Abstract:Despite increasing evidence supporting the efficacy of repair for most meniscus tear types, research assessing the outcomes of repair of complex tears is limited. The purpose of this study is to analyze failure risk and postoperative complications following repair of complex meniscus tears. A retrospective review of medical records was performed for patients who underwent meniscus surgery between 2011 and 2022 at a single academic medical center. Only patients with a complex meniscus tear treated through repair with a minimum follow-up period of 2 years were included. Patients were evaluated for demographic information (age, sex, BMI, race, smoking status), surgical information (type of tear), failure of meniscus repair, and postoperative complications. Failure of meniscus repair was defined as repeat surgery on the index meniscus (including meniscectomy or revision repair) or total knee arthroplasty. A total of 77 patients underwent repair of a complex meniscus tear during the study period (mean age, 32.6 ± 13.9 years; BMI, 28.5 ± 6.5 kg/m2) with an average follow-up time of 4.6 years. Overall, 17 (22.1%) patients had a failure of their meniscus repair, of which 14 underwent partial meniscectomy, 2 underwent a total knee arthroplasty, and 1 had a revision repair. On univariate analysis, previous knee surgery was the only significant predictor of postoperative failure when considering lateral meniscus repairs (p = 0.036) in isolation. All other demographic and surgical variables were statistically insignificant. The only postoperative complication seen acutely after surgery was a surgical site infection (1/77, 1.3%) managed by oral antibiotics. Patients with complex meniscus tears who underwent repair demonstrated a 22.1% failure rate at 4.6 years after surgery and demonstrated a low incidence of acute postoperative complications. Level of evidence is IV.

Background: Previous research has shown that tendon graft soaking in vancomycin or tobramycin solution has no negative effects on graft mechanical properties, but there are no studies that have investigated graft mechanical properties after soaking grafts in gentamicin. Additionally, nearly all published biomechanical studies are based on data collected from a mechanical load frame or strain gauge, which does not provide insight on local graft strains compared with 3-dimensional digital image correlation (3D-DIC).Purpose/Hypothesis: The purpose of this study was to use 3D-DIC to investigate the effects of vancomycin, tobramycin, and gentamicin soaking on tendon graft mechanical properties. It was hypothesized that (1) no significant difference in mechanical properties exists between the saline control, vancomycin, tobramycin, and gentamicin groups and (2) local graft strain at the graft failure location will be greater than global strain spanning the entire graft length.Study Design: Controlled laboratory study.Methods: Human tibialis anterior, peroneus longus, and tibialis posterior tendon grafts were prepared and evenly separated into 4 groups: control, vancomycin (5.0 mg/mL), tobramycin (1.0 mg/mL), and gentamicin (0.8 mg/mL). Grafts were soaked in antibiotic solution for 10 minutes, then removed and painted via airbrush with water-based black paint. Uniaxial tension testing was then completed at a strain rate of 10 mm/min. Data collected were used to calculate Young modulus (YM), elasticity limit (EL), ultimate tensile strength (UTS), and failure strain (FS).Results: There were no significant differences in YM (P = .49), EL (P = .62), UTS (P = .98), and FS (P = .14) between control, vancomycin, tobramycin, and gentamicin, respectively. Additionally, local strain at graft failure location was larger than global strain across the length of the graft.Conclusion: Soaking tendon grafts in vancomycin, tobramycin, or gentamicin does not alter the mechanical properties of grafts under uniaxial loading.Clinical Relevance: If vancomycin use is not possible or is contraindicated for certain patients, surgeons can soak grafts in tobramycin or gentamicin to achieve similarly effective infection mitigation without weakening the graft.

