Adam Blair Yanke

Background: Identifying and addressing mechanical malalignment is an important component of treating symptomatic osteochondral defects with osteochondral allograft (OCA) transplantation. However, little is known about how malalignment influences short- to midterm outcomes after OCA transplantation. Purpose: To evaluate whether mechanical alignment measurements including the hip-knee-ankle (HKA) angle, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and joint line convergence angle (JLCA) predict clinically significant outcome achievement, graft failure, and reoperation after OCA transplantation with or without concomitant realignment. Study Design: Case series; Level of evidence, 4. Methods: Patient-reported outcome measures (PROMs) were collected preoperatively and at a minimum 2-year follow-up in patients receiving OCA from 2005 to 2023. PROMs included the International Knee Documentation Committee score and Knee injury and Osteoarthritis Outcome Score subscales. Clinically significant outcome thresholds were the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS). Preoperative full-length, weightbearing radiographs were used to measure the HKA angle, LDFA, MPTA, and JLCA. Multivariable logistic regression was used for clinically significant outcome achievement and all-cause reoperation; failure and arthroplasty were summarized descriptively because of the low number of events. Results: A total of 66 patients (mean age, 34.1 ± 11.5 years; mean body mass index, 27.8 ± 4.8 kg/m ² ; 50% female) met inclusion criteria. Mean alignment measurements were 1.8°± 4.0° for the HKA angle, 86.8°± 2.3° for the LDFA, 86.3°± 2.3° for the MPTA, and 1.7°± 1.0° for the JLCA. Although PROMs improved at the final follow-up, no preoperative alignment measure was statistically associated with MCID, PASS, or SCB achievement or with all-cause reoperation ( P > .05). In total, 25 (37.9%) patients underwent reoperation; graft survivorship was 93.9%, with 4 failures and 3 arthroplasty conversions. In an exploratory subanalysis, 16 patients with an HKA angle >5° of varus or valgus (13 with concomitant realignment) did not have significantly different rates of reoperation (43.8% vs 36.0%; P = .768) or graft failure (6.3% vs 6.0%; P > .999) compared to their remaining counterparts. Conclusion: In this small, heterogeneous cohort, preoperative mechanical alignment measures were not statistically associated with clinically significant outcome achievement or all-cause reoperation after OCA transplantation. These hypothesis-generating findings do not establish the absence of an alignment effect or define a threshold for realignment because most patients with severe preoperative malalignment underwent concomitant realignment, which may have contributed to the favorable overall outcomes, and failure events were infrequent.

Purpose: To compare biomechanical outcomes between soft‐body (SB) knotless, hard‐body (HB) knotless, and HB knotted anchors when simulating medial patellofemoral ligament reconstruction in a cadaveric model. Methods: Forty‐two anchors were placed in either a direct medial or a superior medial position during a medial patellofemoral ligament reconstruction cadaveric simulation. Each test assessed 1 of 3 anchor types: SB knotless, HB knotted, and HB knotless. Specimens were tested under cyclic loading (10‐60 N, 100 cycles) and load‐to‐failure testing. Outcomes assessed included cyclic elongation, first‐cycle excursion, elongation amplitude, maximum load to failure, stiffness, energy to failure, and failure mode. Results: The SB knotless anchor exhibited significantly greater cyclic elongation compared with knotted and knotless HB anchors ( P < .001, P = .007; respectively). Knotless HB anchors showed the highest maximum load to failure, significantly surpassing knotted HB anchors ( P = .001). Stiffness was highest for knotless HB anchors, also significantly greater than knotted HB anchors ( P = .002). Anchors placed superomedially had higher maximum load than direct medial placement ( P = .017). Bone density was significantly higher in the superior medial position ( P = .007), and univariate linear regression showed a significant positive correlation between bone density and maximum load ( P < .001). Conclusions: Knotless HB anchors showed superior biomechanical performance, with greater maximum load and stiffness compared with knotted HB anchors, although there were slight design differences between the anchor bodies. Both HB anchors showed significantly lower cyclic elongation when compared with the SB anchor; however, no differences were found in cyclic creep. Superomedial anchor placement provided improved biomechanical strength relative to direct medial placement; however, this difference may be attributed to increased bone density in this region. Clinical Relevance: Using knotless HB anchors during medial patellofemoral ligament reconstruction may improve fixation strength and potentially reduce complications associated with anchor failure. Likewise, use of the superomedial aspect of the patella may provide more robust anchor fixation.

