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We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis , and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction., Competing Interests: None declared., (Thieme. All rights reserved.)

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., Competing Interests: None declared., (Thieme. All rights reserved.)

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 cm 2 . 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., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

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., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

We reviewed the literature regarding utility of biologic augmentation in meniscal repair. We hypothesized that the addition of biologic augmentation during meniscal repair improves postoperative knee function and reduces risk of repair failure. PubMed and Embase databases were systematically searched. Included studies were clinical studies in humans, published in English, and reported use of biologic augmentation techniques in addition to meniscal repair (including platelet-rich plasma [PRP], fibrin clot, bone marrow stimulation, meniscal wrapping, and bioscaffolds) for treatment of knee meniscal tears. Outcome measures included repair failure, repeat knee arthroscopic surgery, and magnetic resonance imaging), visual analog scale for pain, the International Knee Documentation Committee questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index Lysholm's Knee Scoring Scale, and the Knee Injury and Osteoarthritis Outcome Score. Study quality was assessed using the modified Coleman methodology score. Nineteen studies reported repair of 1,092 menisci including six studies that investigated fibrin clot augmentation, five studies that investigated PRP augmentation, three studies that investigated bone marrow stimulation augmentation, two studies that used meniscal wrapping augmentation, and three studies that used other techniques. The level of evidence ranged from I to IV and mean modified Coleman methodology score was 43 (range: 17-69), with higher scores noted in studies completed in recent years. PRP and bone marrow stimulation augmentation appear to decrease risk of failure in patients undergoing isolated meniscal repair but do not improve knee symptom scores. Fibrin clot and trephination augmentation techniques do not have sufficient evidence to support decreased failure risk at this time. Meniscal wrapping augmentation and scaffold implantation augmentation appear to be an attractive option to meniscectomy in complicated tears that are not candidates for repair alone, but further confirmatory studies are needed to support initial data. Evidence supporting augmentation of meniscal repair is limited at this time but suggests that the highest likelihood for effectiveness of augmentation is in the settings of isolated meniscal repair or meniscal repairs that would normally not be amenable to repair., Competing Interests: None declared., (Thieme. All rights reserved.)

Level of Evidence: V, Expert opinion., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

We sought to determine the impact of bacterial inoculation and length of exposure on the mechanical integrity of soft tissue tendon grafts. Cultures of Staphylococcus epidermidis were inoculated on human tibialis posterior cadaveric tendon to grow biofilms. A low inoculum in 10% growth medium was incubated for 30 min to replicate conditions of clinical infection. Growth conditions assessed included inoculum concentrations of 100, 1000, 10,000 colony-forming units (CFUs). Tests using the MTS Bionix system were performed to assess the influence of bacterial biofilms on tendon strength. Load-to-failure testing was performed on the tendons, and the ultimate tensile strength was obtained from the maximal force and the cross-sectional area. Displacements of tendon origin to maximal displacement were normalized to tendon length to obtain strain values. Tendon force-displacement and stress-strain relationships were calculated, and Young's modulus was determined. Elastic modulus and ultimate tensile strength decreased with increasing bioburden. Young's modulus was greater in uninoculated controls compared to tendons inoculated at 10,000 CFU (p = 0.0011) but unaffected by bacterial concentrations of 100 and 1000 CFU (p = 0.054, p = 0.078). Increasing bioburden was associated with decreased peak load to failure (p = 0.043) but was most significant compared to the control under the 10,000 and 1000 CFU growth conditions (p = 0.0005, p = 0.049). The presence of S. epidermidis increased elasticity and decreased ultimate tensile stress of human cadaveric tendons, with increasing effect noted with increasing bioburden., (© 2022 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals LLC on behalf of Orthopaedic Research Society.)

Purpose: To evaluate the recurrent dislocation risk and patient-reported outcomes of peroneus longus allograft tissue for medial patellofemoral ligament (MPFL) reconstruction., Methods: Patients who underwent MPFL reconstruction with peroneus longus allograft at an academic center between 2008 and 2016 were identified. Record review and patient contact were used to identify any cases of recurrent patellar dislocation and collect patient-reported outcomes scores (Knee injury and Osteoarthritis Outcome Score [KOOS], Norwich Patellar Instability score, Marx activity scale). Patients with 1-year minimum follow-up were included. Outcomes were quantified and the proportion of patients reaching a previously defined patient acceptable symptom state (PASS) for patellar instability was determined., Results: Sixty-one patients (42 female and 19 male) underwent MPFL reconstruction with peroneus longus allograft during the study period. Forty-six patients (76%) with 1-year minimum follow up were contacted at a mean of 3.5 years postoperative. The mean age at time of surgery was 22 ± 7.2 years. Patient-reported outcomes data were available in 34 patients. Mean KOOS subscale scores were as follows: Symptoms 83.2 ± 19.1, Pain 85.2 ± 17.6, Activities of Daily Living 89.9 ± 14.8, Sports 75 ± 26.2, and Quality of Life 72.6 ± 25.7. The mean Norwich Patellar Instability score was 14.9% ± 17.4%. The mean Marx activity score was 6.0 ± 5.2. No recurrent dislocations were noted during the study period. Sixty-three percent of patients who underwent isolated MPFL reconstruction met PASS thresholds in at least 4 of 5 KOOS subscales., Conclusions: The use of a peroneus longus allograft in MPFL reconstruction in conjunction with other indicated procedures results in a low re-dislocation risk and a high proportion of patients meeting PASS criteria for patient-reported outcome scores 3 to 4 years postoperatively., Level of Evidence: IV, case series., (© 2022 The Authors.)

