Editorial Commentary: Osteochondral Allograft of the Knee-Diffuse Edema at 6 Months on Magnetic Resonance Imaging Predicts Failure.

Cartilage defects alter natural function of articular cartilage and can predispose patients to further cartilage wear and eventual osteoarthritis. These injuries present a challenging problem with a multitude of treatment options and lack of consensus on when to employ each. Options include conservative measures (limited weightbearing and immobilization), debridement, microfracture, autologous chondrocyte implantation, and osteochondral autograft and allograft. Indications may be based on defect size, joint alignment, age, activity level, body mass index, and sex. One option, osteochondral allograft (OCA) transplantation, is typically reserved for large and severe defects or revision. With regard to OCA prognosis, older patients, revision cases, patellar defects, and bipolar lesions confer elevated risk of failure, whereas traumatic or idiopathic cases, unipolar lesions, and short duration of symptoms have reported higher levels of satisfaction. Following surgery, the patient with persistent symptoms can present a conundrum. Recent research shows that in such cases, diffuse edema at 6 months on magnetic resonance imaging often predicts ultimate failure, in which case arthroplasty may be required.

Tobramycin and Vancomycin in an In Vitro Model of Anterior Cruciate Ligament Allograft Decontamination.

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.

More Is Not Merrier: Increasing Numbers of All-Inside Implants Do Not Correlate with Higher Odds of Revision Surgery.

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.

Anterolateral Radial Meniscus Tear Repair using Traction Suture and Super-Hashtag Technique.

Radial meniscus tears occur commonly as traumatic tears in younger patients, as well as in association with concomitant degenerative changes. Traditional management of these tears has centered around partial meniscectomy; however, there has been a more recent trend toward preserving the meniscus and attempting repair. Because of the gapping and displacement that frequently occurs with these tears, repair is often challenging and is done under high amounts of tension. The following article describes a technique using a traction suture to aid in maintaining reduction throughout repair. This is followed by the use of a combination of techniques to form a "super-hashtag" configuration of both vertical and horizontal mattress sutures, leading to a secure repair under little tension.

Horizontal Cleavage Tear Meniscal Repair Using All-Inside Circumferential Compression Sutures.

Horizontal cleavage meniscus tears occur more frequently in older patient populations with degenerative changes within the meniscus. Traditionally, they have been managed with nonsurgical interventions or with partial meniscectomy. As increasing evidence demonstrates the link between partial meniscectomy and progressive osteoarthritis with these types of tears, as well as worse long-term outcomes and reduced cost savings, surgical repair of horizontal cleavage meniscal tears has increased in appropriate patients. This technique article highlights the evaluation, indications, and preferred repair technique for horizontal cleavage tears in appropriately selected patients.

Posterior Meniscal Root Repair With Transtibial Double Tunnel Pullout Technique and Anchor Fixation.

Meniscus root tears are tears that occur within 1 cm of the meniscus root attachment to the tibia. If not repaired, root tears will lead to altered knee biomechanics and accelerated degenerative changes in the knee. In this surgical technique, we demonstrate repair of a meniscus root tear with an all-inside suture repair of the posterior meniscus that is then passed through 2 transtibial tunnels and then fixed with an anchor. After surgery, patients are non-weightbearing for 4 weeks and can return to activity by 6 months.

Horizontal Cleavage Meniscus Tears: Biomechanics, Indications, Techniques, and Outcomes.

¼ Accounting for up to 24% of all meniscus tears, horizontal cleavage tears (HCTs) are a common pathology orthopaedic practitioners should be comfortable managing.¼ 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.¼ 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.¼ 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.

Influence of Staphylococcus epidermidis on Collagen Crimp Patterns of Soft Tissue Allograft.

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.

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.

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.

Patellofemoral articular cartilage damage is associated with poorer patient-reported outcomes following isolated medial patellofemoral ligament reconstruction.

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.

Smaller Iatrogenic Defects Created by Inside-Out Compared With All-Inside Meniscus Repair Devices in Human Cadaveric Model.

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.

Repair of Radial Meniscus Tears Results in Improved Patient-Reported Outcome Scores: A Systematic Review.

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.

Advanced neuroimaging in traumatic brain injury: an overview.

Traumatic brain injury (TBI) is a common condition with many potential acute and chronic neurological consequences. Standard initial radiographic evaluation includes noncontrast head CT scanning to rapidly evaluate for pathology that might require intervention. The availability of fast, relatively inexpensive CT imaging has fundamentally changed the clinician's ability to noninvasively visualize neuroanatomy. However, in the context of TBI, limitations of head CT without contrast include poor prognostic ability, inability to analyze cerebral perfusion status, and poor visualization of underlying posttraumatic changes to brain parenchyma. Here, the authors review emerging advanced imaging for evaluation of both acute and chronic TBI and include QuickBrain MRI as an initial imaging modality. Dynamic susceptibility-weighted contrast-enhanced perfusion MRI, MR arterial spin labeling, and perfusion CT are reviewed as methods for examining cerebral blood flow following TBI. The authors evaluate MR-based diffusion tensor imaging and functional MRI for prognostication of recovery post-TBI. Finally, MR elastography, MR spectroscopy, and convolutional neural networks are examined as future tools in TBI management. Many imaging technologies are being developed and studied in TBI, and some of these may hold promise in improving the understanding and management of TBI. ABBREVIATIONS ASL = arterial spin labeling; CNN = convolutional neural network; CTP = perfusion CT; DAI = diffuse axonal injury; DMN = default mode network; DOC = disorders of consciousness; DTI = diffusion tensor imaging; FA = fractional anisotropy; fMRI = functional MRI; GCS = Glasgow Coma Scale; MD = mean diffusivity; MRE = MR elastography; MRS = MR spectroscopy; mTBI = mild TBI; NAA = N-acetylaspartate; SWI = susceptibility-weighted imaging; TBI = traumatic brain injury; UHF = ultra-high field.