Purpose: To evaluate the effect of preoperative subchondral insufficiency fracture of the knee (SIFK) on the outcomes of medial meniscus posterior root tear repair. Methods: Patients undergoing repair of an isolated primary medial meniscus posterior root tear with ≥2‐year follow‐up were included. Data encompassed demographics, history, magnetic resonance imaging‐confirmed SIFK, subsequent surgery, radiographic osteoarthritis progression, and patient‐reported outcome measures: Knee Injury and Osteoarthritis Outcome Score, Joint Replacement; International Knee Documentation Committee; and Veterans RAND 12‐Item Health Survey. Patients were stratified by SIFK status. Clinically significant improvement was assessed using cohort‐specific minimal clinically important difference thresholds. Results: Ninety‐one patients (mean age: 56.5 ± 9.4 years, 73.6% women; mean body mass index: 32.5 ± 6.1) were included with a follow‐up of 38.3 ± 15.3 months (range, 24‐82), which did not differ between groups ( P = .841). Thirty‐four patients (37.4%) had SIFK, and 85% had SIFK grade 1 or 2. Baseline characteristics did not differ between groups. Compared with patients without SIFK, those with SIFK showed lower rates of achieving the minimal clinically important difference and patient‐acceptable symptom state for Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (80.7% vs 38.2%, P < .001; 61.4% vs 35.3%, P = .028, respectively). Patients with SIFK demonstrated higher rates of subsequent surgery (20.6% [95% confidence interval, 8.7%‐37.9%] vs 5.3% [95% confidence interval, 1.1%‐14.6%]; risk difference, 15.3% [95% confidence interval, 1.6%‐31.9%]; P = .036) and a higher postoperative Kellgren‐Lawrence grade (median [interquartile range], 3.0 [3.0‐4.0] vs 2.0 [2.0‐3.0]; P = .013), with smaller postoperative joint space (2.8 ± 0.6 mm vs 3.8 ± 1.0 mm, P = .002). Conclusions: Preoperative SIFK is associated with lower rates of achieving meaningful clinical improvement along with a higher likelihood of subsequent surgeries and inferior postoperative radiographic osteoarthritis outcomes after medial meniscus posterior root tear repair. Level of Evidence: Level III, retrospective cohort study.

Purpose: To evaluate how major United States commercial insurers justify medical‐necessity criteria for knee osteochondral allograft (OCA) transplantation, characterize the level of evidence (LOE) cited within their policies, and assess whether coverage criteria are supported by the cited literature. Methods: Four major national commercial insurers with publicly available knee OCA policies were identified, and the most recent policy versions were retrieved. Medical‐necessity criteria were extracted, and all cited references applicable to knee OCA were screened, assigned an LOE and publication date, and coded for whether they supported each policy criterion. Coverage stance by lesion site was summarized. Publicly available revision histories were reviewed to compare administrative revision and evidence‐refresh cadence. A deidentified institutional dataset of current procedural terminology 27415 authorization requests was reviewed to contextualize findings in real‐world coverage outcomes. Results: Across the 4 insurers, 40 applicable references were cited: Level V n = 7 (17.5%), Level IV n = 30 (75.0%), and Level III n = 3 (7.5%); Level I and II were 0. One insurer provided no OCA‐specific coverage criteria and instead deferred determinations to proprietary criteria not publicly available. Among the remaining 3 insurers, coverage was most permissive for unipolar femoral condyle lesions. Patellar lesions were explicitly excluded by 1 insurer, whereas bipolar and tibial plateau lesions were each excluded by 2 insurers. Among payers with assessable revision histories, administrative revisions occurred more frequently than documented evidence‐refresh events. In an institutional dataset of 34 current procedural terminology 27415 requests, 7 (20.6%) were initially denied; all cases with documented outcomes were ultimately approved after escalation. Conclusions: Commercial payer knee OCA policies are largely based on older, low‐level evidence, and cited literature seldom supports key medical‐necessity criteria. Clinical Relevance: Identifying discrepancies between insurance coverage and clinical evidence may help clinicians advocate more effectively during preauthorization and appeal processes, reduce delays in care, and inform payers’ efforts to align coverage criteria with modern outcome data.