BACKGROUND:Anterior cruciate ligament (ACL) injuries are common, and ACL reconstruction (ACLR) restores stability and enables return to sport. To date, however, studies have failed to show that ACLR prevents long-term osteoarthritis, but the role of timing of ACLR in osteoarthritis has not been extensively examined in meta-analyses. PURPOSE:To compare the risk of long-term osteoarthritis after early versus delayed ACLR in the literature. STUDY DESIGN:Systematic review and meta-analysis; Level of evidence, 4. METHODS:The PubMed, Embase, and Cochrane Library databases were searched from 2000 to August 2024 for studies comparing osteoarthritis between early and delayed ACLR at a minimum 5-year follow-up. Outcomes are reported as risk reduction with 95% confidence interval for osteoarthritis incidence, and odds ratio with 95% confidence interval for difference in time from injury to surgery. Random-effects models were used. RESULTS:Seventeen studies (3953 ACLRs) were included (mean age, 28.8 years; 67% male; mean follow-up, 13.3 years; 52% meniscectomy; 31% osteoarthritis incidence). The quality of the studies was rated as moderate, with a Methodological Index for Non-Randomized Studies score of 78% of maximum. Overall, earlier ACLR led to a 10% reduction in osteoarthritis compared with delayed ACLR (95% CI, 6%-14%; P < .001). Two studies (1474 patients) reported a 6% incidence reduction when ACLR was performed within versus after 1 month (95% CI, 2%-10%; P = .005). Similarly, 4 studies (349 patients) reported a 16% incidence reduction when ACLR was performed within versus after 6 months (95% CI, 5%-26%; P = .004), and 5 studies (2248 patients) showed a 13% osteoarthritis reduction with ACLR within versus after 12 months (95% CI, 6%-20%; P = .003). Six studies (685 patients) reported that patients without osteoarthritis were operated on a mean 15 months earlier than patients who developed osteoarthritis (95% CI, 2-29 months; P = .03). CONCLUSION:This systematic review with a 5-year minimum follow-up demonstrates that shorter time from injury to ACLR was associated with a decreased incidence of long-term osteoarthritis. This reduced risk was already seen when surgery was performed within 1 month but most pronounced within 6 months and 12 months.

Background:Hamstring tendon autografts are the most commonly used grafts for anterior cruciate ligament (ACL) reconstruction and are usually harvested through an anterior approach. This harvest is not without risks of complications, and the tendons can alternatively be harvested through a posterior approach. Indications:Patients undergoing autograft hamstring ACL reconstruction without previous ipsilateral hamstring harvest or distal hamstring injury. Technique Description:The patient is positioned supine, and the leg is elevated. With the knee in flexion, the semitendinosus can be palpated as the most lateral superficial of the medial hamstring tendons. A small incision is then made over the semitendinosus 1 cm proximal to the flexion crease, and the fascia is opened. An open hamstring stripper is then used to harvest the graft proximally with the leg in extension. The graft is then passed through a closed tendon stripper, and the remaining tendon is stripped distally. The graft is then quadrupled on the back table with the sutures on the inside of the graft, and the graft is soaked in a tobramycin-infused saline solution. Results:Compared to anterior hamstring harvest, posterior harvest is associated with a decreased incidence of (infrapatellar branch) saphenous nerve damage (0.4% vs 10.2%), lower risk of premature graft harvest (0% vs 2-9%), shorter operative time (4 to 13 minutes shorter), and higher cosmetic satisfaction (92% vs 80%). Discussion/Conclusion:Posterior hamstring harvest is a safe and reliable technique that is associated with a lower risk of complications compared to anterior hamstring harvest and should be considered for hamstring autograft ACL reconstruction. Patient Consent Disclosure Statement:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background:Anterior cruciate ligament reconstruction (ACLR) is the standard treatment for ACL injuries; however, over 50% of patients develop post-traumatic osteoarthritis (PTOA) within 10-20 years. Quantitative MRI (qMRI) enables early detection of cartilage and soft tissue changes, and radiomics may enhance understanding of PTOA and knee pain development. Objective:This study investigates structural and soft tissue changes associated with radiographic PTOA and examines their relationship to knee pain in patients 10 years post-ACLR using qMRI-based radiomics analysis. Methods:We analyzed 162 patients from the MOON nested on-site cohort. qMRI acquisitions of the knee and thigh were harmonized across sites to minimize variability. A total of 17656 Radiomic features were extracted from T1ρ and T2 maps from cartilage and menisci, thigh muscle fat fraction maps, and thigh muscle morphology images. Radiomics models for radiographic PTOA (Kellgren-Lawrence ≥ 2) and knee pain (KOOS pain ≤ 85) were developed using Boruta, minimum redundancy maximum relevance, and XGBoost. Results:Eight radiomic features from cartilage, menisci, and muscle regions (quadriceps/adductors) were associated with radiographic PTOA. Six radiomic features from cartilage and menisci were linked to knee pain. Radiomics models outperformed clinical models with AUROC = 0.85 (95% CI: 0.84-0.87) and 0.79 (95% CI: 0.77-0.81) for radiographic PTOA and knee pain, respectively. Conclusion:qMRI-based radiomics identifies cartilage, menisci, and muscle features linked to PTOA and knee pain post-ACLR. Future studies should explore additional tissue features and contralateral knee analyses to further elucidate PTOA progression and pain mechanisms.