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 (R 2  = 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., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Patella alta and elevated tibial tubercle-trochlear groove (TT-TG) distance can predispose patients to lateral patellar dislocations and recurrent instability. Their influence on patient-reported outcomes (PROs) after medial patellofemoral ligament (MPFL) reconstruction is less clear., Hypothesis: We hypothesized that neither moderately increased TT-TG distance nor patella alta would negatively affect PROs after isolated MPFL reconstruction in patients with relatively normal patellar tracking (no large J-sign)., Study Design: Cohort study; Level of evidence, 3., Methods: We identified patients who underwent isolated MPFL reconstruction at a single institution between 2008 and 2016. The decision to perform an isolated MPFL reconstruction was at the discretion of the operating surgeon but was not performed in the setting of a large J-sign. Patient characteristics and surgical details were collected, and patients completed the Norwich Patellar Instability Score, Knee injury and Osteoarthritis Outcome Score, and Marx activity score. Patellar height (Caton-Deschamps Index [CDI]) was assessed on preoperative lateral radiographs, and TT-TG distance was measured on preoperative axial magnetic resonance imaging (MRI) scans. Patients were grouped based on CDI and TT-TG distance, and outcomes were compared. Linear regression modeling was performed to determine whether patella alta or elevated TT-TG distance was associated with poorer PRO scores., Results: Of 165 knees in 152 patients who underwent isolated MPFL reconstruction, 115 patients (125 knees; 76%) with minimum 1-year follow-up were contacted at a mean of 5.2 years after surgery. Recurrent dislocation occurred in 5 of 125 knees (4%). Preoperative radiographs were available in 111 knees (89%), and preoperative MRI scans were available in 89 knees (71%). Mean CDI was 1.13, and 35% had a CDI ≥1.20. Mean TT-TG distance was 17.5 mm, and 26% had a TT-TG distance >20 mm. After adjusting for patient age, sex, body mass index, and graft choice, we observed that neither patella alta nor elevated TT-TG distance were associated with poorer PROs., Conclusion: Isolated MPFL reconstruction in the setting of moderately elevated TT-TG distance or patella alta was not associated with worse PROs in this cohort with relatively normal patellar tracking (no large J-sign)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.C.F. has received education payments from CDC Medical; consulting fees from Bioventus, Ceterix, DePuy/Medical Device Business Services, Linvatec, Smith & Nephew, Vericel, and Zimmer Biomet; nonconsulting fees from Smith & Nephew and Karl Storz Endoscopy America; and honoraria from Vericel. M.D. has received education payments from Smith & Nephew. R.D. has received grant support from Arthrex and education payments from Arthrex and Smith & Nephew. C.K.K. has received grant support from DJO, education payments from CDC Medical, consulting fees from Arthrex and Zimmer Biomet, and nonconsulting fees from Arthrex and Smith & Nephew. R.A.M. has received grant support from DJO and education payments from CDC Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: We evaluated the risk factors for pain catastrophizing, kinesiophobia, and elevated depressive symptoms among patients undergoing high-grade cartilage defect surgery. We hypothesized that cartilage patients would demonstrate high scores on pain catastrophizing, kinesiophobia, and depression testing prior to surgery., Methods: Two hundred and ten patients undergoing surgery for high-grade cartilage defects (56% chondroplasty, 36% microfracture, 22% autologous chondrocyte implantation) completed a preoperative survey before undergoing surgery. Outcome scores assessed were: International Knee Documentation Committee-Symptom (IKDC-S) score, Tegner activity score, Pain catastrophizing scale (PCS), Tampa scale for kinesiophobia (TSK-11), and Patient Health Questionnaire depression scale (PHQ-9). Multivariate logistic regression was used to determine what pre-operative factors predicted pain catastrophizing, kinesiophobia, and elevated depressive symptoms., Results: The mean pre-operative Tegner score was 5.8 (SD 2.4) and IKDC-S score was 44.7 (SD 11.1). Prior to surgery, 19% had abnormal pain catastrophizing (PCS ≥ 20 points), 14.4% had moderate-severe depression (PHQ ≥ 10), and 49.0% had high kinesiophobia (TSK-11 ≥ 25). Lower pre-operative Tegner scores predicted moderate-severe depressive symptoms (per point decrease, OR 1.36, 95% CI 1.06, 1.76; p = 0.008). Predictors of elevated pain catastrophizing were lower pre-operative IKDC-S scores (per 5-point decrease, OR 1.28, 95% CI 1.08, 1.51; p = 0.002) and symptom duration >6 months (OR 2.20 CI 1.14, 4.32; p = 0.02). A lower pre-operative IKDC-S score (per 5-point decrease, OR 1.17, CI 1.03, 1.33; p = 0.02) predicted elevated kinesiophobia., Conclusion: Low self-reported function, low activity level and symptom duration greater than six months are associated with poor preoperative psychological status., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: The objective of this study was to assess potential risk factors, including time delay until implantation, for knee cartilage defect expansion or new high-grade defect formation between biopsy and Autologous Chondrocyte Implantation (ACI) or Matrix Autologous Chondrocyte Implantation (MACI)., Study Design: Consecutive knee ACI and MACI cases by a single surgeon ( n = 111) were reviewed. The relationship between time between biopsy and staged implantation and (1) progression in primary cartilage defect size and (2) development of a new high-grade (Outerbridge grade ≥3) cartilage defect were determined with adjustment for demographics, body mass index, smoking status, coronal alignment, initial cartilage status, and prior surgery., Results: Average size of the primary defect at time of biopsy was 4.50 cm 2 . Mean time to chondrocyte implantation was 155 days. Defect expansion increased 0.11 cm 2 (standard error = 0.03) per month delay to implantation ( P = 0.001). Independent predictors of defect expansion were male sex, smaller initial defect size, and delay to implantation (adjusted mean = 0.15 cm 2 expansion per month). A total of 16.2% of patients ( n = 18/111) developed a new high-grade defect. Independent predictors of a new secondary defect were Outerbridge grade 2 changes (vs. 0-1) on the surface opposing the index defect and delayed implantation (per month increase, adjusted odds ratio = 1.21, 95% confidence interval: 1.01-1.44; P = 0.036)., Conclusions: Patients undergoing 2-stage cell-based cartilage restoration with either ACI or MACI demonstrated long delays between stages of surgery, placing them at risk for expanding defects and development of new high-grade cartilage defects. Patients who were male, had smaller initial defect size, and longer time between surgeries were at greater risk for defect expansion., Level of Evidence: III, retrospective comparative study.

Objective: To determine whether there are differences in symptomatic knee cartilage defects and rates of tobacco use among age-matched athletes versus nonathletes undergoing initial arthroscopic knee surgery who meet demographic and radiographic criteria for cartilage restoration surgery., Design: Age-matched athletes ( n = 186) and nonathletes ( n = 159) age 40 or less with a body mass index (BMI) of 35 kg/m 2 or less (mean 26.8 SD 4.1) and <50% joint space narrowing on weight-bearing radiographs were included. All patients had a symptomatic Outerbridge grade 2 or higher cartilage defect visualized during knee arthroscopy. Relationship between athletic status and chronicity of knee symptoms prior to surgery and tobacco use status, cartilage defect Outerbridge grade, size, and location at time of surgery were characterized., Results: Nonathletes were more likely to smoke ( P < 0.001) and had higher BMI ( P = 0.005). Duration of symptoms prior to surgery was shorter among athletes ( P < 0.001). Grade 4 defects were equally prevalent ( P = 0.96) as were multicompartment grade 3-4 lesions ( P = 0.12). Mean grade 3-4 defect size was similar in lateral ( P = 0.96) and medial compartments ( P = 0.82). There was a trend toward larger anterior compartment defects in nonathletes ( P = 0.07)., Conclusions: Among age-matched athletes and nonathletes with symptomatic cartilage defects who meet demographic criteria for cartilage restoration, nonathletes were more likely to smoke and have a longer duration of symptoms prior to treatment. Athletes tended to present earlier but with similar size defects compared to nonathletes, supporting accelerated treatment of defects in athletes and caution toward allowing continued athletic participation in patients with known cartilage defects.

Purpose: To assess the healing of horizontal cleavage tears of the meniscus 1 year after surgical repair and to determine what modality is best to determine healing., Methods: Patients were prospectively followed for 12 months after surgical meniscus repair using a circumferential compression stitch. Inclusion criteria were preoperative magnetic resonance imaging (MRI) evidence of horizontal cleavage tear, age between 18 and 50 years, and no concomitant anterior cruciate ligament reconstruction. Patients were excluded if they were >50 years old, had a meniscus tear pattern other than horizontal cleavage tear, and underwent concomitant ligament reconstruction. MRIs were performed 1-year postoperatively for evaluation of repair healing. Preoperative and postoperative MRIs of tears were evaluated blindly by a musculoskeletal radiologist. In-office needle arthroscopy was performed at 6 months post-operatively., Results: Eight patients were included and had surgery between March 2016 and November 2017. There were 4 medial and 4 lateral meniscus tears. No patients had recurrence of preoperative symptoms or evidence of retear. Six repairs evaluated by in-office needle (at 5.9 months postsurgery) arthroscopy demonstrated complete healing. Seven of the 8 patients had grade III changes on preoperative MRI, and 1 patient had grade IIc changes. On postoperative MRI, 5 of 7 patients had grade III changes, 1 patient had IIc changes, and 1 had IIb changes. There was no significant difference in the proportion of patients with grade III changes preoperatively compared with postoperatively ( P  = .57). One of 8 patients with preoperative MRIs demonstrated extrusion where no patients demonstrate postoperative MRI evidence of extrusion ( P  = .47)., Conclusions: Horizontal cleavage meniscal tears repaired with a circumferential compression stitch demonstrate healing on in-office needle arthroscopy 6 months after surgery. No evidence of incomplete or failed healing was found. MRI at 1 year after surgery demonstrated residual tear evidence for all patients., Level of Evidence: IV, therapeutic case series., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Competing Interests: The authors report the following potential conflict of interest or source of funding: 2020 POSNA Microgrant Award.