Objective: To determine how fibronectin fragment (Fn-f), a matrikine that induces an osteoarthritis (OA)-like phenotype, reshapes chondrocyte states and transcriptional programs at single-cell resolution. Design: Primary human ankle chondrocytes from two cadaveric donors without OA were treated with PBS or purified recombinant Fn-f for 18 hours and profiled by single-cell RNA sequencing. Transcriptional states were characterized by marker genes and functional enrichment, compared with classifications used for OA chondrocytes, and evaluated for Fn-f-dependent changes in abundance and transcriptional programs. Results: Five transcriptionally distinct populations were identified with features that matched previous classifications of effector, inflammatory, pre-hypertrophic/fibrochondrocyte, reparative, and homeostatic chondrocytes. Fn-f markedly redistributed cells among these states, enriching inflammatory chondrocytes while reducing effector and reparative populations. Within transcriptional states, Fn-f differentially altered matrix/cartilage, inflammatory, and stress/immediate-early programs. These responses did not uniformly correspond to assigned subtype identities, demonstrating that transcriptional programs can be dynamically deployed across chondrocyte states. Conclusions: Controlled perturbations of healthy chondrocytes complement observational OA atlases by resolving stimulus-dependent changes in chondrocyte state abundance and transcriptional programs. Discordance between subtype annotations and dynamic functional programs further highlights the need for harmonized definitions of chondrocytes across phenotypic states.

Purpose: To quantify the variability in tibial tubercle‐to‐posterior cruciate ligament (TT‐PCL) measurements using previously established methodology on axial magnetic resonance imaging scans in patients with and without a history of patellar instability based on placement of the dorsal condylar line. Methods: A retrospective review was performed of patients undergoing isolated medial patellofemoral ligament reconstruction at a single institution (2018‐2021). TT‐PCL was measured using 3 distal‐proximal placements of the dorsal condylar line (proximal, middle, and distal), and values were compared between the instability and control groups and across measurement locations. Analyses were repeated after normalization to tibial width. Results: This study included 64 patients with patellar instability and 30 healthy controls, with no clinically meaningful differences in age or sex distribution. Mean proximal, middle, and distal TT‐PCL distances were higher in the patellar instability cohort than controls (23.10 ± 3.86 vs 21.31 ± 3.98 mm; 23.58 ± 3.80 vs 21.56 ± 3.67 mm; 24.40 ± 4.43 vs 22.13 ± 4.13 mm, respectively), with significant between‐group differences at all axial locations (all P < .05). Normalized TT‐PCL/tibial width ratios also remained higher in the instability cohort (0.32 ± 0.06 vs 0.29 ± 0.05 proximal; 0.33 ± 0.06 vs 0.29 ± 0.06 middle; 0.34 ± 0.06 vs 0.30 ± 0.05 distal), with reduced variability. Receiver operating characteristic analysis showed moderate discrimination (area under the curve 0.67 proximal, 0.67 middle, and 0.69 distal). Conclusions: TT‐PCL measurements increase as the dorsal tibial condylar line is selected more distally, underscoring the need for consistent reference point selection. Normalizing to tibial width reduces variability and enhances comparability across patients. Among the evaluated axial locations, distal TT‐PCL measurements showed the strongest discriminatory performance for patellar instability, although the magnitude of this effect was modest. Clinical Relevance: Future research using a TT‐PCL measurement must report on and be consistent in selecting the axial height from which the magnetic resonance imaging cut is taken.

