Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures.

OBJECTIVE: To create a treatment algorithm for focal grade 3 or 4 cartilage defects of the knee using both classic and novel cartilage restoration techniques. DESIGN: A comprehensive review of the literature was performed highlighting classic as well as novel cartilage restoration techniques supported by clinical and/or basic science research and currently being employed by orthopedic surgeons. RESULTS: There is a high level of evidence to support the treatment of small to medium size lesions (<2-4 cm2) without subchondral bone involvement with traditional techniques such as marrow stimulation, osteochondral autograft transplant (OAT), or osteochondral allograft transplant (OCA). Newer techniques such as autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate implantation have also been shown to be effective in select studies. If subchondral bone loss is present OAT or OCA should be performed. For large lesions (>4 cm2), OCA or matrix autologous chondrocyte implantation (MACI) may be performed. OCA is preferred over MACI in the setting of subchondral bone involvement while cell-based modalities such as MACI or particulated juvenile allograft cartilage are preferred in the patellofemoral joint. CONCLUSIONS: Numerous techniques exist for the orthopedic surgeon treating focal cartilage defects of the knee. Treatment strategies should be based on lesion size, lesion location, subchondral bone involvement, and the level of evidence supporting each technique in the literature.

Efficacy of Multimodal Analgesic Injections in Operatively Treated Ankle Fractures: A Randomized Controlled Trial.

BACKGROUND: Pain management following surgical treatment of an ankle fracture is an under-studied area of clinical practice. The present study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with an operatively treated, closed, rotational ankle fracture. METHODS: Patients indicated for operative fixation of a rotational ankle fracture were randomized to receive multimodal surgical-site injection (ropivacaine 200 mg, epinephrine 0.6 mg, and morphine 5 mg) or no injection (control). Visual analog scale (VAS) pain and opioid consumption data were collected every 4 hours until discharge from the hospital. Length of stay and discharge destination were recorded. Patients were sent automated text messages to report VAS pain and opioid usage during the first 2 weeks after discharge. RESULTS: One hundred patients (49 injection and 51 control) were enrolled. Demographic data were similar between the 2 groups. Mean VAS scores over the first 24 and 48 hours postoperatively were slightly lower in the injection group (42 ± 3 and 41 ± 3, respectively) compared with the control group (52 ± 3 and 50 ± 3, respectively; p = 0.01 and p < 0.01, respectively). The median opioid usage, in terms of morphine equivalent dose, was similar over the first 24 hours between the injection group (25.5; range, 0 to 74.7) and the control group (28.3; range, 2.5 to 91.0; p = 0.35). The median opioid usage from recovery room admission to discharge was also similar between the injection group (29.0; range, 0 to 85.3) and the control group (32.7; range, 4.3 to 215.0; p = 0.35). There were no differences in outpatient VAS scores or opioid consumption during the first 2 weeks postoperatively as assessed with use of automated text messaging. Median length of stay was 22.3 hours (range, 1.7 to 182.3 hours) for the injection group and 22.5 hours (range, 2.2 to 123.3 hours) for the control group (p = 0.71). The response rate for the post-discharge automated text messages was 85.1%. Complication rates were similar. CONCLUSIONS: The use of multimodal surgical-site injections in operatively treated rotational ankle fractures is associated with a reduction in immediate in-hospital pain scores that is statistically significant but below the minimal clinically important difference. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Trends in Knee Articular Cartilage Treatments: An American Board of Orthopaedic Surgery Database Study.

This study aims to evaluate the trends in treatment of knee articular cartilage lesions over the past decade using data obtained from the American Board of Orthopaedic Surgery (ABOS) Part II database. The ABOS Part II database was queried from 2004 to 2013 for chondroplasty, microfracture, and osteochondral grafting procedures. All cases were analyzed for patient age and operating surgeon's fellowship training status. Univariate analysis including chi-square test for categorical variables and Student's t-test for continuous variables was performed to determine if any significant changes in practice patterns were present. Linear regression analyses were utilized to examine temporal trends in procedures performed and fellowship training status. From 2004 to 2013, 25,938 procedures addressing articular cartilage lesions from 3,586 surgeons were identified in the ABOS database. 46.8% of these orthopaedic surgeons had completed a 1-year sports medicine fellowship. Sixty-six percent of cartilage surgeries were performed by sports medicine-trained surgeons. The articular cartilage surgical volume decreased from 3,126 cases in 2004 to 1,690 cases in 2013. The most common procedure coded overall was chondroplasty (80.23%) followed by microfracture (21.37%) and osteochondral grafting (2.1%). The mean age of patients undergoing chondroplasty was 46.9 years; this was significantly higher than microfracture (mean age 40.5 years) or osteochondral grafting procedures (mean age 31.6 years), p < 0.0005. The age of all patients undergoing cartilage surgery significantly decreased between 2004 and 2013, p < 0.001. A dramatic decrease in reported chondroplasty volume was observed between 2011 and 2012. Concurrent osteotomies were used in <1% of procedures addressing cartilage injuries, while 65% of patients underwent concurrent meniscectomy. These described trends are most pronounced in surgeons with sports medicine fellowship training. In conclusion, knee articular cartilage surgical volume and patient age have both sharply declined since 2011, a trend driven by sports medicine-trained Part II examinees. This trend correlates with changes in billing and coding practices, as well as improved education from high-level studies.

PROMIS: a valid and efficient outcomes instrument for patients with ACL tears.

PURPOSE: The current study compares the Patient Reported Outcomes Information System Physical Function Computer Adaptive Test (PROMIS PF CAT) to traditional knee PRO instruments in a healthy population undergoing surgery for ACL injuries with the following objectives: (1) identify and determine the strength of any correlations between the scores of PROMIS PF CAT and current knee PROs or their subscales that measure physical function; (2) evaluate PROMIS PF CAT's test burden; and (3) determine if PROMIS PF CAT has any floor or ceiling effects in this population. METHODS: Patients indicated for ACL surgery completed the Short Form-36 Physical Function (SF-36 PF), Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale (Marx), the EuroQol 5-dimensions Questionnaire (EQ-5D), and PROMIS PF CAT. Correlations between PROs were defined as follows: High (≥ 0.7); high-moderate (0.61-0.69); moderate (0.4-0.6); moderate-weak (0.31-0.39); and weak (≤ 0.3). Floor or ceiling effects were considered significant if 15% or more patients reported the lowest or highest possible total score, respectively. RESULTS: 100 patients participated with a mean age of 26 years (range 11-57). The PROMIS PF CAT demonstrated high correlations with SF-36 PF (r = 0.82, p < 0.01), EQ-5D (r = - 0.70, p < 0.01) KOOS ADL (r = 0.74, p < 0.01), and KOOS Sport (r = 0.70, p < 0.01). There were no ceiling or floor effects for PROMIS PF CAT (0%). The mean number of items completed for the PROMIS PF CAT was 4.2 (median 4; range 4-11). CONCLUSIONS: The PROMIS PF CAT shows a high correlation with commonly employed PROs that also measure physical function with low test burden and without ceiling effects in this relatively young and healthy population.