Context: It is unknown how specific coping strategies are associated with the short-term outcomes among athletes following knee surgery., Objective: 1) To determine whether specific coping strategies are associated with satisfaction, return to sport, self-reported knee function, or kinesiophobia following sports-related knee surgery. 2) To determine whether these associations vary by age, sex, or surgical procedure., Study Design: Case series., Methods: Athletes (n=184 total; n=104 men, n=80 women; n=38 age <20 years, n=35 age 20-25, n=36 age 26-31, n=36 age 32-40, n=39 age >40) who underwent outpatient knee surgery were enrolled from a single center. Utilization of specific coping strategies (self-distraction, use of emotional or instrumental support, venting, positive reframing, and acceptance) was assessed pre-operatively with the Brief-COPE inventory. Relationship between coping strategies and post-operative satisfaction, return to sport, International Knee Documentation Committee-subjective (IKDC-S) and Tampa Scale for Kinesiophobia scores at median 10.7 months follow-up were determined with consideration for age, sex, and surgical procedure., Results: Return to prior level of sport was 72%, and satisfaction was 86%. Most coping strategies had age-specific utilization rates; positive reframing was utilized least frequently in ages <20 years. Satisfaction increased with greater positive reframing among ages <20 years and decreased with greater self-distraction among men. Return to sport was higher with greater positive reframing in ages <32 years. No coping strategies predicted IKDC-S scores. Greater positive reframing correlated with lower kinesiophobia in ages <20 years. Greater instrumental support correlated with lower kinesiophobia in ages >40 years. No other coping strategies were associated with outcomes. Surgical procedure was not related to association between coping strategies and outcomes., Conclusion: Coping strategies have age-specific associations with outcomes after knee surgery in athletes. Positive reframing is infrequently utilized in younger athletes. Greater use of positive reframing in this group may improve satisfaction, return to sport, and lower fear of re-injury.

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., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Objective: To determine whether there are differences by sport or competitive level in symptomatic knee cartilage defects among recreational, high school, or collegiate competitive athletes undergoing initial arthroscopic knee surgery who meet criteria for cartilage restoration surgery., Design: Three hundred recreational ( n = 172) and high school or collegiate competitive athletes ( n = 128) younger than 40 years and body mass index (BMI) <35 kg/m 2 (63% male, mean age 24.3 years, SD 7.1; mean BMI 25.7 kg/m 2 , SD 3.7) with Outerbridge grade 2 or higher symptomatic cartilage defects who underwent arthroscopic knee surgery were identified. The independent relationship between sporting activity or competitive level and cartilage defect location, size, severity, and symptom chronicity were assessed by multivariate regression analysis., Results: Full-thickness defects were present in 24% of competitive athletes and 31% of recreational athletes ( P = 0.21). There was a trend toward an independent association with competitive level and high-grade (3 or 4) multicompartment disease (adjusted odds ratio [aOR] 3.99, 95% confidence interval 0.84-18.8; P = 0.08) or isolated anterior compartment defects (aOR 2.00, 95% CI 0.86-4.62, P = 0.10) but not isolated medial or lateral defects. High-grade defect size was similar among recreational and competitive athletes ( P = 0.71). High-grade lateral defect prevalence differed by sport (running 24%, basketball 23%, soccer 18%, football 5%; P = 0.02) but not medial or anterior defect prevalence., Conclusions: Among recreational and high school or collegiate competitive athletes with symptomatic cartilage defects who meet criteria for cartilage restoration, competitive athletes may have higher risk of high-grade anterior and multicompartment defects but no difference in defect size.

Objective: High rates of operating room (OR) traffic may contribute to surgical air contamination and surgical site infections (SSIs). The purpose of this study was to evaluate room traffic patterns in orthopedic implant procedures to determine the frequency of door openings and if time of day had an effect on room traffic., Methods: In 2015, OR traffic was assessed in orthopedic implant cases. Room traffic was reported as the number of door openings per minute. Counts of how many people were present in the operating room were noted in 5-minute intervals from the time of sterile case opening to dressing placement. Operative cases were observed and categorized into 3 periods (6:00-9:59, 10:00-13:59, and 14:00-17:59) to assess if time of day affected room traffic., Results: Forty-six cases were observed for the present study. Among all cases, the mean room traffic rate was 35.2 openings per hour (SD, 10; range, 13.2-60.8). One-way analysis of variance revealed no statistically significant difference among groups (6:00-9:59 [n = 29], 10:00-13:59 [n = 10], and 14:00-17:59 [n = 7]) as it relates door openings per minute (room traffic rate) (P = 0.9237) or mean number of people in the OR (P = 0.3560). Pearson correlation revealed no correlation between case start time and room traffic rates (P = 0.6129, r2 = 0.0059) or between case start time and mean number of people in the OR (P = 0.3435, r2 = 0.0214)., Conclusions: Room traffic rates and mean number of people in the OR do not correlate with time of day of case in orthopedic implant procedures., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Nearly 1 in 5 American children are obese. The primary purpose of this study is to evaluate the relationship between childhood obesity and perioperative complications, patient-reported outcomes (PRO), and functional recovery after closed reduction and percutaneous pinning (CRPP) of type II and III supracondylar humerus fractures., Methods: Retrospective review of patients treated operatively with CRPP of Wilkins modification of the Gartland classification type II and III supracondylar humerus fractures was performed over a 1-year timeframe (July 1, 2016 to July 1, 2017). One hundred forty-four patients under the age of 16 treated were identified. Obesity was defined as body mass index (BMI) at or above the 95th percentile for age. Obesity as a risk factor for poor outcomes was assessed. The primary outcome measure was postoperative PRO [quick-DASH, Patient Reported Outcomes Measurement Information System (PROMIS)-UE, PROMIS Global Health, and PROMIS Pain scores]., Results: Mean age at surgery was 5.9 years (SD=2.1, 1.07 to 12.2) and mean age at final follow-up (3.3 y) was 8.8 (SD=2.14, 4 to 16). Mean patient BMI was 17.2 (SD=4.48, 12.4 to 56.2). Sixty-six patients were female (45.8%) and 78 patients were male (54.2%). In all, 31 of 144 patients (21.5%) met criteria for obesity. Obesity (95th percentile for BMI or above) was not associated with a higher rate of complications overall (χ2=1.29, P=0.256), range of motion loss (χ2=0.2, P=0.655) or requirement of postoperative physical therapy (χ2=0.17, P=0.678). Seventy-five patients were available and willing to participate in the outcomes score assessments. Mean follow-up for this cohort of 75 patients was 3.3 years (SD=0.31, 2.85 to 3.88). There were no differences in PROMIS pain, PROMIS upper extremity function, PROMIS general health, or quick-DASH scores when comparing obese with nonobese patients., Conclusions: Obesity is a growing concern in the United States and its effect on long-term outcomes after CRPP of supracondylar humerus fractures is unknown. The present study demonstrates no difference in complications or PRO among obese patients compared with nonobese patients., Level of Evidence: Level IV-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Anterior cruciate ligament reconstruction (ACLR) is a common orthopaedic sports medicine procedure, but graft failure is not uncommon and often leads to revision ACLR. Revision surgery can be performed in a 1- or 2-stage fashion., Hypothesis: Graft failure risk, patient-reported outcomes, and anterior knee laxity are similar after 1- and 2-stage revision ACLR., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review of the literature was performed to evaluate patient outcomes after 1- versus 2-stage revision ACLR. A search was performed with the phrase "revision anterior cruciate ligament reconstruction" across Embase, PubMed, Scopus, and SportDiscus from the beginning of their archives through July 12, 2019., Results: Thirteen studies met inclusion criteria and included 524 patients: 319 patients who underwent 1-stage revision ACLR and 205 patients who underwent 2-stage revision ACLR. Two studies compared outcomes of 1- versus 2-stage revision ACLR; 4 studies reported outcomes after 2-stage revision ACLR; and the remaining 7 studies documented outcomes after 1-stage ACLR. The mean follow-up was 4.1 years. The 2 studies that compared 1- versus 2-stage ACLR reported no differences in functional, radiologic, or patient-reported outcomes or failure risk. Overall, 9 studies reported subjective International Knee Documentation Committee (IKDC) scores; 4 studies, Knee injury and Osteoarthritis Outcome Score values; 8 studies, Lysholm scores; and 7 studies, Tegner scores; 8 studies measured anterior laxity with a KT-1000 arthrometer. The mean weighted subjective IKDC score for all studies including this outcome at final follow-up was 66.6 for 1-stage revisions and 65.9 for 2-stage revisions., Conclusion: The available evidence comparing 1- versus 2-stage revision ACLR is retrospective and limited. The results of each approach are similar in appropriately selected patients.