Background: Radial meniscal tears are uniquely challenging because their orientation transects circumferential collagen fibers, thereby disrupting hoop-stress resistance and compromising load transmission. Circumferential compression repair strategies are designed to restore native fiber continuity and more uniformly approximate tear edges. Contemporary approaches may incorporate circumferential capture via all-inside or inside-out techniques, with biologic augmentation to support healing. Indications: Complete or near-complete radial tears of the meniscus at the mid-body or adjacent to the root that disrupt hoop stress transmission. Additional indications include gapping or extrusion at the radial cleft when tissue quality is adequate, and the tear pattern is nondegenerative and noncomplex, supporting meniscal preservation. Technique Description: A patient with acute lateral joint-line pain was found on magnetic resonance imaging and arthroscopy to have an isolated, complete mid-body radial tear of the lateral meniscus. After debridement, circumferential fiber tape augmentation was performed by passing suture tape through the mensicocapsular junction and securing it with transtibial posterior and anterior tibial fixation to recreate a tensionable hoop vector and achieve anatomic side-to-side reduction. The repair was reinforced with inside-out horizontal mattress sutures, and notch microfracture was performed to biologically augment healing. Results: Expected outcomes include a stable, anatomic repair with improved restoration of hoop stresses and reduced gapping/extrusion. Patients typically experience early pain improvement and regain near-full range of motion by 2 to 3 months, with progressive functional recovery. Supporting biomechanical and preclinical data suggest that circumferential augmentation better normalizes contact mechanics and limits extrusion compared with simple repair. Discussion/Conclusion: Circumferential fiber tape augmentation is a viable technique for complete or near-complete radial meniscal tears to better restore hoop stress transmission through uniform, anatomic edge compression. When combined with standard meniscal repair and biologic augmentation, it can provide a stable construct with encouraging early clinical recovery. Further prospective, long-term comparative studies are recommended to define durability, optimal indications, and outcomes compared with conventional radial tear repair techniques. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Purpose: To compare patellotrochlear index (PTI) and Caton‐Deschamps index (CDI) measurements between normal and dysplastic trochleae, to evaluate the ability of PTI to discriminate patella alta, and to examine the relation of both indices with functional engagement as represented by the instability resolution angle (IRA). Methods: Surgical patients diagnosed with patellofemoral instability between 2016 and 2024 who underwent preoperative magnetic resonance imaging and true lateral radiographs were retrospectively reviewed. Patellar height was measured using PTI on magnetic resonance imaging and CDI on radiographs, and IRA was recorded intraoperatively. Trochlear dysplasia was graded by Dejour classification and stratified into low‐grade (normal/type A) and high‐grade (types B‐D). Differences in PTI and CDI across dysplasia grades and associations among CDI, PTI, and IRA were evaluated using mixed‐effects modeling; IRA analyses were limited to knees with intraoperative measurements. Results: A total of 152 knees (96 women, mean age 23.3 ± 9.8 years) were included. PTI differed across Dejour grades ( P = .001) and was higher in type A and D trochleae relative to normal trochleae. CDI also differed across grades ( P  = .004) and was lower in type A and C trochleae relative to normal trochleae. Using thresholds of CDI ≥ 1.2 and PTI ≤ 0.28, 38.2% of knees showed discordant patella alta classification. In nondysplastic knees, all PTI‐defined patella alta cases were also CDI‐defined patella alta, but concordance declines in high‐grade dysplasia (61.1%). The CDI‐PTI association differed by dysplasia stratum ( P = .30), with a significant inverse association in normal/type A but not high‐grade dysplasia. Neither index was associated with IRA ( P > .05). Conclusions: PTI and CDI show strong agreement in nondysplastic knees but diverge significantly in high‐grade trochlear dysplasia, where PTI fails to correspond with CDI in identifying patella alta. Level of Evidence: Level III, retrospective comparative cohort study.

