 categories related to ACLR, including member demographics, preoperative management, primary ACLR techniques and graft choice, use of concomitant procedures and biological augmentation, postoperative rehabilitation, and more. RESULTS The survey was completed by the 140 members of the ACL SG. Fifty per cent of members are from Europe, 29% from the USA, 15% from the Asia-Pacific and the remaining 6% are from Latin America, the Middle East, New Zealand and Africa. Most (92%) do not believe there is a role for non-operative management of ACL tears in higher level athletes; conversely, most agree there is a role for non-operative management in lower impact athletes (92%). A single-bundle (90%) technique with hamstring autograft (53%) were most common for primary ACLR. Tunnel position varied among respondents. Sixty-one per cent do not use allograft for primary ACLR. Fifty per cent of respondents use cortical suspensory fixation on the femur, with variable responses on the tibia. Most (79%) do not use biologics in primary ACLR, while 83% think there is a selective role for extra-articular augmentation in primary ACLR. Fifty per cent prefer bone-tendon-bone autograft for revision ACLR and extra-articular augmentation is more commonly used (13% always, 26% often) than in primary ACLR (0% always, 15% often). A majority (53%) use a brace after primary ACLR. The most common responses for minimal time to return to play after primary ACLR were 6-8 months (44%) and 8-12 months (41%). CONCLUSION We presented the thoughts and preferences of the ACL SG on the management of ACL injuries. This survey will help to facilitate an ongoing discussion with regard to ACLR by providing global insights into the current surgical trends in ACLR. LEVEL OF EVIDENCE Level V, Expert Opinion.
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Affiliation(s)
- Seth L Sherman
- Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Jacob Calcei
- Orthopaedic Surgery, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
| | - Taylor Ray
- Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | | | - Volker Musahl
- Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - John A Bergfeld
- Orthopaedic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Marcus P Arnold
- Orthopaedics, Practice LEONARDO, Hirslanden Clinic Birshot, Münchenstein, Switzerland
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Milliron EM, Magnussen RA, A Cavendish P, P Quinn J, DiBartola AC, Flanigan DC. Repair of Radial Meniscus Tears Results in Improved Patient-Reported Outcome Scores: A Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e967-e980. [PMID: 34195666 PMCID: PMC8220631 DOI: 10.1016/j.asmr.2021.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 03/04/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose To quantify healing rates and patient-reported outcome scores following repair of radial meniscus tears. Methods PubMed, Scopus, and Embase databases were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria included: human subjects with meniscal tears, full-text English language, average follow-up of at 1 year, and publication after the 2000. Exclusion criteria included technical, biomechanical, and cadaveric studies. Study quality was assessed using Coleman Methodology Scores and Methodological Index for Non-Randomized Studies (MINORS) criteria. Results Twelve studies reported on the repair of 243 radial tears in 241 patients. The mean Modified Coleman Methodology Score was 46.8, range 26-60, with a mean level of evidence of 3.5. Arthroscopic techniques were used in all studies, with 1 study using an arthroscopic-assisted 2-tunnel trans-tibial pullout technique. The mean patient age was 32 years (11-71). The mean follow-up was 35 months (12 to 75.6). The average time to surgery was 10.9 months (0.5-22.4). Eight of the 12 studies reported concomitant anterior cruciate ligament (ACL) reconstruction, with 64% having concomitant ACL injury. The most common outcome measure was the Lysholm score, which improved from 47-68.9 preoperatively to 86.4-95.6 postoperatively. Tegner Activity Scale improved from 2.5-3.1 preoperatively to 4.7-6.7 postoperatively. Healing rates were reported via magnetic resonance imaging and second-look arthroscopy. Second-look arthroscopy was performed for a variety of indications, including removal of screw, washers or plates, dissatisfaction with original procedure, partial healing found on magnetic resonance imaging, or desire of the patient to know the true healing status before return to sport. Of those assessed, 62.0% had complete healing, 30.0% partial healing, and 8.0% failure to heal. Conclusions Patient-reported outcomes of radial meniscus repair with and without ACL reconstruction are encouraging, with high patient-reported outcomes reported at final follow-up when compared with preoperative scores. Among all meniscus repairs assessed for healing, the majority demonstrated at least some healing with an overall low rate of failure. Level of Evidence IV; systematic review of level III-IV studies.
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Affiliation(s)
- Eric M Milliron
- College of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.,Sports Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Parker A Cavendish
- College of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - John P Quinn
- College of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Alex C DiBartola
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.,Sports Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.,Cartilage Restoration Program, Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
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Fabricant PD, Heath MR, Veerkamp M, Gruber S, Green DW, Strickland SM, Wall EJ, Mintz DN, Emery KH, Brady JM, Ellis HB, Farr J, Heyworth BE, Koh JL, Kramer D, Magnussen RA, Redler LH, Sherman SL, Tompkins M, Wilson PL, Shubin Stein BE, Parikh SN. Reliability of Radiologic Assessments of Clinically Relevant Growth Remaining in Knee MRI of Children and Adolescents With Patellofemoral Instability: Data From the JUPITER Cohort. Orthop J Sports Med 2021; 9:2325967121991110. [PMID: 33912616 PMCID: PMC8047867 DOI: 10.1177/2325967121991110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/09/2020] [Indexed: 11/16/2022] Open
Abstract
Background Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient's skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy. Purpose The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability. Results Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements). Conclusion Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable.