When compared to meniscectomy, meniscus allograft transplantation (MAT) may provide superior long-term benefits to young, active patient populations who have lost meniscal function because of irreparable damage, such as, an avascular tear, previous repair failure, and unsalvageable tear types. Positive outcomes are most likely to be achieved when meniscus allograft transplantation is performed in appropriately selected patients. Indications include patients younger than 50 years of age, with a history of subtotal or total meniscectomy without concomitant articular cartilage defects, uncorrectable joint malalignment, and/or knee instability. Outcomes for meniscal allograft transplantation are promising with studies reporting long-term graft survivorship as high as 89% at 10 years and significant improvements in multiple patient reported outcome measures. LEVEL OF EVIDENCE: Level V.

Background: Unanticipated severe injury to part of the musculoskeletal system, referred to as orthopedic trauma, can be debilitating. It can also be accompanied by equally debilitating psychological distress, but little is known about the effective interventions for psychological sequelae of orthopedic trauma., Questions/purposes: We sought to determine the effectiveness of interventions on psychological outcomes, such as post-traumatic stress disorder (PTSD), depression, and pain catastrophizing (feelings of helplessness, excessive rumination, and exaggerated description of pain), after major orthopedic trauma., Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement as guidelines, we systematically searched Scopus, PubMed, and Google Scholar. Studies included for review were English-language interventional studies in an orthopedic trauma population that included assessment of post-injury psychological distress or disability as either a primary or secondary aim., Results: Twelve studies were identified, including six randomized trials, three prospective cohort studies, and three retrospective cohort studies. Study sample sizes ranged from 48 to 569 patients, the mean age ranged from 29 to 52.8 years, and the percentage of male patients ranged from 38 to 90%. We examined four categories of interventions. Peer group treatment (one study) significantly reduced rates of depression but had low participation rates. Brief interventions to teach coping and self-efficacy skills (two studies) decreased depression, pain catastrophizing, and anxiety scores while increasing self-efficacy on short-term follow-up. Individualized counseling and rehabilitation (four studies) resulted in a consistent reduction in the risk of PTSD. Early amputation was found to result in lower rates of PSTD than limb salvage in US military personnel (four studies). One study examined surgeons' confidence in dealing with possible psychological distress; surgeons who participated in a program on collaborative care were significantly more confident that they could help their patients with such issues., Conclusion: Interventional strategies, including group interventions, brief individual interventions, longitudinal counseling, and consideration of early amputation in selected populations have proved effective in reducing negative psychological sequelae of major orthopedic trauma. Further research that determines the effects of interventions in this population is needed., Competing Interests: Conflict of InterestJames C. Kirven, BS, Joshua S. Everhart, MD, MPH, Alex C. DiBartola, MD, MPH, Jeremy Jones, MD, and Ryan K. Harrison, MD, declare that they have no conflicts of interest. David C. Flanigan, MD, reports receiving personal fees from Ceterix Orthopaedics, Conmed, Depuy Mitek, Histogenics, Moximed, Smith & Nephew, Vericel, and Zimmer Biomet, outside the submitted work., (© Hospital for Special Surgery 2019.)

Purpose: To analyze the clinical outcomes and survivorship of meniscal horizontal cleavage tear (HCT) repairs with hopes of guiding future treatment decisions., Methods: Standard systematic review methodology was used. A comprehensive search of PubMed was conducted on June 1, 2019. The inclusion criteria were articles that were published in English, involved human subjects, and reported on at least 1 outcome after repair of HCTs. The exclusion criteria included technique guides and reviews, studies without full text available, and studies with HCT outcomes not separated from other repair groups. Effect heterogeneity was determined using the I 2 measure. Forest plots were created in addition to a random-effects model to show the results., Results: The systematic review yielded 19 studies evaluating 289 knees in a total of 273 patients. At most recent follow-up, there was a high probability of return to sport (93.1% [67 of 72]). Overall, 74% of patients (67 of 90) were symptom free at last follow-up, and 80% expressed satisfaction with their overall result (80 of 100). The most frequently reported subjective outcome was the Lysholm score, which improved from a preoperative study range of 48 to 79 (I 2  = 20.7%, P = .283) to a postoperative study range of 56 to 99 (I 2  = 49%, P = .081). The next most commonly reported was the International Knee Documentation Committee subjective score, which improved from a preoperative study range of 16 to 49 (I 2  = 47.7%, P = .125) to a postoperative study range of 72 to 95 (I 2  = 0%, P = .660). An overall 11.7% reported risk of reoperation was found, with most cases involving revision meniscectomy. Rates of complications beyond fixation failure were overall very low, with infrequent reports of septic arthritis and transitory dysesthesia., Conclusions: The short- to intermediate-term results of repair of HCTs are comparable to prior studies. Survivorship is comparable to repairs of other types of meniscal tears with high rates of return to sport and low complication rates., Level of Evidence: Level IV, systematic review of Level I-IV studies., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Platelet-rich plasma (PRP) has gained significant interest in recent years to potentially add biological augmentation of healing to surgical repairs of soft-tissue injuries. We sought to determine whether perioperative PRP injection influences the risk of failure following rotator cuff repair., Methods: A systematic search was performed in the Embase and PubMed databases and identified 16 randomized controlled trials or prospective cohort studies (1045 participants) reporting rates of failure, defined as a subsequent tear on postoperative imaging, after rotator cuff repair with or without perioperative PRP administration. A random-effects meta-analysis of the included studies was performed to determine the pooled effect of PRP administration on the postoperative failure risk., Results: Among the 16 studies investigating rotator cuff repairs, PRP augmentation resulted in a 25% reduction in the risk of repair failure, with low heterogeneity among the included studies. A significant protective effect was seen for studies of only small to medium tears (7 studies) (P = .007) and studies including large or massive tears (9 studies) (P < .001)., Conclusions: Intraoperative PRP reduces the failure risk following rotator cuff repair and has a consistent effect regardless of tear size. However, because of the variability in PRP preparations, a specific recommendation cannot be made., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether articular cartilage damage noted at the time of primary anterior cruciate ligament reconstruction (ACLR) affects the likelihood of achieving ≥ 90% symmetry for isokinetic extension strength at 6 months after surgery or risk of recurrent ACL injury., Methods: Five hundred and eight patients underwent primary ACLR and diagnostic arthroscopy. All identified cartilage lesions were graded using the Outerbridge system. All patients underwent isokinetic strength testing. The association between cartilage Outerbridge grade and a ≥ 90% Limb Symmetry Index (LSI) and recurrent ACL injury risk at mean 38.7 month follow-up (SD 31.8) was evaluated via multivariate regression analysis., Results: Grade 2 or higher damage was present in 394 (77.5%) of patients, grade 3 or higher in 143 (28.1%) and grade 4 in 83 (16.4%) at time of ACLR. Ipsilateral ACLR graft rupture occurred in 31 (6.1%) of patients. Contralateral ACL injury occurred in 19 (3.7%). Patients with grade 2 or higher damage were significantly less likely to meet an LSI goal of ≥ 90% for fast (300°/s) isokinetic extension. There was no association with slow isokinetic extension. Cartilage lesion severity at or beyond grade 2 had a similar effect on isokinetic testing results regardless of compartment involvement or performance of microfracture. Patients with grade 2-4 cartilage damage were less likely to sustain a second ipsilateral ACL injury or a contralateral native ACL injury., Conclusions: Cartilage damage seen at time of ACL reconstruction is common and associated with lower likelihood of achieving ≥ 90% symmetry for isokinetic extension strength at 6 months after surgery. However, lower recurrent ACL injury rates are seen in patients with concurrent cartilage damage. These data may inform future clinical decisions regarding operative managment of recurrent ACL injuries., Level of Evidence: III.