Background:Bone-patellar tendon-bone (BPTB) graft for anterior cruciate ligament (ACL) reconstruction (ACLR) is the second most common graft worldwide and the most common graft in the United States. Fixation generally consists of screws, which can have risks, such as graft damage or cutting, loss of tension, or suture breakage while fixating. All-inside reconstruction is generally used for soft-tissue grafts and has advantages over full tunnels. Therefore, we present a technique for ACLR using an all-inside BPTB autograft. Indications:Patient with symptomatic ACL stability and no signs of patella alta, as this increases the risk of graft-tunnel mismatch. Technique Description:Preoperative magnetic resonance imaging is reviewed for tendon length, along with the Ohio State University Graft Metrix Table, which is presented. The patient is positioned supine in a leg holder. Standard anterior incision for patellar tendon harvest is performed, paratenon is preserved, and a 13-mm long and 10-mm wide patellar bone block is harvested along with the middle-third patellar tendon and a 15 to 20 mm long and 10-mm wide tibial bone block. The tibial side is prepared for the femoral tunnel using standard adjustable loop fixation with a cortical button, and the patellar side for the tibial tunnel using quadriceps tendon adjustable loop fixation. Standard femoral and tibial all-inside tunnels are drilled with maximum sockets, and the graft is passed from the anteromedial portal into the joint, the bone plugs are pulled into the sockets, and the adjustable loop fixation is tightened. Results:No studies have reported on outcomes of all-inside BPTB ACLR. Soft-tissue graft all-inside fixation has been shown to lead to better patient-reported outcomes, less tunnel widening, better knee laxity, and less pain. Discussion/Conclusion:The all-inside ACLR with a BPTB graft is a safe and straightforward technique that can be performed using standard equipment. It has the aforementioned benefits of all-inside tunnel sockets and prevents the potential complications of screw fixation. Patient Consent Disclosure Statement:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication. Level of Evidence:Level 5.

Abstract:This cohort study aimed to identify whether time greater than 3 months between the onset of new symptoms of instability after primary anterior cruciate ligament (ACL) reconstruction (ACLR) and subsequent revision ACLR influences outcomes of revision surgery. We hypothesized greater than 3 months from onset of symptoms to revision ACLR is associated with increased intra-articular damage and poorer outcomes following revision ACLR. A retrospective chart review was conducted to identify patients who underwent revision ACLR at a large tertiary referral institution between 2008 and 2019. Demographic, surgical, and postsurgical data were collected. Patients who underwent revision ACLR within 3 months of documented graft symptomology were defined as the Early Revision group, and patients who underwent revision ACLR at or greater than 3 months after onset of graft symptomology were defined as the Late Revision group. Demographic data, intraoperative findings, subsequent graft failure, and patient-reported outcomes were compared between the groups. A total of 74 patients met inclusion criteria. Patients in the Late Revision group were more likely to have cartilage damage in the patella, trochlea, medial tibial plateau, lateral femoral condyle, and lateral tibial plateau. Patients in the Late Revision group were also more likely to have concomitant lateral meniscus tears. Medial meniscus tears identified at time of surgery in this group were also less likely to be deemed repairable. No significant differences were noted in postoperative Knee Injury and Osteoarthritis Outcome Scores, Marx Activity scores, or ACL graft retear risk based on the time from injury to surgery. Undergoing revision ACLR more than 3 months after graft tear is associated with more severe articular cartilage damage, more frequent lateral meniscus pathology, and a greater incidence of irreparable medial meniscus tears. No significant differences in patient-reported outcomes or revision graft failure risk were observed. Abstract:LEVEL OF EVIDENCE:  III.