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Affiliation(s)
- Peter D Fabricant
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Madison R Heath
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Matthew Veerkamp
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Simone Gruber
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Daniel W Green
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Sabrina M Strickland
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Eric J Wall
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Douglas N Mintz
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Kathleen H Emery
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | - Jacqueline M Brady
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Henry B Ellis
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Jack Farr
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Benton E Heyworth
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Jason L Koh
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Dennis Kramer
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Robert A Magnussen
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Lauren H Redler
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Seth L Sherman
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Marc Tompkins
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Philip L Wilson
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Beth E Shubin Stein
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Shital N Parikh
- Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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30
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Everhart JS, Jones MH, Yalcin S, Reinke EK, Huston LJ, Andrish JT, Cox CL, Flanigan DC, Kaeding CC, Magnussen RA, Obuchowski N, Parker RD, Pedroza AD, Sanders RA, Winalski CS, Spindler KP. The Clinical Radiographic Incidence of Posttraumatic Osteoarthritis 10 Years After Anterior Cruciate Ligament Reconstruction: Data From the MOON Nested Cohort. Am J Sports Med 2021; 49:1251-1261. [PMID: 33793363 PMCID: PMC8375261 DOI: 10.1177/0363546521995182] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of posttraumatic osteoarthritis (PTOA) based on clinical radiographic grading criteria at 10 years after anterior cruciate ligament (ACL) reconstruction (ACLR) has not been well-defined in a prospective cohort of young athletic patients. HYPOTHESIS Among young athletic patients, there is a high incidence of clinical radiographic PTOA at 10 years after ACLR. Additionally, there is a significant difference in clinical radiographic osteoarthritis (OA) changes (joint space narrowing and osteophyte formation) between ACL-reconstructed and contralateral knees at 10 years. STUDY DESIGN Case series; Level of evidence, 4. METHODS The first 146 patients in an ongoing nested cohort study of the Multicenter Orthopaedic Outcomes Network (MOON) prospective cohort presented for a minimum 10-year follow-up. Included patients had a sports-related ACL injury, were aged <33 years at the time of ACLR, had no history of ipsilateral or contralateral knee surgery, and did not undergo revision ACLR before follow-up. Bilateral knee metatarsophalangeal view radiographs were obtained and graded according to International Knee Documentation Committee (IKDC), Osteoarthritis Research Society International (OARSI), and modified Kellgren-Lawrence (KL) criteria by 2 blinded reviewers. The incidence and severity of ipsilateral and contralateral radiographic OA were determined among patients without a contralateral ACL injury before 10-year follow-up (N = 133). RESULTS Interrater reliability was substantial for the IKDC (Gwet Agreement Coefficient [AC] 1 = 0.71), moderate for the KL (0.48), and almost perfect for the OARSI (0.84) grading systems. Among patients with a contralateral radiographically normal knee, the 10-year incidence of clinical radiographic PTOA after ACLR was 37% as defined by osteophytes and 23% as defined by joint space narrowing. The maximum side-to-side difference in the OARSI osteophyte grade in the medial or lateral compartment was 0 in 65% of patients, 1 in 20%, and ≥2 in 15%. The maximum side-to-side difference in the OARSI joint space narrowing grade was 0 in 77% of patients, 1 in 19%, and ≥2 in 4%. CONCLUSION In young active patients, the 10-year incidence of clinical radiographic PTOA after ACLR was 37% as defined by osteophytes and 23% as defined by joint space narrowing. The mean difference in the degree of osteophyte formation (≤1 grade in 85%) and joint space narrowing (≤1 grade in 96%) between the ACL-reconstructed and contralateral knees was small. REGISTRATION NCT02717559 (ClinicalTrials.gov identifier).
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Affiliation(s)
| | - Josh S. Everhart
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Morgan H. Jones
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Sercan Yalcin
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Emily K. Reinke
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura J. Huston
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Jack T. Andrish
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles L. Cox
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - David C. Flanigan
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Nancy Obuchowski
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard D. Parker
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Angela D. Pedroza
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Carl S. Winalski
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt P. Spindler
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
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Colatruglio M, Flanigan DC, Long J, DiBartola AC, Magnussen RA. Outcomes of 1- Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:798-804. [PMID: 32673067 DOI: 10.1177/0363546520923090] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is a common orthopaedic sports medicine procedure, but graft failure is not uncommon and often leads to revision ACLR. Revision surgery can be performed in a 1- or 2-stage fashion. HYPOTHESIS Graft failure risk, patient-reported outcomes, and anterior knee laxity are similar after 1- and 2-stage revision ACLR. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of the literature was performed to evaluate patient outcomes after 1- versus 2-stage revision ACLR. A search was performed with the phrase "revision anterior cruciate ligament reconstruction" across Embase, PubMed, Scopus, and SportDiscus from the beginning of their archives through July 12, 2019. RESULTS Thirteen studies met inclusion criteria and included 524 patients: 319 patients who underwent 1-stage revision ACLR and 205 patients who underwent 2-stage revision ACLR. Two studies compared outcomes of 1- versus 2-stage revision ACLR; 4 studies reported outcomes after 2-stage revision ACLR; and the remaining 7 studies documented outcomes after 1-stage ACLR. The mean follow-up was 4.1 years. The 2 studies that compared 1- versus 2-stage ACLR reported no differences in functional, radiologic, or patient-reported outcomes or failure risk. Overall, 9 studies reported subjective International Knee Documentation Committee (IKDC) scores; 4 studies, Knee injury and Osteoarthritis Outcome Score values; 8 studies, Lysholm scores; and 7 studies, Tegner scores; 8 studies measured anterior laxity with a KT-1000 arthrometer. The mean weighted subjective IKDC score for all studies including this outcome at final follow-up was 66.6 for 1-stage revisions and 65.9 for 2-stage revisions. CONCLUSION The available evidence comparing 1- versus 2-stage revision ACLR is retrospective and limited. The results of each approach are similar in appropriately selected patients.