Background: The purpose of the study is to determine whether patient age group (≥40 years versus <40 years) and pre-injury activity level are independently predictive of symptomatic failure rates and patient-reported outcomes after meniscus repair with or without concomitant anterior cruciate ligament reconstruction (ACLR) at mean five years of follow-up., Methods: Two hundred and twenty-five patients (n = 61, age ≥40 years; n = 164, age <40; 11% sedentary, 63% recreational athletes, 26% competitive athletes; 72% cutting-pivoting sports, 28% non-cutting or non-pivoting sports) who underwent meniscal repair were assessed for symptomatic failure and subjective knee function at mean 5.4 years of follow-up. Symptoms were assessed with Knee Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective (IKDC-S) scores., Results: Repair failure was 20% overall with no association with age group (<40 vs. ≥40 years) or level of activity. When compared with sedentary patients, IKDC-S scores were not associated with age group but were lower among sedentary patients (mean: 59.6, SE: 4.9) compared with recreational (mean: 78.9, SE: 2.5; p = 0.007) or competitive athletes (mean: 79.2, SE: 3.8; p = 0.02). KOOS-ADL scores were independently associated with age and were higher among patients <40 years. KOOS-pain, KOOS-sport, or KOOS-QOL were not associated with age group. Sedentary status was independently associated with lower KOOS scores for all sub-scores., Conclusions: Meniscal repair failure rates and patient-reported outcomes do not differ substantially between older or younger patients of similar pre-injury activity level. Sedentary patients regardless of age have worse self-reported subjective outcomes compared with active patients., Competing Interests: Declaration of competing interest The authors received no funding for this study and report no conflicts of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Operating room (OR) traffic and door openings increase potential for air contamination in the OR and create distractions for surgical teams. A multidisciplinary intervention was developed among OR staff, surgical staff, vendors, radiology, and anesthesia and approved by the hospital system's patient and quality safety department for implementation. Interventions included education, OR signage, and team-based accountability and behavioral interventions. After interventions were implemented, a second prospective, observational data collection was performed and compared to preintervention OR traffic. A total of 35 cases were observed over the 3-month period in the preintervention group; 42 cases were observed in the postintervention group. Average door openings per minute decreased by 22% ( P = .0011) after intervention. All surgical groups excluding anesthesia had significant reductions in OR traffic following the intervention. Behavioral interventions that focus on education, awareness, and efficiency strategies can decrease overall OR traffic for orthopedic cases.

Purpose: To determine if tunnel widening, defined as change in maximal tunnel diameter from the time of initial bone tunnel drilling to revision surgery is associated with bacterial deoxyribonucleic acid (DNA) presence and concentration in torn graft tissue from failed anterior cruciate ligament reconstructions (ACLRs)., Methods: Thirty-four consecutive revision ACLRs were included (mean age 27.3 years SD 10.9; median time to failure 4.9 years range 105 days-20 years). Graft selection of the failed reconstruction was 68% autograft, 26% allograft, and 6% autograft/allograft hybrid with a mean drilled tunnel diameter of 8.4 mm SD 0.8. Maximal tunnel diameters prior to revision were measured on pre-operative three-dimensional imaging and compared to drilled tunnel diameters at the time of the previous reconstruction. Tissue biopsies of the failed graft were obtained from tibial, femoral, and intraarticular segments. Sterile water left open to air during revision ACLRs and tissue from primary ACLRs were used as negative controls. Clinical cultures were obtained on all revision ACLRs and PCR with universal bacterial primer on all cases and negative controls. Fluorescence microscopy was used to confirm the presence and location of biofilms in two patients with retrieved torn graft tissue and fixation material. Amount of tunnel widening was compared to bacterial DNA presence as well as bacterial DNA concentration via Welch ANOVA., Results: Bacterial DNA was present in 29/34 (85%) revision ACLRs, 1/5 (20%) of primary ACLR controls and 0/3 (0%) sterile water controls. Cultures were positive (coagulase negative Staphylococcus sp.) in one case, which also had the greatest degree of tunnel widening. Femoral widening was greater in cases with detectable bacterial DNA (mean widening 2.6 mm SD 3.0) versus without (mean 0.3 mm SD 0.6) (p = 0.003) but was unaffected by bacterial DNA concentration (p = 0.44). Tibial widening was not associated with the presence of bacterial DNA (n.s.); however, higher bacterial DNA concentrations were observed in cases with tibial widening ≥ 3.0 mm (median 2.47 ng bacterial DNA/µg total DNA) versus widening < 3.0 mm (median 0.97 ng bacterial DNA/µg total DNA) (p = 0.046). Tunnel widening was not associated with time to failure, graft selection, or number of prior surgeries (n.s., all comparisons). Fluorescence microscopy confirmed the presence of biofilms on ruptured tendon graft as well as fixation material in 2/2 cases., Conclusion: Bacterial DNA is commonly encountered on failed ACLR grafts and can form biofilms. Bacterial DNA does not cause clinically apparent infection symptoms but is associated with tunnel widening. Further research is needed to determine whether graft decontamination protocols can reduce graft bacterial colonization rates, ACLR tunnel widening or ACLR failure risk., Level of Evidence: Therapeutic III.

Background: Postoperative care is essential to optimizing patient outcome. We sought to determine the incidence and associated demographic and surgical factors of postoperative patient loss to follow-up following hand and upper extremity surgery. Methods: In all, 2834 surgical cases (2467 patients) were retrospectively reviewed. All surgical cases from July 2014 to June 2015 at a single practice with five surgeons were assessed. Charts were reviewed for compliance with postoperative follow-up. Variables were described with proportions and compared using logistic regression analysis. Results: In total, 2563 cases (2388 patients) met the inclusion criteria. Overall loss to follow-up rate was 26%. Patients lost to follow-up based on insurance type were 13% for worker's compensation, 22% for private insurance, 21% for Medicare, 38% for Medicaid, and 44% for self-pay. Patients with expected short-term follow-up were lost at a 23% rate. Expected mid- and long-term follow-up patients were lost at 34% and 20% rates, respectively. Patients below 30 years old were lost to follow-up at a 42% rate compared to patients 30 to 64 years old (26%) and greater than or equal to 65 years (13%). Males had a higher rate of loss to follow-up, 32%, compared with females (22%). Patients living greater than 50 miles from our surgery center were lost to follow-up at a rate of 31%, compared with those who lived less than 50 miles (25%). Conclusions: We have identified demographic variables associated with patients being lost to follow-up after hand and upper extremity surgery. With this knowledge, we hope to develop methods of either improving in-office follow-up rates or discover new avenues to deliver postoperative care.