PURPOSE:To assess the outcomes and complication rates of early weightbearing (either immediate weightbearing as tolerated or partial weightbearing) and delayed weightbearing (an initial period of non-weightbearing or toe-touch weightbearing) following distal femoral osteotomy (DFO). METHODS:A systematic literature search using PubMed, Embase and Cochrane Reviews was performed. Inclusion criteria were studies reporting on outcomes and complications after DFO with a minimum 1-year follow-up. Methodologic quality of studies was assessed using the methodological index for non-randomised studies (MINORS) criteria. Data collection included incidence of nonunion, delayed union, loss of fixation or deformity correction, knee stiffness, venous thromboembolism (VTE) and patient-reported outcome measures (PROMs). Meta-analysis was performed utilising random effects models, with statistically significant results denoted by a p-value < 0.05. RESULTS:Twenty-six studies (23 level IV and 3 level III) with 814 patients were included (mean age 42 years, mean follow-up 5.2 years). All but one study (25/26 [96.2%]) had moderate quality methodology. Statistical comparison was limited by low event frequency, and thus no statistically significant associations were identified, and p-values were omitted. The overall complication rates were nonunion 2.5% (95% confidence interval [CI] 1.6%-3.8%), delayed union 0.6% (95% CI 0.1%-3.3%), loss of fixation or deformity correction 1.4% (95% CI 0.5%-3.5%), knee stiffness 2.9% (95% CI 1.4%-6.1%), VTE 0.9% (95% CI 0.3%-2.3%). Validated PROMs were reported in 11 of 26 studies (42%) using heterogeneous instruments, precluding quantitative pooling and meta-analysis. CONCLUSIONS:There were relatively low overall mean rates of delayed union, nonunion, loss of fixation or deformity correction, and VTE after DFO, regardless of an early or delayed post-operative weightbearing protocol. Due to limited comparative data and the risk of selection bias, definitive conclusions cannot be drawn regarding the safety of early weightbearing after DFO, underscoring the need for prospective controlled studies. LEVEL OF EVIDENCE:Level IV.

BACKGROUND:Persistent knee pain can develop after anterior cruciate ligament injury with subsequent anterior cruciate ligament reconstruction (ACLR) despite a functionally intact graft. PURPOSE:To identify the prevalence of clinically significant knee pain in patients at 2, 6, and 10 years after ACLR. STUDY DESIGN:Cohort study; Level of evidence, 2. METHODS:3272 patients were enrolled into the Multicenter Orthopaedic Outcomes Network (MOON) between 2002 and 2008 across 7 centers. Each patient completed a questionnaire at baseline that included demographic characteristics, injury factors, participation in sports, and validated outcome measures including the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale (scored 0-100 with higher scores signifying less pain). Each patient completed the questionnaire again at 2, 6, and 10 years postoperatively. Three different criteria were used to define clinically significant knee pain: KOOS pain ≤70 points, KOOS pain ≤80 points, or responding "moderate,""severe," or "extreme" to a KOOS pain question. RESULTS:Median age in the cohort was 23 years (interquartile range, 17-27 years) at the time of enrollment, and 44% of patients were female. A total of 2798 patients (85%) responded to the questionnaire at 2 years postoperatively, with 2759 (84%) responding at 6 years and 2526 (77%) at 10 years. The prevalence of those with KOOS pain ≤70 was 9.3%, 9.0%, and 9.1% at 2, 6, and 10 years after surgery, respectively. The prevalence of KOOS pain ≤80 was 16.6%, 16.3%, and 15.7% at each timepoint, respectively. When a KOOS pain response of "moderate,""severe," or "extreme" was used, the prevalence was 26.3%, 22.9%, and 22.6% at 2, 6, and 10 years, respectively. Interestingly, very few patients had persistent pain at all 3 follow-up points: 48 (1.6%) reported a KOOS pain score ≤70 points, 103 (3.5%) reported a KOOS pain score ≤80 points, and 161 (5.6%) reported moderate or severe pain. CONCLUSION:The prevalence of clinically significant postoperative knee pain after ACLR was up to 26% at 2 years postoperatively, a percentage that remained unchanged or slightly decreased at 6- and 10-year follow-up. Despite this finding, it was uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints.