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Affiliation(s)
- Matthew Colatruglio
- OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - David C Flanigan
- OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joseph Long
- OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Alex C DiBartola
- OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert A Magnussen
- OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Brown CR, Ghenbot S, Magnussen RA, Harangody S, Flanigan DC, Miller TL. Unplanned Emergency Visits and Admissions After Orthopaedic Ambulatory Surgery in the First 2 Years of Operation of a University Ambulatory Surgery Center. Am J Sports Med 2021; 49:505-511. [PMID: 33332176 DOI: 10.1177/0363546520976626] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ambulatory surgeries have increased in recent decades to help improve efficiency and cost; however, there is a potential need for unplanned postoperative admission, clinic visits, or evaluation in the emergency department (ED). PURPOSE/HYPOTHESIS The purpose was to determine the frequency, reasons, and factors influencing hospitalizations, return to clinic, and/or ED encounters within 24 hours of ambulatory surgery. The time frame for data collection was the first 2 years of operation of a university sports medicine ambulatory surgery center (ASC). We hypothesized that the percentage of encounters would be low and primarily because of pain or postoperative complication. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A retrospective review was performed of all patients undergoing ambulatory surgery at an ASC during the first 2 years of its operation (November 2016 to October 2018). Data including age, sex, Current Procedural Terminology code, procedure performed, American Society of Anesthesiologists classification, body mass index, medical history, and tobacco use were collected. Patients seeking care in the ED, inpatient, or outpatient setting within the first 24 hours after surgery were identified and the reasons for these encounters were categorized into 1 of 3 groups: (1) medical complication, (2) postoperative pain, or (3) other postoperative complication. Logistic regression models were used to assess risk factors for these encounters. RESULTS A total of 4650 sports medicine procedures were performed at the university ASC during the study period. A total of 35 patients (0.75%) sought additional care within 24 hours of surgery. Medical complications were the primary reason for seeking care (n = 16; 45.7%). Patients who sought treatment within 24 hours of surgery tended to be older, had more medical comorbidities, and were more likely to have undergone upper extremity (particularly shoulder) procedures. In the multivariable analysis, patients with higher ASA scores were more likely to seek additional care (P < .005) and there was a trend toward increased risk of seeking additional care with upper extremity surgery (P = .077). CONCLUSION Orthopaedic procedures performed in an ASC result in a relatively low percentage of patients seeking additional care within the first 24 hours after surgery, consistent with other reports in the literature. Upper extremity procedures, particularly those of the shoulder, may carry an increased risk of requiring medical treatment within 24 hours of surgery. Even in the first 2 years of operation of a university-based ASC, low rates of postoperative complications and unplanned admissions can be maintained.
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Affiliation(s)
- Chelsea R Brown
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sennay Ghenbot
- College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sarah Harangody
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Timothy L Miller
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Vajapey S, Ghenbot S, Baria MR, Magnussen RA, Vasileff WK. Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review. Sports Health 2020; 13:258-264. [PMID: 33252310 DOI: 10.1177/1941738120951764] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results. OBJECTIVE To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure. DATA SOURCES PubMed, MEDLINE, EMBASE, and Google Scholar. STUDY SELECTION The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected. RESULTS There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking. CONCLUSION PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.
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Affiliation(s)
- Sravya Vajapey
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Sennay Ghenbot
- The Ohio State University School of Medicine, Columbus, Ohio
| | - Michael R Baria
- Department of Physical Medicine & Rehabilitation, The Ohio State University, Columbus, Ohio
| | - Robert A Magnussen
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - W Kelton Vasileff
- Sports Medicine Research Institute, Department of Orthopaedics, The Ohio State University, Columbus, Ohio
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Everhart JS, Magnussen RA, Abouljoud MM, Regalado LE, Kaeding CC, Flanigan DC. Meniscus tears accelerate joint space loss and lateral meniscal extrusion increases risk of knee arthroplasty in middle-aged adults. J Orthop Res 2020; 38:2495-2504. [PMID: 32221990 DOI: 10.1002/jor.24672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 02/04/2023]
Abstract
We sought to use publicly available data from the Osteoarthritis Initiative (OAI), a multicenter prospective cohort study, to determine the rate of joint space loss and likelihood of knee arthroplasty due to magnetic resonance imaging (MRI)-diagnosed meniscal tears or meniscal extrusion in middle-aged adults with no to mild knee osteoarthritis. Participants (n = 2199; mean age, 60.2 years) with Kellgren-Lawrence osteoarthritis grades 2 (mild) (48.7%) or 0 to 1 (none) (51.3%) underwent knee MRIs at enrollment and were followed radiographically for 8 years and for total knee arthroplasty (TKA) for 9 years. Rate of joint space loss and risk of arthroplasty due to meniscal tears and/or extrusion were determined by multivariate modeling. Prevalence of baseline medial meniscus tears was 21.3% and lateral tears was 12.8%; 26.9% had medial meniscal extrusion (79.6%, <2 mm; 20.4%, +2 mm) and 5.4% had lateral extrusion (75.9%, <2 mm; 24.1%, +2 mm). Median medial joint space loss was 0.06 mm/y and lateral was 0.05 mm/y. Medial tears regardless of extrusion were associated with accelerated medial joint space loss (additional mean, 0.05 mm/y; P = .001). Lateral tears were associated with accelerated lateral joint space loss (additional 0.09 mm/y; P < .001) as was lateral extrusion (additional 0.10 mm/y; P < .001). The yearly incidence of knee arthroplasty was 0.5% without lateral extrusion, 1.5% with extrusion less than 2.0 mm, and 3.7% with extrusion greater than or equal to 2.0 mm. Both medial and lateral tears accelerate joint space loss in middle-aged adults. Lateral meniscal extrusion further accelerates joint space loss and increases risk of progression to TKA within 9 years.