Fibronectin-binding protein A (FnBPA), a protein displayed on the outer surface of Staphylococcus aureus, has a structured A-domain that binds fibrinogen (Fg) and a disordered repeat-region that binds fibronectin (Fn). Amino acid substitutions in Fn-binding repeats (FnBRs) have previously been linked to cardiovascular infection in humans. Here we used microtiter and atomic force microscopy (AFM) to investigate adhesion by variants of full-length FnBPA covalently anchored in the outer cell wall of Lactococcus lactis, a Gram-positive surrogate that otherwise lacks adhesins to mammalian ligands. Fn adhesion increased in five of seven FnBPA variants under static conditions. The bond targeting Fn increased its strength with load under mechanical dissociation. Substitutions extended bond lifetime (1/k off ) up to 2.1 times for FnBPA-Fn. Weaker adhesion was observed for Fg in all FnBPA variants tested with microtiter. However, mechanical dissociation with AFM showed significantly increased tensile strength for Fg interacting with the E652D/H782Q variant. This is consistent with a force-induced mechanism and suggests that the dock, lock, and latch (DLL) mechanism is favored for Fg-binding under mechanical stress. Collectively, these experiments reveal that FnBPA exhibits bimodal, ligand-dependent adhesive behavior. Amino acid substitutions in the repeat-region of FnBPA impact binding to both ligands. This was unexpected for Fg since all variants have the same A-domain sequence, and the Fg-binding site is distant from the repeat region. This indicates that FnBRs may fold back on the A-domain in a way that impacts the DLL binding mechanism for Fg.

Background: The time required to develop a secondary cartilage or meniscal injury in the medial compartment after anterior cruciate ligament (ACL) injury is not well understood., Purpose: To determine the association between time delay until ACL reconstruction and the presence of medial compartment Outerbridge grade 3 or 4 chondral injury or medial meniscal tear requiring treatment., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 609 patients underwent primary ACL reconstruction at a single institution at a median 46 days between injury and surgery (61.4% male; mean age, 26.5 years [SD, 11.1]). Chondral status was graded according to Outerbridge criteria at the time of surgery. Multivariate regression analysis was used to assess the relationship between time delay until surgery and medial compartment chondral injury or meniscal injury requiring treatment. Adjustment was performed as needed for patient demographics, sporting activity, and prior knee injuries. Time until surgery had a nonlinear association with medial compartment health and was more effectively described in discrete intervals rather than as a continuous variable. The optimal time intervals to predict medial compartment health were determined by comparison of Bayes information criterion values between fully adjusted regression models., Results: After controlling for relevant confounders, delay of surgery >8 weeks had an increased likelihood of a medial meniscal tear requiring partial meniscectomy (adjusted odds ratio [aOR], 2.30; 95% CI, 1.04-5.12; P = .04) and a decreased likelihood of a meniscal tear requiring repair (aOR, 0.50; 95% CI, 0.32-0.76; P = .001). Delay of surgery >5 months had an increased likelihood of a medial Outerbridge grade ≥3 chondral defect (aOR, 3.11; 95% CI, 1.64-5.87; P = .001) or a grade 4 defect (aOR, 3.84; 95% CI, 1.75-8.45; P = .001)., Conclusion: From the time of ACL injury, risk of an irreparable medial meniscal tear found at the time of ACL reconstruction is significantly increased by 8 weeks, and risk of high-grade medial chondral damage is increased by 5 months.

Purpose: To systematically review the literature to determine what clinical factors influence patient outcomes after meniscal root repairs., Methods: A systematic review of multiple databases was performed. The inclusion criteria included English language, studies evaluating clinical and/or radiographic factors related to meniscal root repair outcomes, medial or lateral posterior root repairs, and human studies. The exclusion criteria included meniscectomy studies, meniscal body studies, technique descriptions, studies reporting only failure rate of meniscal repairs, multiligament repairs, abstracts, controlled laboratory studies, meta-analyses, and systematic reviews., Results: Five studies were included for final analysis including four case series and one retrospective cohort study. A total of 178 patients in the five studies underwent posterior meniscal root repair (179 knees total). The mean age was 51.4 years. The mean duration of follow-up was 34.5 months. The mean Moga quality rating for case series studies was 15 points (83.3%) and NOS score for the retrospective comparative study was 8. Body mass index (BMI) was not associated with outcomes in 3/3 studies assessing BMI. Increased age was associated with worse outcome in 1/5 studies and had no association in 4/5 studies. Knee varus >5° was associated with worse outcomes in 3/3 studies., Conclusions: Risk factors for poor clinical outcomes after posterior meniscal root repair include pre-existing high-grade (Outerbridge grade ≥ 3) chondral lesions and severe varus knee alignment (>5°) for medial root repairs., Level of Evidence: IV, systematic review., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: To determine whether bacterial DNA will be detectable by polymerase chain reaction (PCR) in torn graft tissue at the time of revision anterior cruciate ligament reconstruction (ACLR)., Methods: A total of 31 consecutive revision ACLR cases from 1 center from 2014-2016 were recruited. No patients had clinical signs of infection on presentation. Torn graft tissue was obtained in revision cases and subjected to clinical culture and PCR analysis with a universal bacterial primer. Fluorescence microscopy was used to confirm the presence of a biofilm. We obtained negative control samples of water open to air on the field and excess primary ACLR graft tissue, as well as torn native ligament, to evaluate for PCR positivity due to environmental contamination., Results: Clinical cultures were positive (coagulase-negative Staphylococcus) in 1 revision case (3%, 1 of 31). Bacterial DNA was detectable in most revision ACLR cases (87.0%, 27 of 31), and there was a low rate of PCR positivity in negative control samples of water open to air (0%, 0 of 3), excess primary ACLR graft tissue after passage (20%, 1 of 5), or native torn ligament (20%, 1 of 5). Bacterial biofilm presence on failed graft tissue as well as monofilament suture was visually confirmed with fluorescence microscopy., Conclusions: Bacterial DNA is frequently present in failed ACLR grafts, with high rates of DNA detection by PCR but low culture positivity., Level of Evidence: Level IV, case series., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopaedic procedures. While generally successful, failure resulting in revision surgery is reported to be between 1.9 - 4.9%. However, when not related to traumatic re-injury, failure mechanism is poorly understood. One potential but understudied mechanism of ACL reconstruction failure is infection. We describe three patients with previous ACL reconstructions who later developed infection with Propionibacterium acnes. Two cases presented with knee pain and swelling, and one presented with instability. While only two of the three cases received antibiotic treatment, all three cases were free of knee and infectious symptomatology at most recent follow-up. P. acnes infection may represent one potential mechanism for biologic failure of ACL reconstruction and anaerobic operative cultures may be used to identify its presence.

