Krych, Aaron J

Background: Osteochondral allograft transplant and autograft transplant for femoral head defects have emerged as promising treatments for concomitant cartilage and subchondral bone injuries in young patients. Purpose: To evaluate the clinical and radiological outcomes of patients who underwent osteochondral allograft or autograft transplant for femoral head defects and identify any risk factors that may lead to conversion to total hip arthroplasty (THA). Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent osteochondral allograft or autograft transplant for femoral head defects across 2 institutions were analyzed. Clinical outcomes were assessed at final follow-up with the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool (iHOT-12). Complications and reoperations were recorded. Patients were assessed radiographically preoperatively and at final follow-up for osteoarthritis using Tönnis grading. Results: A total of 27 patients were included in this study (19 osteochondral allograft transplant, 8 osteochondral autograft transplant). The mean follow-up for the allograft and autograft cohorts was 2.8 and 9.5 years, respectively. The mean defect size for patients who underwent allograft and autograft transplant was 2.8 × 2.1 cm and 1.6 × 1.0 cm, respectively. The mean mHHS, HOS-ADL, HOS-SSS, and iHOT-12 for the allograft cohort were 86.7, 92.8, 81.4, and 79.0, respectively, and for the autograft cohort were 87.6, 92.7, 83.1, and 82.0, respectively. No significant difference in outcomes was noted for patients who underwent femoral head allograft versus nonorthotopic femoral condyle allograft transplant. For the allograft cohort, 4 patients (21.1%) underwent conversion to THA at a mean of 1.9 years. Of the remaining 15 allograft patients, only 1 patient (6.7%) had radiographic osteoarthritis progression. None of the patients in the autograft cohort underwent conversion to THA. Conclusion: Osteochondral allograft and autograft transplant for femoral head defects demonstrated overall favorable clinical outcomes and rates of conversion to THA. Additionally, nonorthotopic femoral condyle allografts demonstrated similar outcomes to femoral head allografts. Both osteochondral allograft and autograft transplant should be considered for patients with focal femoral head defects.

Abstract Hip chondral defects often are encountered at the time of hip arthroscopy and can result in substantial pain and dysfunction. With the evolution of cell‐based techniques, there is growing interest in single‐stage, arthroscopic treatment of such chondral lesions. Arthroscopic orthobiologic delivery remains technically challenging, given the constrained and concave nature of the acetabulum and the need to perform instrumentation taking into account nearby structures such as the articular surface, hip capsule, and labrum. In this Technical Note, we describe our preferred method for arthroscopic delivery of orthobiologics at the time of single‐stage cartilage repair, which allows for needle‐based transcapsular, translabral access of hip chondral defects for both the acetabulum and femoral head. Technique Video video See video under supplementary data.

» Femoroacetabular impingement (FAI) is the premature contact of the femoral head-neck junction with the superior acetabular rim during hip range of motion, which may further damage intra-articular soft tissue structures and lead to the accelerated development of osteoarthritis. » FAI syndrome is diagnosed by a triad of symptoms, clinical signs, and imaging findings, and is a common cause of hip pain in young patients that have a significant impact on patient hip-related function and quality of life. » The treatment of FAI syndrome begins with noninvasive nonoperative modalities such as patient education and supervised exercise-based physical therapy. For recalcitrant symptoms, various injections have been explored for both diagnostic and therapeutic purposes; however, the efficacy of these interventions have generally not been demonstrated outside of the short term » In this article, we examine the available literature regarding the nonoperative treatment of FAI and provide insight into the effectiveness of current treatment modalities.

Abstract The ability of the knee to resist valgus stress is largely a result of the integrity of the superficial medial collateral ligament (MCL) and neighboring supporting structures (i.e., deep MCL, semimembranosus, and posterior oblique ligament). The MCL is known to have a robust healing capacity; consequently, the decision to proceed with operative versus nonoperative management of even grade III MCL tears is controversial. When it comes to operative management of these injuries, the decision to proceed with repair or reconstruction is nuanced because the chronicity and location of the MCL tear (i.e., proximal, midsubstance, or distal) largely determine which technique is appropriate. In distal MCL avulsions, including the so‐called Stener lesion, with good tissue quality, direct MCL repair has shown excellent mid‐term outcomes. Consequently, there is a growing need to understand different techniques to address MCL incompetence. In this article, we present a method for primary MCL repair using a washer post–suture post construct. Technique Video video See video under supplementary data.

