Autologous Chondrocyte Implantation and Tibial Tubercle Osteotomy for Patellofemoral Chondral Defects: Improved Pain Relief and Occupational Outcomes Among US Army Servicemembers.

BACKGROUND: The occupational and functional results of patellofemoral autologous chondrocyte implantation (ACI) are underreported. This investigation sought to establish clinical outcomes and rates for return to work in a predominantly high-demand military cohort undergoing this procedure. PURPOSE: To determine the return-to-work, pain relief, and perioperative complication rates in a high-demand athletic cohort undergoing patellofemoral ACI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All military servicemembers from 2 military medical centers undergoing ACI for high-grade patellofemoral chondral defects between 2006 and 2014 were identified, and data were abstracted from their medical records and clinical databases. Demographic and surgical variables were obtained for patients with at least 2 years of postoperative follow-up, and perioperative complications, rates of return to work, and survivorship from revision were quantified. RESULTS: Seventy-two patients (72%) had >2-year follow-up and had patellofemoral ACI for high-grade chondral defects, with 66 knees (91%) undergoing a concomitant offloading tibial tubercle osteotomy. Mean follow-up was 4.3 years (range, 2.0-9.9 years). The mean ± SD age was 34.4 ± 6.1 years; 86% were male; and 57% were involved in military occupational specialties of heavy or very heavy demand. Second-generation patellofemoral ACI with a type I/III collagen membrane was used for 85% of knees. Most defects were isolated to the patella (n = 40, 55%). The mean total defect surface area was 4.5 ± 2.9 cm2 (range, 2.7-13.5 cm2). Fifty-six servicemembers (78%) returned to their occupational specialties. Three patients (4.1%) were classified as having surgical failures, requiring subsequent knee arthroplasty (n = 2) or a revision chondral procedure (n = 1). Mean visual analog scores improved significantly from 6.5 ± 1.5 to 3.2 ± 2.1 ( P < .0001). Multivariate analysis identified use of a periosteal patch as the only significant independent predictor for surgical ( P = .013) and overall ( P = .033) failures. Age <30 years ( P = .019), female sex ( P = .019), and regular tobacco use ( P = .011) were independent predictors of overall failure. CONCLUSION: For patellofemoral chondral defects without a failed primary procedure, second-generation ACI successfully returned to work 78% of patients of moderate to very heavy occupational demand with significantly decreased patient-reported knee pain. Risk factors after ACI for patellofemoral articular lesions for overall failure were age <30 years, female sex, and tobacco use, while surgical and overall failures were associated with periosteal patch use.

The efficacy of combined cryotherapy and compression compared with cryotherapy alone following anterior cruciate ligament reconstruction.

While cryotherapy has been shown to decrease postoperative pain after anterior cruciate ligament (ACL) reconstruction, less is known of the effects of combined cryotherapy and compression. The goal of this study was to compare subjective and objective patient outcomes following ACL reconstruction with combined compression and cryotherapy compared with traditional ice therapy alone. Patients undergoing ACL reconstruction were randomized to cryotherapy/compression device (group 1) or a standardized ice pack (group 2). Both groups were instructed to use the ice or cryotherapy/compression device three times per day and return to the clinic at 1, 2, and 6 weeks postoperatively. Patient-derived outcome measurements used in this study consisted of the visual analog scale (VAS), the Lysholm knee score, Short Form-36 (SF-36), and single assessment numerical evaluation (SANE). Circumferential measurements of the knee at three locations (1 cm proximal to patella, mid-patella, and 1 cm distal to patella) were also obtained as a measure of postoperative edema. Narcotic medication use was recorded by questionnaire. The primary outcome measure (VAS) was significantly different among groups in the preoperative measurement, despite similarities in group demographics. Baseline VAS for group 1 was 54.9 compared with group 2 at 35.6 (p = 0.01). By 6 weeks, this had lowered to 28.1 and 40.3, respectively, resulting in a significant 27-point decrease in mean VAS for group 1 (p < 0.0001). However, the small increase in VAS for group 2 was not significant (p = 0.34). No significant differences were noted for the Lysholm, SF-36, or SANE scores either between groups or time points. Furthermore, no significant differences were noted for any of the circumferential measurements either between groups or time points. Of all patients, 83% of group 1 discontinued narcotic use by 6 weeks, compared with only 28% of group 2 (p = 0.0008). The use of combined cryotherapy and compression in the postoperative period after ACL reconstruction results in improved, short-term pain relief and a greater likelihood of independence from narcotic use compared with cryotherapy alone.

The relationship between posterior tibial slope and anterior cruciate ligament injuries.

BACKGROUND: Two previous studies have examined the association between an increased posterior tibial slope and anterior cruciate ligament (ACL) injuries as measured on plain radiographs. The study results were contradictory, with 1 reporting a statistical difference and the other showing no association. PURPOSE: To determine if there is a difference in posterior tibial slope angle between patients with a history of noncontact ACL injury and a control group with no history of ACL injury. A secondary objective was to examine differences in tibial slope angle between male and female subjects within each group. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We identified all noncontact ACL injuries that were treated operatively at the United States Military Academy, West Point, New York, from 2004 to 2007. We digitally measured the posterior tibial slope from plain film radiographs of 140 noncontact ACL injuries, stratified them by sex, and compared them with a control cohort of 179 patients and radiographs. RESULTS: Subjects in the noncontact ACL group had significantly greater slope angles (9.39 degrees +/- 2.58 degrees) than did control subjects (8.50 degrees +/- 2.67 degrees) (P = .003). The trend toward greater tibial slope angles in the noncontact ACL group was also observed when each sex was examined independently; however, the difference was only statistically significant for the female subjects between the injury and control groups (9.8 degrees +/- 2.6 degrees vs 8.20 degrees +/- 2.4 degrees) (P = .002). CONCLUSION: Despite the identification of an increased posterior tibial slope as a possible risk factor for women, more research that combines the multifactorial nature of an ACL injury must be performed.

The circumferential antishock sheet.

Hemorrhage control in patients with pelvic ring disruptions remains problematic. To decrease bleeding, efforts have been made to acutely reduce and stabilize the pelvis. The goals of rapid pelvic reduction and stabilization are restoration of normal pelvic volume, protection of the early clot, and improved patient comfort. The use of military antishock trousers, hip spica casts, external fixators, antishock pelvic clamps, early open reduction/internal fixation, and open packing have been reported in the literature. A simple temporary technique of reduction is reported using a circumferential bed sheet. The sheet is placed between the iliac crests and the greater trochanters, encircling the pelvis. The circumferential sheet provides stabilization for transportation and allows transfemoral angiographic embolization or exploratory laparotomy at the receiving hospital. Definitive fixation can then be accomplished.