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Affiliation(s)
- Joshua S Everhart
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Moneer M Abouljoud
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Luis E Regalado
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christopher C Kaeding
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Duerr RA, Harangody S, Magnussen RA, Kaeding CC, Flanigan DC. Technique for Biplanar Lateral Opening Wedge Distal Femoral Osteotomy in the Valgus Knee. Arthrosc Tech 2020; 9:e1323-e1333. [PMID: 33024673 PMCID: PMC7528581 DOI: 10.1016/j.eats.2020.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/24/2020] [Indexed: 02/03/2023] Open
Abstract
Valgus malalignment can be corrected with a biplanar lateral opening wedge distal femoral osteotomy (bLOWDFO) in patients with symptomatic lateral compartment disease. Advantages of a lateral opening wedge technique over the medial closing wedge technique include avoidance of vascular structures and theoretically better control of the amount of correction. The advantages of a bLOWDFO over a uniplanar osteotomy are that it creates a larger surface area for healing, and provides inherent stability to control the osteotomy intraoperatively. The purpose of this article is to present a reproducible technique for bLOWDFO and review the indications, preoperative planning, rationale, and clinical outcomes.
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Affiliation(s)
- Robert A. Duerr
- Address correspondence to Robert A. Duerr, M.D., Department of Orthopedic Surgery, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202 U.S.A.
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Morris JH, Magnussen RA, DiBartola AC, Aldabbeh S, Duerr RA, Kaeding CC, Flanigan DC. Patient Outcomes After Horizontal Cleavage Tear Repair: A Systematic Review. Arthroscopy 2020; 36:2316-2331. [PMID: 32360266 DOI: 10.1016/j.arthro.2020.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the clinical outcomes and survivorship of meniscal horizontal cleavage tear (HCT) repairs with hopes of guiding future treatment decisions. METHODS Standard systematic review methodology was used. A comprehensive search of PubMed was conducted on June 1, 2019. The inclusion criteria were articles that were published in English, involved human subjects, and reported on at least 1 outcome after repair of HCTs. The exclusion criteria included technique guides and reviews, studies without full text available, and studies with HCT outcomes not separated from other repair groups. Effect heterogeneity was determined using the I2 measure. Forest plots were created in addition to a random-effects model to show the results. RESULTS The systematic review yielded 19 studies evaluating 289 knees in a total of 273 patients. At most recent follow-up, there was a high probability of return to sport (93.1% [67 of 72]). Overall, 74% of patients (67 of 90) were symptom free at last follow-up, and 80% expressed satisfaction with their overall result (80 of 100). The most frequently reported subjective outcome was the Lysholm score, which improved from a preoperative study range of 48 to 79 (I2 = 20.7%, P = .283) to a postoperative study range of 56 to 99 (I2 = 49%, P = .081). The next most commonly reported was the International Knee Documentation Committee subjective score, which improved from a preoperative study range of 16 to 49 (I2 = 47.7%, P = .125) to a postoperative study range of 72 to 95 (I2 = 0%, P = .660). An overall 11.7% reported risk of reoperation was found, with most cases involving revision meniscectomy. Rates of complications beyond fixation failure were overall very low, with infrequent reports of septic arthritis and transitory dysesthesia. CONCLUSIONS The short- to intermediate-term results of repair of HCTs are comparable to prior studies. Survivorship is comparable to repairs of other types of meniscal tears with high rates of return to sport and low complication rates. LEVEL OF EVIDENCE Level IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Jesse H Morris
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedic Surgery and Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Alex C DiBartola
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Summer Aldabbeh
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A Duerr
- Department of Orthopaedic Surgery and Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Christopher C Kaeding
- Department of Orthopaedic Surgery and Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedic Surgery and Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.; Cartilage Restoration Program, Columbus, Ohio, U.S.A..
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Flanigan DC, Shemory S, Lundy N, Stitgen M, Long JM, Magnussen RA. Medial patellofemoral ligament reconstruction with allograft versus autograft tissue results in similar recurrent dislocation risk and patient-reported outcomes. Knee Surg Sports Traumatol Arthrosc 2020; 28:2099-2104. [PMID: 32185451 DOI: 10.1007/s00167-020-05920-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/24/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE To determine the rate of recurrent dislocation and patellar instability following medial patellofemoral ligament (MPFL) reconstruction with allograft or autograft tissue and compare patient-reported outcomes for patients undergoing allograft and autograft MPFL reconstruction. METHODS One hundred and fifteen MPFL reconstructions (78 allograft, 37 autograft) without concurrent bony procedures performed between 2008 and 2014 by four sports medicine fellowship-trained orthopedic surgeons at our center were identified. Patient demographics and surgical data were identified by chart review. Chart review and patient interviews were undertaken to identify recurrent patellar dislocations and as recurrent subjective patellofemoral instability. Recurrent dislocation and subjective instability risk were compared between the allograft and autograft groups. RESULTS Eighty-seven patients (76%) with complete baseline data and minimum 1-year follow-up were contacted at a mean of 4.1 years following isolated MPFL reconstruction, including 57 patient with allograft reconstructions and 30 with autograft reconstructions. No significant differences in patient sex, age at reconstruction, body mass index, or time to follow-up were noted between groups. Recurrent dislocation occurred in 2 patients in the allograft group (3.5%) and 1 patient in the autograft group (3.3%), (n.s.). Recurrent subjective instability occurred in 17 patients in the allograft group (28.9%) and 11 patients in the autograft group (36.7%), (n.s.). No significant differences in patient-reported outcomes were noted between groups. CONCLUSION The use of either allograft or autograft tissue for MPFL reconstruction results in low (< 3%) risk of recurrent patellar dislocation. Risk of recurrent subjective instability is higher but is similar for both graft types. Surgeons can utilize either graft choice at their discretion without anticipating a significant impact of graft choice on patient outcomes. LEVEL OF EVIDENCE III.
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Affiliation(s)
- David C Flanigan
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Scott Shemory
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Nathaniel Lundy
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Michael Stitgen
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Joseph M Long
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA.
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.