BACKGROUND:Anterior cruciate ligament (ACL) graft tears and contralateral ACL tears are both relatively common after primary ACL reconstruction (ACLR). There is little prior work comparing the outcomes of reconstruction after these injuries. HYPOTHESIS:The authors hypothesize that patient-reported outcome measures (PROMs) and activity level are lower after revision ACLR than after primary contralateral ACLR. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:From a cohort of 2333 patients who underwent primary unilateral ACLR, 267 were identified who underwent subsequent revision ACLR or primary contralateral ACLR within 5 years of primary ACLR. After exclusion of 11 patients who had both injuries, 256 were eligible for the study, including 124 who underwent revision ACLR and 132 who underwent primary contralateral ACLR. Patients were contacted for follow-up at 6 years after the primary ACLR, and PROMs were collected, including subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score for pain (KOOS-Pain) and knee-related quality of life (KOOS-QOL), and Marx activity level. Patient demographics, surgical factors, and PROMs were compared between groups. Beta regression models with identity link were used to determine whether side of subsequent surgery (revision vs primary contralateral ACLR) was a significant predictor of outcome. RESULTS:Of 256 patients, 223 (87%) were contacted and completed PROMs at 6 years after the primary ACLR. At baseline, there were no significant differences between groups except that the subsequent revision group had a lower incidence of partial lateral meniscectomy and a higher incidence of lateral meniscal repair and was more likely to have received allograft for the primary ACLR than the subsequent contralateral reconstruction group. The median time from primary ACLR to second ACL surgery was lower in the revision group (1.3 years) than the contralateral group (2.0 years; P < .001). When controlling for demographics, surgical factors, and baseline PROMS, the revision ACL group demonstrated a 7.8-point lower International Knee Documentation Committee score (P < .001), a 3.2-point lower KOOS-Pain score (P = .012), a 10.4-point lower KOOS-QOL score (P < .001), and 2.0-point lower Marx score (P = .002) than the contralateral ACLR group. CONCLUSION:Patients who undergo revision ACLR within 5 years of primary ACLR demonstrate poorer PROMs and lower activity levels than those who undergo primary contralateral ACLR during this period. These 2 groups of patients should not be pooled to study outcomes of ACLR.

Background: Proximal patellar tendinopathy is common in athletes, with a reported incidence up to 45% in jumping athletes, and can often be treated nonoperatively. If surgery is required, open debridement is often performed, but arthroscopic debridement has several advantages—including higher rates and earlier return to sports. Indications: Patients with (1) symptoms of anterior knee pain or pain with patellar tendon loading activities, (2) who have not responded to nonoperative treatment, and (3) have proximal partial articular-sided fraying of the patellar tendon on magnetic resonance imaging (MRI). Technique Description: The patient is positioned supine, and standard arthroscopy equipment is used. The anterolateral portal is created more laterally than the standard portal, and the anteromedial portal is created under vision more medially than the standard. The ligamentum mucosum and Hoffa's fat pad are debrided until the proximal part of the patellar tendon is visualized. A spinal needle is placed through the tendinopathy part of the tendon based on preoperative MRI. The tendon is debrided with a shaver from the anteromedial and later anterolateral portal until healthy intact patellar tendon fibers are visualized. Bony resection of the inferior pole of the patella is performed to avoid impingement. Results: Arthroscopic partial patellar tendon debridement has been shown to lead to superior outcomes compared to open debridement, with a treatment success of 91%, a return to sports of 96%, a return to the previous level of 77%, and a mean time to return to sports of 3.9 months. Inferior pole resection has been shown to be superior compared to no resection. Discussion/Conclusion: Arthroscopic debridement of proximal patellar tendinopathy with partial tearing is a minimally invasive and successful procedure and should be considered for athletes after failure of nonoperative treatment. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication. Level of Evidence: Level 3.