Background: Cartilage lesions of the knee are difficult to treat. Lesion size is a critical factor in treatment algorithms, and the accurate, reproducible sizing of lesions is important. In this study, we evaluated the interrater and intrarater reliability of, and correlations in relation to, various arthroscopic sizing techniques., Methods: Five lesions were created in each of 10 cadaveric knees (International Cartilage Repair Society grade 3C). Three orthopaedic surgeons used 4 techniques (visualization and use of a 3-mm probe, a simple metal ruler, and a sliding metallic ruler tool) to estimate lesion size. Repeated-measures data were analyzed using a mixed-effect linear model. The differences between observed and gold-standard (plastic mold) values were used as the response. Intraclass and interclass correlation coefficient (ICC) values for intrarater and interrater reliability were computed, as were overall correlation coefficients between measurements and gold standards., Results: The mean lesion size was 2.37 cm (range, 0.36 to 6.02 cm). Rater, lesion location and size, and measurement method all affected the cartilage defect measurements. Surgeons underestimated lesion size, and measurements of larger lesions had a higher percentage of error compared with those of smaller lesions. When compared with plastic molds of lesions, 60.5% of surgeon measurements underestimated lesion size. Overall, the correlation between measurements and gold standards was strongest for the simple metal ruler method and weakest for the visualization method., Conclusions: Several factors may influence arthroscopic estimation of cartilage lesion size: the lesion location, measurement tool, surgeon, and defect size itself. The intrarater and interrater reliability was moderate to good using a 3-mm probe, sliding metallic ruler tool, or simple metal ruler and was fair to moderate using visualization only., Clinical Relevance: There is a need for more accurate methods of determining the size of articular cartilage lesions.

The Staphylococcus aureus cell surface contains cell wall-anchored proteins such as fibronectin-binding protein A (FnBPA) that bind to host ligands ( e.g. fibronectin; Fn) present in the extracellular matrix of tissue or coatings on cardiac implants. Recent clinical studies have found a correlation between cardiovascular infections caused by S. aureus and nonsynonymous SNPs in FnBPA. Atomic force microscopy (AFM), surface plasmon resonance (SPR), and molecular simulations were used to investigate interactions between Fn and each of eight 20-mer peptide variants containing amino acids Ala, Asn, Gln, His, Ile, and Lys at positions equivalent to 782 and/or 786 in Fn-binding repeat-9 of FnBPA. Experimentally measured bond lifetimes (1/ k off ) and dissociation constants ( K d = k off / k on ), determined by mechanically dissociating the Fn·peptide complex at loading rates relevant to the cardiovascular system, varied from the lowest-affinity H782A/K786A peptide (0.011 s, 747 μm) to the highest-affinity H782Q/K786N peptide (0.192 s, 15.7 μm). These atomic force microscopy results tracked remarkably well to metadynamics simulations in which peptide detachment was defined solely by the free-energy landscape. Simulations and SPR experiments suggested that an Fn conformational change may enhance the stability of the binding complex for peptides with K786I or H782Q/K786I ( K d app = 0.2-0.5 μm, as determined by SPR) compared with the lowest-affinity double-alanine peptide ( K d app = 3.8 μm). Together, these findings demonstrate that amino acid substitutions in Fn-binding repeat-9 can significantly affect bond strength and influence the conformation of Fn upon binding. They provide a mechanistic explanation for the observation of nonsynonymous SNPs in fnbA among clinical isolates of S. aureus that cause endovascular infections., (© 2017 by The American Society for Biochemistry and Molecular Biology, Inc.)

Purpose: To assess the isokinetic, functional, and patient-reported outcomes of femoral nerve block (FNB) compared with traditional multimodal anesthesia for FNB in anterior cruciate ligament (ACL) reconstruction., Methods: A systematic search of PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Reviews, and Google Scholar was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Effects of FNB on quadriceps function were evaluated by isokinetic testing, functional scoring systems, range of motion, and patient self-report questionnaires. Heterogeneous reporting of outcomes precluded a formal meta-analysis. The methodologic merit of all studies included was evaluated by the Coleman Methodology Score., Results: Six studies were identified with outcome measures reported between 7 days and 6 months postoperatively. At 6 months, 2 of 4 studies that reported isokinetic testing found significantly greater deficits among patients who received a nerve block; one of the remaining studies showed a deficit at 6 weeks but not 6 months. Limited data showed no significant differences in functional or patient-reported outcomes at 6 months after reconstruction, and data regarding the impact of FNB on return to sport were inconclusive. The mean Coleman Methodology Score for the included studies was 53, indicating poor overall methodologic quality of the available literature., Conclusions: The limited data available suggest that FNB causes a measurable deficit in quadriceps isokinetic strength during the early postoperative period but has no effect on functional outcomes or return to sport at 6 months after ACL reconstruction. However, current clinical evidence is not sufficient to draw any valid or definitive conclusions regarding the effect of FNB on postoperative outcomes after ACL reconstruction., Level of Evidence: Level IV, systemic review of Level I through IV studies., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Bacterial infection after hardware implantation in orthopedic surgery is a devastating issue as it often necessitates increased hospital costs and stays, multiple revision surgeries, and prolonged use of antibiotics. Because of the nature of hardware implantation into the body, these infections are commonly in the form of attached biofilms. The current literature on a range of methodologies to study clinically explanted infected orthopedic hardware, with potential biofilm, in the laboratory setting is limited. General methods include traditional and advanced culturing techniques, microscopy imaging techniques, and techniques that manipulate genetic material. The future of diagnostic techniques for infected implants, innovative hardware design, and treatment solutions for patients all depend on the successful evaluation and characterization of clinical samples in the laboratory setting. This review provides an overview of current methods to study biofilms associated with orthopedic infections and insight into future directions in the field., (© 2017 APMIS. Published by John Wiley & Sons Ltd.)