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Duerr RA, Harangody S, Magnussen RA, Kaeding CC, Flanigan DC. Technique for Medial Closing-Wedge Proximal Tibia Osteotomy in the Valgus Knee. Arthrosc Tech 2020; 9:e925-e933. [PMID: 32714800 PMCID: PMC7372308 DOI: 10.1016/j.eats.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/14/2020] [Indexed: 02/03/2023] Open
Abstract
Valgus malalignment can be corrected with a medial closing-wedge proximal tibia osteotomy in patients with symptomatic lateral compartment disease. Advantages of this technique include the inherent stability of the closing wedge with direct bone contact and reliable healing that enables early weight bearing and shorter recovery time. In addition, a tibial-based osteotomy alters joint contact forces in both flexion and extension versus femoral-based osteotomies. The purpose of this article is to present a reproducible technique for medial closing-wedge proximal tibia osteotomy and review the indications, preoperative planning, rationale, and clinical outcomes.
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Affiliation(s)
- Robert A. Duerr
- Address correspondence to Robert A. Duerr, M.D., Jameson Crane Sports Medicine Institute, Department of Orthopaedics, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr., Columbus, OH 43202.
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Colatruglio M, Flanigan DC, Harangody S, Duerr RA, Kaeding CC, Magnussen RA. Identifying Patients With Patella Alta and/or Severe Trochlear Dysplasia Through the Presence of Patellar Apprehension in Higher Degrees of Flexion. Orthop J Sports Med 2020; 8:2325967120925486. [PMID: 32528996 PMCID: PMC7265191 DOI: 10.1177/2325967120925486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Recurrent patellar instability is frequently treated surgically with reconstruction of the medial patellofemoral ligament (MPFL). Patients with significant patella alta, trochlear dysplasia, and/or an elevated tibial tubercle–trochlear groove (TT-TG) distance may benefit from a concurrent bony procedure such as tibial tubercle osteotomy or trochleoplasty. The indications to perform such procedures are traditionally based on imaging criteria but remain controversial. Patellar apprehension is common in patients with patellar instability but typically resolves in higher degrees of knee flexion. Hypothesis: The persistence of patellar apprehension at greater than 60° of knee flexion is associated with patella alta, an increased TT-TG distance, and trochlear dysplasia. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 76 patients with recurrent patellar instability were prospectively identified in a sports medicine clinic. Patellar apprehension was evaluated in each patient. Apprehension was defined as the patient reporting that the patella felt unstable to lateral patellar translation. Apprehension was first assessed at full knee extension and repeatedly assessed as the knee was flexed in 10° intervals, as measured using a goniometer. The degree of flexion at which patellar apprehension disappeared was recorded. Plain radiographs and magnetic resonance imaging (MRI) scans were obtained for all patients. Patellar height was assessed with the Caton-Deschamps (CD) index, and trochlear morphology was assessed through measurements of the sulcus angle and depth on MRI and classified using the Dejour classification system. Imaging measurements of patients in whom apprehension resolved by 60° of knee flexion were compared with measurements for those with apprehension that persisted deeper into flexion. Results: Apprehension resolved by 60° of flexion in 56 patients and persisted into deeper flexion in 20 patients. The patients with a delayed resolution of apprehension demonstrated a higher CD index; elevated TT-TG distance; increased sulcus angle; decreased sulcus depth; and higher incidence of Dejour type B, C, or D dysplasia (all P < .05). Of the 20 patients with a delayed resolution of apprehension, 18 had either Dejour type B, C, or D dysplasia or a CD index of at least 1.30. A delayed resolution of apprehension was present in 11 of the 16 patients with Dejour type B, C, or D dysplasia. Conclusion: Overall, 90% of patients with significant patella alta and the majority of patients with high-grade trochlear dysplasia demonstrated patellar apprehension that persisted beyond 60° of knee flexion. Additionally, 90% of patients with persistent apprehension had significant patella alta and/or trochlear dysplasia. Further work is needed to evaluate the utility of these findings to inform surgical decision-making in this population.
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Affiliation(s)
- Matthew Colatruglio
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David C. Flanigan
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sarah Harangody
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert A. Duerr
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher C. Kaeding
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert A. Magnussen
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Robert A. Magnussen, MD, MPH, Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202, USA ()
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Castoldi M, Magnussen RA, Gunst S, Batailler C, Neyret P, Lustig S, Servien E. A Randomized Controlled Trial of Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction With and Without Lateral Extra-articular Tenodesis: 19-Year Clinical and Radiological Follow-up. Am J Sports Med 2020; 48:1665-1672. [PMID: 32368935 DOI: 10.1177/0363546520914936] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone-patellar tendon-bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients. PURPOSE The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire). RESULTS Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups (P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy. CONCLUSION There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.
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Affiliation(s)
- Marie Castoldi
- Institut Universitaire Locomoteur et du Sport, Department of Orthopaedic Surgery, Centre Hospitalo-Universitaire de Nice, Nice, France
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stanislas Gunst
- Department of Orthopedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence, Lyon, France
| | - Cécile Batailler
- Department of Orthopedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence, Lyon, France
| | | | - Sébastien Lustig
- Department of Orthopedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence, Lyon, France
| | - Elvire Servien
- Department of Orthopedic Surgery and Sport Medicine, Croix-Rousse Hospital, FIFA Medical Center of Excellence, Lyon, France.,EA 7424-Inter-university Laboratory of Human Movement Science, University Lyon 1, Lyon, France
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DiBartola AC, Magnussen RA, Flanigan DC. Editorial Commentary: Anterior Cruciate Ligament Autograft Morbidity: Who Needs Strong Hamstrings in Greater Than 90° of Knee Flexion? Arthroscopy 2020; 36:1417-1418. [PMID: 32370903 DOI: 10.1016/j.arthro.2020.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 02/02/2023]
Abstract
An understanding of expected morbidity of various anterior cruciate ligament graft options is important to inform patient expectations and facilitate successful return to sport following anterior cruciate ligament reconstruction. Hamstring harvest results in decreased hamstring strength. Gracilis preservation may mitigate the degree of strength loss, particularly in deep knee flexion. The extent to which knee flexion strength at high flexion angles is important to return to play and functional outcomes remains unknown and is likely sport-dependent.