OBJECTIVE:To investigate the association of age, body mass index (BMI), and systemic indices of the immune system and inflammation with the odds of undergoing total knee arthroplasty (TKA) following anterior cruciate ligament reconstruction (ACLR). METHODS:This retrospective, case-control study consisted of three groups of patients that underwent ACLR: (1) those with a documented knee osteoarthritis (OA) diagnosis and TKA procedure (Cases, n = 15), (2) those without a documented knee OA diagnosis or TKA procedure (control-1 [CON1], n = 15), and (3) those with a documented knee OA diagnosis but without a TKA procedure after ACLR (control-2 [CON2], n = 15). Control groups were matched to the Cases (1:1:1) based on sex and date of ACLR. Logistic regression analyses consisted of two models. Model 1 examined risk factors of TKA (Cases vs CON1 and CON2) and Model 2 examined risk factors of a documented knee OA diagnosis (Cases and CON2 vs CON1) following ACLR. Risk factors included age at ACLR, BMI, and systemic indices of the immune system and inflammation (systemic inflammation response index, systemic immune-inflammatory index [SII], and neutrophil-to-lymphocyte, platelet-to-lymphocyte [PLR], and monocyte-to-lymphocyte ratios). RESULTS:Increased age (p = 0.01) and BMI (p < 0.01) were associated with significantly high odds of undergoing TKA. Increased BMI (p = 0.02) and PLR (p = 0.05) and decreased SII (p = 0.03) were risk factors for a documented knee OA diagnosis. CONCLUSION:Increased BMI and systemic inflammatory-immune indices associated with increased odds of subsequent knee OA diagnosis following ACLR. Increased age and BMI associated with increased odds of subsequent knee OA diagnosis and TKA following ACLR. LEVEL OF EVIDENCE:III. What are the new findings?

Background: Medial meniscal repair performed at the time of primary anterior cruciate ligament reconstruction (ACLR) has been shown to be significantly associated with subsequent surgery, and subsequent surgery has been associated with increased Knee injury and Osteoarthritis Outcome Score (KOOS) pain score and decreased patient satisfaction. Hypothesis/Purpose: The purpose was to determine if medial meniscal repair decreases KOOS pain 10 years after ACLR and to assess the consequences of subsequent surgery on the development of KOOS pain. The authors hypothesized that medial meniscal repair performed at the time of primary ACLR decreases the likelihood of developing KOOS pain. It was further hypothesized that surgery performed subsequent to medial meniscal repair and primary ACLR increases KOOS pain 10 years after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Our inclusion criteria were all patients undergoing unilateral primary ACLR from 2002 to 2008 who were enrolled in the Multicenter Orthopaedic Outcomes Network without a history of medial or lateral meniscal surgery and contralateral ACLR. Causal mediation analysis using R software (Version 4.2.3) was employed to compare 2 effects on the development of significant knee pain, as represented by a KOOS pain score <80, at 10-year follow-up: (1) medial meniscal repair for longitudinal tears >10 mm in medial-to-lateral length and (2) medial meniscal excision at baseline of ACLR. A directed acyclic graph was constructed to provide a qualitative representation of the influence of known confounders that have been shown to affect the outcome of interest. Missing data were multiply imputed using multivariate imputation by chained equations. All tests were 2-sided, assuming a type I error rate of .05. Results: In total, 2387 participants (1074 female [45%]; 1313 male [55%]) were included in the final analysis. In 1502 (62.9%) cases, there was no medial meniscal tear reported. Of the 885 cases with medial meniscal tears, no treatment was performed in 109 (12.4%), meniscal excision was performed in 396 (44.7%), and meniscal repair was performed in 380 (42.9%). An overall 1825 of 2387 (76.5%) patients reported KOOS pain at 10-year follow-up: 252 (13.8%) had KOOS pain <80 and 1573 had ≥80. In the KOOS pain <80 group, 75 (29.8%) had subsequent surgery. In the KOOS pain ≥80 group, 223 (14.2%) had subsequent surgery. The step-by-step approach to causal mediation analysis demonstrated that a medial meniscal procedure (ie, no treatment for the tear, repair, or excision) significantly affected the likelihood of subsequent surgery (χ 2 = 28.9; P < .001) and subsequent surgery significantly increased the likelihood of KOOS pain <80 (χ 2 = 17.3; P < .001). However, the direct effect of a successful medial meniscal repair without subsequent surgery decreased the likelihood of KOOS pain <80 by 7.1% when compared with medial meniscal excision (95% CI, –13.3% to −1%; P = .024). When subsequent surgery was performed after medial meniscal repair and ACLR, the likelihood of KOOS pain <80 increased by 2.9% (95% CI, 1.1%-5.3%; P < .001.) Conclusion: Successful medial meniscal repair performed at the time of primary ACLR decreased clinically significant knee pain 10 years postoperatively. However, the mediating effect of subsequent surgery was significant and diminished the overall contribution of medial meniscal repair in decreasing the likelihood of KOOS pain. Continued efforts should be made to decrease the likelihood of subsequent surgery after medial meniscal repair performed at the time of primary ACLR.