Purpose: To compare tibial tubercle‐trochlear groove (TT‐TG) and tibial tubercle‐posterior cruciate ligament (TT‐PCL) distances across grades of trochlear dysplasia (TD) in patients with patellofemoral instability, to evaluate their relations with knee rotation angle (KRA) and patellar lateralization, measured as patellar tendon‐lateral trochlear ridge (PTLTR), and to determine its influence on surgical indications for realignment procedures. Methods: Patients with patellofemoral instability treated between 2017 and 2024 were retrospectively reviewed. Magnetic resonance imaging measurements included TT‐TG, TT‐PCL, TTdiff (TT‐TG − TT‐PCL), KRA, and PTLTR. TD was graded by Dejour classification and grouped as normal/low grade (normal‐A) or high grade (B‐D). Pathologic thresholds were defined as TT‐TG ≥ 15 mm, TT‐PCL ≥ 24 mm, and PTLTR ≥ 5.6 mm. Independent‐samples t‐tests, Mann‐Whitney U tests, Pearson correlation coefficients, Fisher's exact tests, and receiver operating characteristic curve analysis were used as appropriate. Results: A total of 153 patients were included. Mean TT‐TG and TT‐PCL were 17.3 ± 5.6 and 21.7 ± 4.1 mm, respectively. High‐grade TD showed significantly greater TT‐TG (18.7 ± 6.3 vs 16.0 ± 5.6 mm, P = .002), KRA (4.4 ± 6.8° vs 1.9 ± 8.0°, P < .001), and PTLTR (18.2 ± 8.5 vs 12.6 ± 8.1 mm, P < .001), whereas TT‐PCL did not differ between groups ( P = .387). TT‐TG correlated positively with KRA ( r = 0.47, P < .001), whereas TT‐PCL showed a weak inverse correlation ( r = −0.18, P = .027); TTdiff showed the strongest association ( r = 0.56, P < .001). PTLTR correlated with TT‐TG ( P < .001) but not TT‐PCL. Threshold analysis revealed discordance: 39.2% of normal/low‐grade and 44.6% of high‐grade TD patients were pathologic by TT‐TG despite normal TT‐PCL, whereas only 26.8% met TT‐PCL criteria overall ( P = .004). Conclusions: TT‐PCL underestimates functional patellar lateralization and surgical candidacy for realignment, particularly in high‐grade TD where rotational malalignment is prominent. TT‐TG shows stronger associations with rotational alignment and patellar engagement. Level of Evidence: Level III, retrospective cohort study.

Background: Bone–patellar tendon–bone (BTB) autografts have been considered the gold standard for anterior cruciate ligament reconstruction, although the popularity of quadriceps tendon (QT) autografts is increasing. Hypothesis/Purpose: The purpose of this study was to compare the ultrasound-derived cross-sectional area (CSA) and biomechanical strength of BTB and QT grafts harvested with different techniques. The authors hypothesized that ultrasound CSA measurements would be reliable and that QT grafts would be larger and stronger than BTB grafts, without differences between QT harvest methods. Study Design: Controlled laboratory study. Methods: Thirty grafts from 15 cadaveric knees included 15 BTB grafts harvested with a 9-mm double-blade scalpel, 7 full-thickness QT grafts harvested with the same 9-mm double-blade scalpel (DB-QT), and 8 QT grafts harvested with a proprietary 9-mm cylindrical QT harvester (CH-QT). CSA was measured at 3 regions with ultrasound by 2 raters, followed by cyclic loading and pull-to-failure testing. Between-group differences were analyzed, and associations between CSA and biomechanical outcomes were assessed with linear regression. Results: Ultrasound CSA demonstrated good to excellent reliability (ICC _2,1 = 0.70-0.87; ICC _{2, k} = 0.82-0.93). CSA differed between graft types (mean ± SD; BTB, 0.44 ± 0.08 cm ² ; CH-QT, 0.64 ± 0.10; DB-QT, 0.97 ± 0.22; all pairwise P < .01), with heterogeneous variance (Levene P = .002). DB-QT demonstrated greater CSA variability than BTB ( P = .005) and no difference in variability when compared with CH-QT ( P = .055). Maximum load and energy to maximum load differed significantly (both omnibus P < .001) with DB-QT > CH-QT > BTB, with significant post hoc differences. In paired-knee analyses, pooled QT grafts also demonstrated greater maximum displacement than BTB grafts from the same specimens. CH-QT demonstrated significantly greater variability in maximum load than BTB ( P = .002) and DB-QT ( P = .045). Mean displacement at maximum load and stiffness were similar, although variance differed. Cyclic elongation differed among grafts (omnibus P = .011), with DB-QT < CH-QT < BTB, while other cyclic measures did not differ. When grafts were pooled, CSA correlated positively with maximum load and energy to maximum load; however, within–graft type regressions were not significant. After normalization to CSA, stress and strain were similar across graft types. Conclusion: QT grafts were significantly larger and stronger than BTB, with full-thickness double-blade harvest producing the greatest CSA and load to failure. Ultrasound was a reliable tool to measure CSA, which correlated with graft strength. Clinical Relevance: QT grafts demonstrate greater structural capacity than BTB, and QT harvest technique influences graft size and strength, with double-blade harvest producing larger, stronger grafts.