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Magnussen RA. Editorial Commentary: So Your Knee Has a Big Pivot Shift Before Anterior Cruciate Ligament Surgery-Why Does that Matter??? Arthroscopy 2020; 36:1407-1408. [PMID: 32370902 DOI: 10.1016/j.arthro.2020.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 02/02/2023]
Abstract
Control of anterolateral knee laxity has always been a major goal of anterior cruciate ligament (ACL) reconstruction. The recent focus on the anatomy of the anterolateral knee and new studies demonstrating decreased graft failure risk with the additional of lateral procedures to intra-articular ACL reconstruction have given these procedures new relevance. A key question that drives indications is which patients benefit the most from these procedures. Those patients with increased rotational knee laxity, particularly in the absence of a repairable meniscus injury, may be good candidates. ACL injury chronicity, bony anatomy, concomitant anterolateral injury, and other factors all contribute to increased anterolateral knee laxity. This high laxity population is ideal for evaluation of the effectiveness of new methods to control knee laxity and improve outcomes of isolated intra-articular ACL reconstruction.
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Everhart JS, Magnussen RA, Cavendish PA, Axcell K, Blackwell R, Kaeding CC, Flanigan DC. Subjective Knee Function and Risk of Failure Are Equivalent for Men and Women at 5 Years After Meniscus Repair. Arthroscopy 2020; 36:816-822. [PMID: 31919022 DOI: 10.1016/j.arthro.2019.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether subjective knee function or risk of repair failure differ between men and women at mean 5 years following meniscal repair with or without concomitant anterior cruciate ligament reconstruction. METHODS A total of 235 patients (97 women, 138 men; mean age, 29.1 years; standard deviation, 11.3) were assessed for meniscus repair failure and postoperative knee function at mean 5.8 years follow-up. Knee symptoms were assessed with International Knee Documentation Committee Subjective (IKDC-S) scores. Postoperative activity scores were assessed with Marx activity score. Independent effects of patient age and activity level on meniscus failure risk and patient-reported outcomes were determined by multivariate analysis with adjustment for age, body mass index, anterior cruciate ligament status, tear pattern, and number of implants used at the time of surgery. RESULTS Failures occurred in 18.9% of men and 21.0% of women with no difference in mean time to failure (P = .75) or risk of failure for men vs women (P = .57) in the univariate analysis. Male sex was not an independent risk factor for failure after adjustment for patient age, body mass index, concomitant anterior cruciate ligament status, tear pattern, or number of implants used (P = .16). Marx activity scores at follow-up were higher among men in multivariate analysis (P = .009). Men and women had similar IKDC-S scores at follow-up in the unadjusted (P = .25) and multivariate analyses (P = .21). CONCLUSIONS Following meniscus repair, both sexes report similar subjective knee function, though men have higher self-reported activity scores. Meniscus repair failure risk does not differ between men or women at mid-term follow up. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Joshua S Everhart
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Parker A Cavendish
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Kent Axcell
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Ryan Blackwell
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Christopher C Kaeding
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.
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Hamilton C, Flanigan DC, Patel KH, Lundy N, Blackwell R, Magnussen RA. Meniscus repair failure risk does not differ by sex: a systematic review. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Everhart JS, Magnussen RA, Poland S, DiBartola AC, Blackwell R, Kim W, Kaeding CC, Flanigan DC. Meniscus repair five-year results are influenced by patient pre-injury activity level but not age group. Knee 2020; 27:157-164. [PMID: 31806508 DOI: 10.1016/j.knee.2019.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/09/2019] [Accepted: 11/10/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of the study is to determine whether patient age group (≥40 years versus <40 years) and pre-injury activity level are independently predictive of symptomatic failure rates and patient-reported outcomes after meniscus repair with or without concomitant anterior cruciate ligament reconstruction (ACLR) at mean five years of follow-up. METHODS Two hundred and twenty-five patients (n = 61, age ≥40 years; n = 164, age <40; 11% sedentary, 63% recreational athletes, 26% competitive athletes; 72% cutting-pivoting sports, 28% non-cutting or non-pivoting sports) who underwent meniscal repair were assessed for symptomatic failure and subjective knee function at mean 5.4 years of follow-up. Symptoms were assessed with Knee Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective (IKDC-S) scores. RESULTS Repair failure was 20% overall with no association with age group (<40 vs. ≥40 years) or level of activity. When compared with sedentary patients, IKDC-S scores were not associated with age group but were lower among sedentary patients (mean: 59.6, SE: 4.9) compared with recreational (mean: 78.9, SE: 2.5; p = 0.007) or competitive athletes (mean: 79.2, SE: 3.8; p = 0.02). KOOS-ADL scores were independently associated with age and were higher among patients <40 years. KOOS-pain, KOOS-sport, or KOOS-QOL were not associated with age group. Sedentary status was independently associated with lower KOOS scores for all sub-scores. CONCLUSIONS Meniscal repair failure rates and patient-reported outcomes do not differ substantially between older or younger patients of similar pre-injury activity level. Sedentary patients regardless of age have worse self-reported subjective outcomes compared with active patients.
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Affiliation(s)
- Joshua S Everhart
- The Ohio State University Wexner Medical Center, United States of America
| | - Robert A Magnussen
- The Ohio State University Wexner Medical Center, United States of America
| | - Sarah Poland
- The Ohio State University Wexner Medical Center, United States of America
| | - Alex C DiBartola
- The Ohio State University Wexner Medical Center, United States of America
| | - Ryan Blackwell
- The Ohio State University Wexner Medical Center, United States of America
| | - Walter Kim
- The Ohio State University Wexner Medical Center, United States of America
| | | | - David C Flanigan
- The Ohio State University Wexner Medical Center, United States of America.