Purpose:The purpose of this study was to investigate the association of age at anterior cruciate ligament reconstruction (ACLR) with systemic indices of the immune system and inflammation after surgery. Methods:This study consisted of a retrospective, cohort design. Patients (male and female, ≥18 years) that underwent ACLR at a single academic institution and with complete blood cell (CBC) count data obtained ≥ 1-year after surgery were included. Patients with a documented diagnosis of knee osteoarthritis (OA) before ACLR were excluded, while those with a documented diagnosis of knee OA after ACLR were included in this study. The systemic inflammation response index (SIRI), systemic immune-inflammatory index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) were calculated from the CBC data. Patients (n = 198) were separated into groups based on age at ACLR: (1) 18-29 y (n = 96), (2) 30-39 y (n = 50), or (3) ≥40 y (n = 52). Results:Subject characteristics (patient sex, height, body mass, and body mass index), follow-up interval, time from ACLR to CBC assessment, and concomitant procedures performed at ACLR were not significantly different between age groups. The PLR, NLR, MLR, and SII were not significantly different between groups, while the SIRI was significantly lower in the 30-39 (p < 0.01) and ≥40 y (p < 0.01) groups compared to the 18-29 y group. An older age at ACLR (i.e., 30-39 y and ≥40 y) was associated with an increased occurrence (11.5 and 12 %, respectively) of a knee OA diagnosis following surgery compared to that in the younger age group (18-29 y, 1.0 %; p = 0.04). Conclusion:We conclude that an older age at ACLR associated with a lower systemic inflammatory response index at a minimum of 1-year following surger. Level of evidence:Level III.

Background:In recurrent patellar instability, medial patellofemoral ligament reconstruction (MPFLR), with or without concomitant bony procedures, has become the treatment of choice to stabilize the patellofemoral joint. In the setting of recurrent patellar instability after primary MPFLR, revision MPFLR can be considered. Numerous potential risk factors for failure of isolated primary MPFLR have been evaluated with mixed findings. Purpose/Hypothesis:The purpose of this study was to compare anatomic and demographic patient characteristics between patients undergoing primary and revision MPFLR. It was hypothesized that patients undergoing revision MPFLR will demonstrate a higher prevalence of anatomic risk factors and J-tracking and will demonstrate more articular cartilage damage than patients undergoing primary MPFLR. Study Design:Cross-sectional study; Level of evidence, 3. Methods:A retrospective chart review was performed to identify patients who underwent primary MPFLR between 2009 and 2021 and revision MPFLR between 2009 and 2023. Patients were categorized into 2 groups based on whether they underwent primary or revision MPFLR. Demographic (age, sex, and body mass index [BMI]), anatomic characteristics (patellar height, trochlear morphology, and tibial tubercle-trochlear groove distance), physical examination findings (presence or absence of a J-sign), and intraoperative findings (articular cartilage damage of the patellofemoral joint) were compared between these groups. Results:A total of 164 patients who underwent MPFLR within this period, including 26 revision and 138 primary procedures, were evaluated. No difference in patient age, sex, or any measure of patellar height was noted between the 2 groups. The revision MPFLR group was noted to have a higher BMI (29.9 kg/m2 vs 27.2 kg/m2; P = .036), a higher mean sulcus angle (145° vs 140°; P = .007), more frequent presence of a crossing sign (77% versus 18%; P < .001), and were more likely to have a J-sign (42% vs 22%; P = .048) than the primary MPFLR group. Intraoperatively, the revision MPFLR group had a higher prevalence of articular cartilage damage (81% versus 37%; P < .0001) than the primary MPFLR group. Conclusion:Patients undergoing revision MPFLR had more prior patellar dislocations, higher BMI, and more trochlear dysplasia (increased sulcus angle and more frequent crossing sign) than those undergoing primary MPFLR. The revision group was also more likely to have a J-sign on clinical examination and patellar articular cartilage damage at the time of arthroscopy.