Abstract There are multiple underlying etiologies of patellar instability including both osseous and soft‐tissue factors. Obligate flexion dislocation consists of lateral dislocation of the patella, occurring each time the knee flexes. This generally results from a predominantly lateral contracture of the extensor mechanism and can be technically challenging to manage. Quadricepsplasty can be of particular clinical utility for obligate flexion dislocation and constitutes a realignment of the proximal soft‐tissue attachments of the patella. The described technique features isolation of the 4 muscles of the quadriceps and subsequent stepwise lengthening of the vastus lateralis, advancement of the vastus medialis obliquus, and Z‐lengthening of the rectus femoris and vastus intermedius. This technique can be used in isolation or in combination with other procedures, such as medial patellofemoral ligament reconstruction, to surgically address patellofemoral maltracking. Technique Video video See video under supplementary data.

Background: While patients may report painful or prominent hardware after tibial tubercle osteotomy (TTO), little is known about the frequency, associated factors, and outcomes after removal of symptomatic hardware. Purpose/Hypothesis: The purpose was to investigate the incidence of hardware removal after TTO due to pain or complications, factors associated with hardware removal, and postoperative outcomes after removal. It was hypothesized that clinical outcomes would be similar between patients who underwent TTO without hardware removal and those who underwent TTOs and subsequently hardware removal. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis was performed on patients who underwent TTO at a single institution from 2000 to 2023. Age at the time of the index surgery, sex, race, body mass index, number and size of screws, tibial tubercle–trochlear groove distance, and reason for hardware removal were collected retrospectively. Knee radiographs were reviewed for measurement of soft tissue–hardware distance. Patients were contacted via email to capture final patient-reported outcome measures (PROMs). A univariate logistic regression model was used to determine factors associated with hardware removal. Results: A total of 152 patients representing 171 knees were included. Of the overall cohort, 38 knees (22.2%) in 32 patients underwent TTO with subsequent hardware removal. The most common reason for hardware removal was anterior knee pain (79%). Compared with patients aged 11 to 20 years, patients aged 21 to 30 years demonstrated higher odds of undergoing hardware removal (OR, 3.67; 95% CI, 1.51-9.44; P = .009). Compared with a soft tissue–hardware distance of 0 to 4.9 mm, a distance of 10.0 to 14.9 mm demonstrated lower odds of hardware removal (OR, 0.24; 95% CI, 0.07-0.84; P = .027). Visual analog scale scores (0-10 scale) improved by a mean of 3.6 points after hardware removal ( P = .003). In patients undergoing hardware removal for pain, no difference in final PROMs was found compared with patients who underwent TTO without hardware removal. Conclusion: Hardware removal in patients undergoing TTO was mainly attributed to hardware-related pain/irritation. On average, pain scores improved after hardware removal. There was no difference in final PROMs between patients who had their hardware removed due to pain (eg, without any clinically relevant concomitant pathology) and patients who did not require hardware removal. Size and number of screws were not associated with a subsequent hardware removal procedure. The thickness of the soft tissue envelope overlying implanted hardware was inconsistently associated with lower odds of hardware removal.

Abstract Hip arthroscopy is a technically demanding procedure that can require a substantial volume of irrigation fluid. Techniques should be explored to optimize fluid use while ensuring satisfactory surgical instrumentation and labral repair. In this technical note, we present a method for performing a dry arthroscopic labral repair. This technique can be used in the treatment of a variety of labral pathologies, including primary labral repair with knotless or hand‐tied anchors, revision labral repair, and labral reconstruction, without the need for irrigation fluid. Additionally, we discuss supplemental techniques that can be used during other portions of the arthroscopic hip procedure to limit irrigation fluid use. Technique Video video See video under supplementary data.

Abstract The standard of care for hip labral tears is arthroscopic repair, with labral reconstruction performed more commonly for irreparable tears in order to avoid isolated labral debridement. However, labral reconstruction can be technically demanding. We provide a concise step‐by‐step guide for performing labral reconstruction or augmentation using a modified retrograde pull‐through technique, including tips, tricks, and surgeon pearls, and pitfalls. Despite the procedure's technically challenging nature, we believe our technique highlights several important steps to improve the practicality and efficiency of the case and produce satisfactory patient outcomes. Technique Video video See video under supplementary data.