Background: The objective of this study was to systematically evaluate the existing literature to compare the biomechanical effects of low dose and high dose gamma irradiation on commonly used ACL allografts., Methods: A systematic search was performed in PubMed, Cumulative Index for Nursing and Allied Health Literature (CINAHL), Cochrane Reviews, SCOPUS, and SportDiscus. Nine studies were identified that met the following inclusion criteria: 1) controlled laboratory study, 2) investigation of standard allografts for anterior cruciate ligament reconstruction (ACLR), 3) gamma irradiation (dose reported) and a negative control group, and 4) mechanical loading (results reported)., Results: Nine studies met all inclusion and exclusion criteria. There was a dose-dependent relationship between radiation and decreased mechanical tendon integrity. Low dose radiation (<2.5Mrad [Mrad]) showed graft weakening with an average of 4.3% decrease in load to failure (standardized mean difference [SMD], 0.23; 95% CI 0.216, 0.68; p=0.31), whereas high-dose radiation showed a significantly larger (32.4% average) decrease in load to failure (SMD, 1.79; 95% CI 1.194, 2.38; p<0.001)., Conclusions: Gamma irradiation has a negative effect on tendon allograft strength that is dose-dependent, with particularly large effects noted at irradiation doses of ≥2.5Mrad., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Bacterial biofilms are the main etiological agent of periprosthetic joint infections (PJI); however, it is unclear if biofilms colonize one or multiple components. Because biofilms can colonize a variety of surfaces, we hypothesized that biofilms would be present on all components. 16S ribosomal RNA (rRNA) gene sequencing analysis was used to identify bacteria recovered from individual components and non-absorbable suture material recovered from three PJI total knee revision cases. Bray-Curtis non-metric multidimensional scaling analysis revealed no significant differences in similarity when factoring component, material type, or suture versus non-suture material, but did reveal significant differences in organism profile between patients (P < 0.001) and negative controls (P < 0.001). Confocal microscopy and a novel agar encasement culturing method also confirmed biofilm growth on a subset of components. While 16S sequencing suggested that the microbiology was more complex than revealed by culture contaminating, bacterial DNA generates a risk of false positives. This report highlights that biofilm bacteria may colonize all infected prosthetic components including braided suture material, and provides further evidence that clinical culture can fail to sufficiently identify the full pathogen profile in PJI cases., (© FEMS 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To perform a systematic review of the use of autologous chondrocyte implantation (ACI) in the adolescent knee., Specific Aims: (1) quantify clinical outcomes of ACI in adolescent knees, (2) identify lesion and patient factors that correlate with clinical outcome, and (3) determine the incidence of complications of ACI in adolescents., Methods: PubMed, MEDLINE, SCOPUS, CINAHL, and Cochrane Collaboration Library databases were searched systematically. Outcome scores recorded included the International Knee Documentation Committee score, the International Cartilage Repair Society score, the Knee Injury and Osteoarthritis Outcome Score, the visual analog scale, the Bentley Functional Rating Score, the Modified Cincinnati Rating System, Tegner activity Lysholm scores, and return athletics. Outcome scores were compared among studies based on proportion of adolescents achieving specific outcome quartiles at a minimum 1-year follow-up. Methodologic quality of studies was evaluated by Coleman Methodology Scores (CMSs)., Results: Five studies reported on 115 subjects who underwent ACI with periosteal cover (ACI-P; 95, 83%), ACI with type I/type III collagen cover (ACI-C; 6, 5%), or matrix-induced ACI (MACI; 14, 12%). Mean patient age was 16.2 years (range, 11 to 21 years). All studies were case series. Follow-up ranged from 12 to 74 months (mean, 52.3 months). Mean defect size was 5.3 cm(2) (range, 0.96 to 14 cm(2)). All studies reported improvement in clinical outcomes scores. Graft hypertrophy was the most common complication (7.0%). The mean preoperative clinical outcome percentage (based on percentage of outcome scale used) was 37% (standard deviation [SD], 18.9%) and the mean postoperative clinical outcome percentage was 72.7% (SD, 16.9%). The overall percentage increase in clinical outcome scores was 35.7% (SD, 14.2%). Mean CMS was 47.8 (SD, 8.3)., Conclusions: Cartilage repair in adolescent knees using ACI provides success across different clinical outcomes measures. The only patient- or lesion-specific factor that influenced clinical outcome was the shorter duration of preoperative symptoms., Level of Evidence: Level IV, systemic review of Level I-IV studies., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Compare histological outcomes after microfracture (MF), autologous chondrocyte implantation (ACI), and osteochondral autograft transfer (OATS)., Methods: Literature review using PubMed MEDLINE, SCOPUS, Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Cochrane Collaboration Library. Inclusion criteria limited to English language studies International Cartilage Repair Society (ICRS) grading criteria for cartilage analysis after ACI (autologous chondrocyte implantation), MF (microfracture), or OATS (osteochondral autografting) repair techniques., Results: Thirty-three studies investigating 1511 patients were identified. Thirty evaluated ACI or one of its subtypes, six evaluated MF, and seven evaluated OATS. There was no evidence of publication bias (Begg's p=0.48). No statistically significant correlation was found between percent change in clinical outcome and percent biopsies showing ICRS Excellent scores (R(2)=0.05, p=0.38). Percent change in clinical outcome and percent of biopsies showing only hyaline cartilage were significantly associated (R(2)=0.24, p=0.024). Mean lesion size and histological outcome were not correlated based either on percent ICRS Excellent (R(2)=0.03, p=0.50) or percent hyaline cartilage only (R(2)=0.01, p=0.67). Most common lesion location and histological outcome were not correlated based either on percent ICRS Excellent (R(2)=0.03, p=0.50) or percent hyaline cartilage only (R(2)=0.01, p=0.67)., Conclusions: Microfracture has poorer histologic outcomes than other cartilage repair techniques. OATS repairs primarily are comprised of hyaline cartilage, followed closely by cell-based techniques, but no significant difference was found cartilage quality using ICRS grading criteria among OATS, ACI-C, MACI, and ACI-P., Level of Evidence: IV, meta-analysis., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Endovascular infections caused by Staphylococcus aureus involve interactions with fibronectin present as extracellular matrix or surface ligand on host cells. We examined the expression, structure, and binding activity of the two major S. aureus fibronectin-binding proteins (FnBPA, FnBPB) in 10 distinct, methicillin-resistant clinical isolates from patients with either persistent or resolving bacteremia. The persistent bacteremia isolates (n = 5) formed significantly stronger bonds with immobilized fibronectin as determined by dynamic binding measurements performed with atomic force microscopy. Several notable differences were also observed when the results were grouped by clonal complex 5 (CC5) strains (n = 5) versus CC45 strains (n = 5). Fibronectin-binding receptors on CC5 formed stronger bonds with immobilized fibronectin (P < 0.001). The fnbA gene was expressed at higher levels in CC45, whereas fnbB was found in only CC5 isolates. The fnbB gene was not sequenced because all CC45 isolates lacked this gene. Instead, comparisons were made for fnbA, which was present in all 10 isolates. Sequencing of fnbA revealed discrete differences within high-affinity, fibronectin-binding repeats (FnBRs) of FnBPA that included (i) 5-amino-acid polymorphisms in FnBR-9, FnBR-10, and FnBR-11 involving charged or polar side chains, (ii) an extra, 38-amino-acid repeat inserted between FnBR-9 and FnBR-10 exclusively seen in CC45 isolates, and (iii) CC5 isolates had the SVDFEED epitope in FnBR-11 (a sequence shown to be essential for fibronectin binding), while this sequence was replaced in all CC45 isolates with GIDFVED (a motif known to favor host cell invasion at the cost of reduced fibronectin binding). These complementary sequence and binding data suggest that differences in fnbA and fnbB, particularly polymorphisms and duplications in FnBPA, give S. aureus two distinct advantages in human endovascular infections: (i) FnBPs similar to that of CC5 enhance ligand binding and foster initiation of disease, and (ii) CC45-like FnBPs promote cell invasion, a key attribute in persistent endovascular infections., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Medical implants, like cardiovascular devices, improve the quality of life for countless individuals but may become infected with bacteria like Staphylococcus aureus. Such infections take the form of a biofilm, a structured community of bacterial cells adherent to the surface of a solid substrate. Every biofilm begins with an attractive force or bond between bacterium and substratum. We used atomic force microscopy to probe experimentally forces between a fibronectin-coated surface (i.e., proxy for an implanted cardiac device) and fibronectin-binding receptors on the surface of individual living bacteria from each of 80 clinical isolates of S. aureus. These isolates originated from humans with infected cardiac devices (CDI; n = 26), uninfected cardiac devices (n = 20), and the anterior nares of asymptomatic subjects (n = 34). CDI isolates exhibited a distinct binding-force signature and had specific single amino acid polymorphisms in fibronectin-binding protein A corresponding to E652D, H782Q, and K786N. In silico molecular dynamics simulations demonstrate that residues D652, Q782, and N786 in fibronectin-binding protein A form extra hydrogen bonds with fibronectin, complementing the higher binding force and energy measured by atomic force microscopy for the CDI isolates. This study is significant, because it links pathogenic bacteria biofilms from the length scale of bonds acting across a nanometer-scale space to the clinical presentation of disease at the human dimension.

It is well established that bacteria are able to respond to temporal gradients (e.g., by chemotaxis). However, it is widely held that prokaryotes are too small to sense spatial gradients. This contradicts the common observation that the vast majority of bacteria live on the surface of a solid substrate (e.g., as a biofilm). Herein we report direct experimental evidence that the nonmotile bacterium Staphylococcus aureus possesses a tactile response, or primitive sense of touch, that allows it to respond to spatial gradients. Attached cells recognize their substrate interface and localize adhesins toward that region. Braille-like avidity maps reflect a cell's biochemical sensory response and reveal ultrastructural regions defined by the actual binding activity of specific proteins., (Copyright © 2010 Biophysical Society. Published by Elsevier Inc. All rights reserved.)