Background:The effect of body mass index (BMI) on complication risk, recurrent instability risk, and patient-reported outcomes (PROs) after surgical intervention for recurrent patellar instability is unclear. Purpose/Hypothesis:The purpose was to evaluate the differences in complications, recurrence, and PROs in obese and nonobese patients undergoing isolated medial patellofemoral ligament reconstruction (MPFLR). It was hypothesized that obesity is associated with increased complication risk, increased risk of recurrent patellar instability, and poorer PROs after MPFLR. Study Design:Cohort study; Level of evidence, 3. Methods:A retrospective review identified all patients who underwent isolated MPFLR over an 8.5-year period at an academic medical center. Records were reviewed for demographic, physical examination, radiographic, surgical, and clinical outcome data. Patients were contacted to collect PROs, including the Norwich Patellar Instability score, Marx activity scale score, and Knee injury and Osteoarthritis Outcome Score (KOOS). Patients were stratified by BMI (<30 and ≥30 kg/m2 for primary analysis and then by ≥35 kg/m2 for secondary analysis) and complications and outcomes were compared. Regression analysis was then performed to evaluate the effects of increased BMI on PROs. Results:The records of 107 patients were analyzed in this investigation. Complication rates were similar across groups. Patients with a BMI ≥35 kg/m2 demonstrated a lower Marx activity scale score compared with those with a BMI <30 kg/m2 (P = .039). Regression analysis demonstrated no association between BMI and PROs adjusting for age, sex, and articular cartilage damage. Conclusion:No significant differences in complications or repeat dislocation risk after isolated MPFLR were noted based on BMI ≥30 or <30 kg/m2. Patients with a BMI ≥35 kg/m2 demonstrated lower activity level, but no other differences in PROs compared with patients with a BMI <30 kg/m2.

BACKGROUND:Advancements in technology and techniques have shaped meniscus repair outcomes, but long term results remain unclear. This review aims to comprehensively evaluate studies with a mean follow-up of greater than 10 years following inside-out, outside-in, all-inside, open, or pull-out repair techniques. In addition, this article will review the impact of concomitant anterior cruciate ligament (ACL) reconstruction on long-term meniscus repair outcomes and compare osteoarthritis risk of patients treated partial meniscectomy compared with meniscus repair. We hypothesize there is increased evidence of osteoarthritis following partial meniscectomy compared to all types of meniscal repair. METHODS:PubMed and EMBASE databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria included full-text English language, human patients with at least one outcome reported after meniscus repair, and publication before June 22, 2021. Exclusion criteria included mean follow up of less than 10 years, published before the year 2000, or significant concomitant procedures within the knee during meniscus repair. RESULTS:Inside-out, all-inside, trans-tibial pull-out, and open repair techniques of meniscal tears demonstrate clinical success and good long-term outcomes. Data regarding the impact of concomitant anterior cruciate ligament reconstruction on meniscus repair outcomes are conflicting. The risk of osteoarthritis is reduced in meniscal repair when compared with partial meniscectomy. CONCLUSION:Outcomes of meniscus repair are favorable at 10 years post-operative regardless of technique. While the impact of concomitant ACL reconstruction on meniscus repair outcomes is unclear, meniscus repair is associated with decreased osteoarthritis risk compared to partial meniscectomy. Level of evidence IV; systematic review of level III-IV studies.