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.

Tibial Tubercle Osteotomy for Patellar Chondral Pathology in an Active United States Military Population.

PURPOSE: To quantify rates of perioperative complications, secondary surgery, subjective pain relief, and knee-related medical separation in an active military population after a tibial tubercle osteotomy (TTO) for the primary indication of chondral pathology. METHODS: All active-duty service members undergoing TTO with a minimum of 2 years' follow-up were isolated from the Military Health System database. The exclusion criteria were patients with patellar instability, other periarticular osteotomy, and insufficient follow-up. Demographic information and surgical characteristics were abstracted from the electronic health record and correlated with improvement in pain and medical discharge from the military. RESULTS: A total of 76 patients (86 knees) who underwent TTO for patellofemoral chondromalacia were identified with a mean age of 32.3 years. Major and minor complications occurred in four patients (4.7%) and three patients (3.5%), respectively, and the overall improvement in the visual analog scale score after TTO was 1.5 (P < .0001). At a mean follow-up of 3.4 years (range, 2.0 to 7.3 years), 37% of patients were unable to return to modified military activity because of knee-related limitations. Junior military rank group (P = .0084), age younger than 35 years (P = .0031), bilateral TTO procedures (P = .0294), and tobacco use (P = .0218; odds ratio, 3.29; 95% confidence interval, 1.19 to 9.12) were risk factors for medical separation, whereas absence of concomitant chondral repair (P = .5408), previous knee procedures (P = .9674), and greater occupational demands (P = .7062) were not. CONCLUSIONS: At short-term to midterm follow-up, 63% of patients successfully returned to military function with a low rate of perioperative complications (8%). The postoperative decrease in pain after TTO is of unknown clinical significance. Age younger than 35 years, junior military rank, bilateral TTO procedures, and tobacco use were significant risk factors for medical separation, whereas absence of concomitant cartilage repair, previous knee procedures, and lower occupational demands were not associated with improved visual analog scale scores or prevention of knee-related medical discharge. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Staged correction of an equinovarus deformity due to pyoderma gangrenosum using a Taylor spatial frame and tibiotalar calcaneal fusion with an intramedullary device.

Pyoderma gangrenosum is a rare autoinflammatory syndrome manifested by skin lesions eventually creating ulcers. Surgical management can lead to scarring and contracture at the site of the lesion due to the pathergy phenomenon. A 43-year-old woman presented with a 5-year history of severe equinovarus deformity due to chronic pyoderma gangrenosum on her posteromedial ankle. She underwent a staged fusion. A gradual "closed" correction was performed in a Taylor spatial frame for 8 weeks in order to obviate the need for a surgical release in the area of the ulcer. She was ambulatory and full weight-bearing within 4 weeks of her frame removal. She maintained her correction with an accommodative foot orthosis until she had an uneventful tibiotalar calcaneal fusion with an intramedullary device. This case represents the success of using a Taylor spatial frame for staged fusion involving soft-tissue correction of severe, rigid equinovarus deformity due to pyoderma gangrenosum.

Burden of musculoskeletal disease and nonbattle nontraumatic injury in both war and disaster zones.

Disasters, both man-made and natural, are a known cause of morbidity and mortality among vulnerable populations. The initial phase of public health response typically addresses immediate traumatic injury or death in the wake of a disaster. However, little is known about the magnitude and cost of subsequent nontraumatic injury and illness in disaster zones. Known as ``the hidden epidemic,'' the incidence and epidemiology of disease and nonbattle injuries among military service members in deployed settings has been more extensively investigated and may serve as a proxy for the evaluation of civilian populations following natural disaster. Further, prior reports from the military setting may serve to inform the broader population on the ultimate burden of nontraumatic injury and illness in recent disasters, particularly as they relate to musculoskeletal health.