Background: Nonoperative and operative management techniques after anterior cruciate ligament (ACL) injury are both appropriate treatment options for selected patients. However, the subsequent development of posttraumatic knee osteoarthritis (PTOA) remains an area of active study. Purpose: To compare the risk of PTOA between patients treated without surgery and with ACL reconstruction (ACLR) after primary ACL disruption using a machine learning causal inference model. Study Design: Cohort study; Level of evidence, 3. Methods: A geographic database identified patients undergoing ACLR between 1990 and 2016 with minimum 7.5-year follow-up. Variables collected include age, sex, body mass index, activity level, occupation, relevant comorbid diagnoses, radiographic findings, injury characteristics, and clinical course. Treatment effects of ACLR on the development of PTOA and progression to total knee arthroplasty (TKA) were analyzed with machine learning models (MLMs) in a causal inference estimator (targeted maximum likelihood estimation, TMLE), while controlling for confounders. Results: The study included 1194 patients with a minimum follow-up of 7.5 years, among whom 974 underwent primary reconstruction and 220 underwent nonoperative treatment. A total of 215 (22%) patients developed symptomatic PTOA in the ACLR group compared with 140 (64%) in the nonoperative treatment group ( P < .001), whereas 25 (3%) patients underwent TKA in the ACLR group compared with 50 (23%) in the nonoperative treatment group ( P < .001). Patients in the ACLR group had delayed TKA compared with patients in the nonoperative treatment group (193.4 vs 166.0 months, respectively; P = .02). TMLE evaluation revealed that reconstruction decreased the risk of PTOA by 11% (95% CI, 8%-13%; P < .001) compared with nonoperative treatment but did not demonstrate a significant effect on the rate of progression to TKA. Survival analysis with random forest algorithm demonstrated significant delay to the onset of PTOA as well as time to progression of TKA in patients undergoing ACLR. Additional risk factors for the development of PTOA, irrespective of treatment, included older age at injury, greater body mass index, total number of arthroscopic knee surgeries, and residual laxity at follow-up. Conclusion: MLMs in a causal inference estimator found ACLR to exert a significant treatment effect in reducing the rate of development of PTOA by 11% compared with nonoperative treatment. ACLR also delayed the onset of PTOA and progression to TKA.

Background: Recent biomechanical evidence for adjustable suture anchor (ASA)–based posterior medial meniscus root (PMMR) fixation has shown promising results compared with conventional transtibial pull-out repair (TPOR). However, ASA fixation has not been evaluated in human tissue to 100,000 cycles. Hypothesis: ASA repair would lead to increased primary fixation strength and less cyclic displacement than conventional TPORs. Study Design: Controlled laboratory study. Methods: A total of 32 human medial menisci were used, 8 of which were intact specimens and served as native controls. For the others, PMMR tears were created and repaired using 3 different techniques (n = 8 group). Two conventional PMMR repairs were prepared consisting of two No. 2 simple sutures (TSS) and two No. 2 sutures in a Mason-Allen (MA) configuration, all tied over a cortical button. The knotless ASA repair was fixed in MA with repair sutures tensioned at 120 N (MA-120). The repairs’ initial force, stiffness, and relief displacement from the tensioned state toward repair unloading (2 N) were measured after fixation. All repair constructs were loaded for 100,000 cycles, with displacement and stiffness measured, and finally were pulled to failure. Results: The TPORs demonstrated similar primary fixation and cyclic loading behavior except for initial cyclic displacement (cycle 10). The ASA repair provided a higher initial repair load ( P < .001) and stiffness ( P < .001) with relief displacement similar to conventional TPORs. Lower initial cyclic displacement ( P < .011; cycle 10) with overall higher repair stiffness ( P < .011) resulted in significantly lower displacement ( P < .001) throughout testing for ASA repair. Although both TPORs were completely loose after 100,000 cycles, the ASA repair achieved near-native dynamic meniscal stabilization. The TSS repair had lower overall ultimate load ( P < .001) and ultimate stiffness ( P < .023) compared with the ASA repair. All repairs had lower ultimate stiffness and loads than the native meniscus ( P < .001). Conclusion: The ASA repair resulted in improved primary PMMR fixation that was stiffer with less cyclic displacement than conventional TPORs and approached that of the human meniscal function after 100,000 load cycles in a cadaveric model. However, all repair techniques had lower ultimate strength than the native human PMMR. Clinical Relevance: Knotless ASA meniscus root fixation resulted in higher tissue compression and less displacement in a cadaveric model; however, future clinical series with surveillance imaging will define the overall significance of healing rates.