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Flanigan DC, Everhart JS, DiBartola AC, Dusane DH, Abouljoud MM, Magnussen RA, Kaeding CC, Stoodley P. Bacterial DNA is associated with tunnel widening in failed ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 2019; 27:3490-3497. [PMID: 30810788 DOI: 10.1007/s00167-019-05405-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 02/06/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE To determine if tunnel widening, defined as change in maximal tunnel diameter from the time of initial bone tunnel drilling to revision surgery is associated with bacterial deoxyribonucleic acid (DNA) presence and concentration in torn graft tissue from failed anterior cruciate ligament reconstructions (ACLRs). METHODS Thirty-four consecutive revision ACLRs were included (mean age 27.3 years SD 10.9; median time to failure 4.9 years range 105 days-20 years). Graft selection of the failed reconstruction was 68% autograft, 26% allograft, and 6% autograft/allograft hybrid with a mean drilled tunnel diameter of 8.4 mm SD 0.8. Maximal tunnel diameters prior to revision were measured on pre-operative three-dimensional imaging and compared to drilled tunnel diameters at the time of the previous reconstruction. Tissue biopsies of the failed graft were obtained from tibial, femoral, and intraarticular segments. Sterile water left open to air during revision ACLRs and tissue from primary ACLRs were used as negative controls. Clinical cultures were obtained on all revision ACLRs and PCR with universal bacterial primer on all cases and negative controls. Fluorescence microscopy was used to confirm the presence and location of biofilms in two patients with retrieved torn graft tissue and fixation material. Amount of tunnel widening was compared to bacterial DNA presence as well as bacterial DNA concentration via Welch ANOVA. RESULTS Bacterial DNA was present in 29/34 (85%) revision ACLRs, 1/5 (20%) of primary ACLR controls and 0/3 (0%) sterile water controls. Cultures were positive (coagulase negative Staphylococcus sp.) in one case, which also had the greatest degree of tunnel widening. Femoral widening was greater in cases with detectable bacterial DNA (mean widening 2.6 mm SD 3.0) versus without (mean 0.3 mm SD 0.6) (p = 0.003) but was unaffected by bacterial DNA concentration (p = 0.44). Tibial widening was not associated with the presence of bacterial DNA (n.s.); however, higher bacterial DNA concentrations were observed in cases with tibial widening ≥ 3.0 mm (median 2.47 ng bacterial DNA/µg total DNA) versus widening < 3.0 mm (median 0.97 ng bacterial DNA/µg total DNA) (p = 0.046). Tunnel widening was not associated with time to failure, graft selection, or number of prior surgeries (n.s., all comparisons). Fluorescence microscopy confirmed the presence of biofilms on ruptured tendon graft as well as fixation material in 2/2 cases. CONCLUSION Bacterial DNA is commonly encountered on failed ACLR grafts and can form biofilms. Bacterial DNA does not cause clinically apparent infection symptoms but is associated with tunnel widening. Further research is needed to determine whether graft decontamination protocols can reduce graft bacterial colonization rates, ACLR tunnel widening or ACLR failure risk. LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA. .,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.
| | - Joshua S Everhart
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Alex C DiBartola
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Devendra H Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, USA
| | - Moneer M Abouljoud
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Christopher C Kaeding
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Paul Stoodley
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA.,Department of Microbial Infection and Immunity, The Ohio State University, Columbus, USA.,National Centre for Advanced Tribology, Department of Mechanical Engineering, Southampton University, Southampton, UK
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Beals C, Flanigan DC, Peters N, Kim W, Early N, Shemory S, Vasileff WK, Magnussen RA. Inter-rater reliability of TT-TG distance is good and does not vary based on preselected versus independent slice selection on MRI. J ISAKOS 2019. [DOI: 10.1136/jisakos-2019-000306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Léger-St-Jean B, Gorica Z, Magnussen RA, Vasileff WK, Kaeding CC. Accelerated rehabilitation results in good outcomes following acute repair of proximal hamstring ruptures. Knee Surg Sports Traumatol Arthrosc 2019; 27:3121-3124. [PMID: 29725745 DOI: 10.1007/s00167-018-4964-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/23/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess outcomes of patients who underwent proximal hamstring repair utilizing an accelerated rehabilitation protocol with immediate weight bearing as tolerated and no bracing. METHODS Retrospective chart review identified 47 proximal hamstring tendon repairs with suture anchors in 43 patients performed during 2008-2015. Rehabilitation included no immobilization or limited weightbearing. Patients were contacted by phone to assess outcomes utilizing the lower extremity functional score (LEFS), single-assessment numeric evaluation (SANE), and Marx activity scale. Overall patient-reported scores were calculated and results of acute and chronic repairs compared. RESULTS Thirty-four patients (38 repairs, 80.8%) were available for follow-up at mean of 4.1 ± 2.0 years following repair. There were two re-tears: one complete rupture 5 weeks postoperative and one partial rupture 10 weeks postoperative in the chronic group. Patients in general reported low pain and good function with a mean LEFS score of 87 ± 21%, a mean SANE score of 88.1 ± 11.6, and a mean numeric pain score of 8.5 ± 15.3 in the last week and 12.2 ± 21.1 with activity. The acute repair group was noted to have a higher mean LEFS score (93.7 versus 79.8%, p = 0.004) and SANE score (91.3 versus 83.8, p = 0.047), and lower pain with activity (21.7 versus 4.8, p < 0.001) as compared to the chronic group. CONCLUSIONS Repair of acute proximal hamstring ruptures results in good function and pain relief with the use of a rehabilitation protocol that does not require weight-bearing restrictions or bracing. LEVEL OF EVIDENCE III, therapeutic.
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Affiliation(s)
- Benjamin Léger-St-Jean
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Zylyftar Gorica
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA. .,OSU Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.
| | - W Kelton Vasileff
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.,OSU Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Christopher C Kaeding
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.,OSU Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
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Ithurburn MP, Paterno MV, Thomas S, Pennell ML, Evans KD, Magnussen RA, Schmitt LC. Change in Drop-Landing Mechanics Over 2 Years in Young Athletes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2019; 47:2608-2616. [PMID: 31373856 DOI: 10.1177/0363546519864688] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND While between-limb landing asymmetries after anterior cruciate ligament reconstruction (ACLR) are linked with poor function and risk of additional injury, it is not currently understood how landing symmetry changes over time after ACLR. PURPOSE/HYPOTHESIS The purpose was to investigate how double-legged drop vertical jump (DVJ) landing and single-legged drop-landing symmetry changed from the time of return-to-sport (RTS) clearance to 2 years later in a prospective cohort of young athletes after ACLR. It was hypothesized that double-legged DVJ landing and single-legged drop-landing symmetry would improve from the time of RTS to 2 years later. STUDY DESIGN Descriptive laboratory study. METHODS The authors followed 64 young athletes with primary, unilateral ACLR for 2 years after RTS clearance. At the time of RTS and 2 years later, between-limb symmetry values for biomechanical variables of interest (VOIs) were calculated with 3-dimensional motion analysis during double-legged DVJ and single-legged drop-landing tasks. VOIs included knee flexion excursion, peak internal knee extension moment, peak vertical ground-reaction force, and peak trunk flexion (for single-legged task only). Symmetry values and proportions of participants meeting 90% symmetry cutoffs were compared between time points. RESULTS For double-legged DVJ landing, symmetry values for all VOIs and the proportions meeting 90% cutoffs for peak internal knee extension moment and peak vertical ground-reaction force were higher at 2 years after RTS as compared with RTS. For single-legged drop-landing, symmetry values were higher for knee flexion excursion and lower for peak trunk flexion at 2 years after RTS as compared with RTS, but the proportions meeting 90% cutoffs for all VOIs did not differ between time points. CONCLUSION Double-legged DVJ landing symmetry improved across VOIs over the 2 years after RTS following ACLR, while single-legged drop-landing did not improve as consistently. The implications of longitudinal landing asymmetry after ACLR should be further studied.
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Affiliation(s)
- Matthew P Ithurburn
- Department of Physical Therapy and Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mark V Paterno
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Staci Thomas
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael L Pennell
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Kevin D Evans
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Laura C Schmitt
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Division of Physical Therapy, The Ohio State University, Columbus, Ohio, USA
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50
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Jones MH, Oak SR, Andrish JT, Brophy RH, Cox CL, Dunn WR, Flanigan DC, Fleming BC, Huston LJ, Kaeding CC, Kolosky M, Kuyumcu G, Lynch TS, Magnussen RA, Matava MJ, Parker RD, Reinke EK, Scaramuzza EA, Smith MV, Winalski C, Wright RW, Zajichek A, Spindler KP. Predictors of Radiographic Osteoarthritis 2 to 3 Years After Anterior Cruciate Ligament Reconstruction: Data From the MOON On-site Nested Cohort. Orthop J Sports Med 2019; 7:2325967119867085. [PMID: 31516911 PMCID: PMC6719483 DOI: 10.1177/2325967119867085] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Multiple studies have shown that patients are susceptible to posttraumatic osteoarthritis (PTOA) after an anterior cruciate ligament (ACL) injury, even with ACL reconstruction (ACLR). Prospective studies using multivariable analysis to identify risk factors for PTOA are lacking. Purpose/Hypothesis: This study aimed to identify baseline predictors of radiographic PTOA after ACLR at an early time point. We hypothesized that meniscal injuries and cartilage lesions would be associated with worse radiographic PTOA using the Osteoarthritis Research Society International (OARSI) atlas criteria. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 421 patients who underwent ACLR returned on-site for standardized posteroanterior semiflexed knee radiography at a minimum of 2 years after surgery. The mean age was 19.8 years, with 51.3% female patients. At baseline, data on demographics, graft type, meniscal status/treatment, and cartilage status were collected. OARSI atlas criteria were used to grade all knee radiographs. Multivariable ordinal regression models identified baseline predictors of radiographic OARSI grades at follow-up. Results: Older age (odds ratio [OR], 1.06) and higher body mass index (OR, 1.05) were statistically significantly associated with a higher OARSI grade in the medial compartment. Patients who underwent meniscal repair and partial meniscectomy had statistically significantly higher OARSI grades in the medial compartment (meniscal repair OR, 1.92; meniscectomy OR, 2.11) and in the lateral compartment (meniscal repair OR, 1.96; meniscectomy OR, 2.97). Graft type, cartilage lesions, sex, and Marx activity rating scale score had no significant association with the OARSI grade. Conclusion: Older patients with a higher body mass index who have an ACL tear with a concurrent meniscal tear requiring partial meniscectomy or meniscal repair should be advised of their increased risk of developing radiographic PTOA. Alternatively, patients with an ACL tear with an articular cartilage lesion can be reassured that they are not at an increased risk of developing early radiographic knee PTOA at 2 to 3 years after ACLR.
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Affiliation(s)
| | - Morgan H Jones
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Sameer R Oak
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Jack T Andrish
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert H Brophy
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles L Cox
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Warren R Dunn
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - David C Flanigan
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Braden C Fleming
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura J Huston
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher C Kaeding
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Kolosky
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Gokhan Kuyumcu
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - T Sean Lynch
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert A Magnussen
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew J Matava
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard D Parker
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Emily K Reinke
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Erica A Scaramuzza
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew V Smith
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Carl Winalski
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Rick W Wright
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Alexander Zajichek
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt P Spindler
- Investigation performed at Vanderbilt University, Nashville, Tennessee, USA, and the Cleveland Clinic, Cleveland, Ohio, USA
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