Guillem Gonzalez-Lomas

Background/Objectives: This investigation was performed because corticosteroid injections are commonly used for symptomatic relief in patients with meniscal deficiency, yet their effect on graft survivorship and postoperative outcomes following meniscal allograft transplantation (MAT) remains poorly understood, with limited literature specifically addressing this topic. The aim of this study is to evaluate whether preoperative intra-articular corticosteroid injections (ICS) are associated with reoperation after MAT. Secondary aims included comparing reoperation-free survival, patient-reported outcome measures (PROMs), and patient acceptable symptom state (PASS) achievement. Methods: A retrospective review of 130 adults undergoing meniscal allograft transplantation (MAT) between 2011 and 2023 was performed. Patients with documented corticosteroid injection (CSI) status and ≥2 years of follow-up were included. Exclusion criteria included prior meniscal allograft transplantation, receipt of non-corticosteroid injections (e.g., hyaluronic acid or platelet-rich plasma), concomitant osteotomy procedures, multi-ligament knee reconstruction or inadequate follow-up. Propensity score matching (2:1 no steroid: steroid) based on age, sex, body mass index, fixation technique, operative compartment, and concomitant procedures yielded 54 matched patients (35 no steroid, 19 steroid). The primary outcome was ipsilateral knee reoperation, categorized as major reoperation (revision MAT, anterior cruciate ligament reconstruction, osteochondral allograft transplantation, conversion to total knee arthroplasty, meniscectomy and meniscus repair). Minor reoperations included irrigation and debridement, lysis of adhesions or manipulation under anesthesia, hardware removal, chondroplasty, and synovectomy. Reoperation-free survival was assessed using Kaplan–Meier analysis. PROMs and PASS were compared using adjusted regression models. Statistical significance was set at p < 0.05. Results: Baseline characteristics and follow-up were comparable between groups (7.6 ± 3.5 vs. 6.6 ± 3.2 years; p = 0.30). Overall reoperation occurred in 37.1% of patients in the no-steroid group and 31.6% in the steroid group (p = 0.771). Major reoperation rates were similar (17.1% vs. 15.8%; p = 1.000. There was no significant difference in minor reoperations between groups (20.0% vs. 10.5%; p = 0.468). Kaplan–Meier analysis demonstrated no difference in reoperation-free survival (p = 0.903), with comparable survival at the 1-, 2-, and 5-year time points. No individual subtypes differed significantly between groups. PROMs and PASS achievement were also similar, with no statistically significant differences observed. Conclusions: Preoperative corticosteroid injection was not associated with increased reoperation risk, inferior reoperation-free survival, or worse patient-reported outcomes following meniscal allograft transplantation. However, given the study’s limited power, lack of detailed injection characteristics, and the use of a heterogeneous complication outcome, these findings should be interpreted cautiously, as further investigation is warranted.

Background: The purpose of our study was to identify force plate-derived balance metrics that were predictive of multimodal return-to-sport test findings in a sample of anterior cruciate ligament reconstruction patients. Methods: We conducted a cross-sectional study of anterior cruciate ligament reconstruction patients who were at least 6 months postoperative. Subjects completed our multimodal Institutional RTS testing battery which included testing of hip and knee range of motion (ROM), isokinetic quadriceps strength, and core trunk muscle strength (Bunkie test), as well as balance testing on a force plate. Balance metrics predictive of Institutional RTS test findings for the involved leg were identified using multivariable regression with stepwise selection. Model significance was assessed at α = 0.002. Results: Sixteen subjects (7M, 9F) were enrolled in our study with a median age of 29 years (range 20–47). Multivariate multiscale entropy (MMSE _xyz ) of the involved leg was predictive of knee flexion active ROM ( P = .02) and Bunkie stabilizing test score ( P = .03), MMSE _xyz of the uninvolved leg was predictive of Bunkie lateral and medial test scores ( P = .02 and P = .02), and interlimb symmetry of MMSE _xyz was predictive of triple jump test score ( P = .007). Interlimb symmetry of the COP _x shift balance metric was predictive of hip internal rotation active and passive ROM ( P = .008 and P = .03) and step-down test score ( P = .004). Conclusion: Force plate-based balance testing metrics are predictive of some return-to-sport test findings including knee flexion ROM and Bunkie test scores, but further analysis is needed to identify balance metrics predictive of quadriceps isokinetic testing and muscle flexibility testing results.

Background: Nordic combined (NC) and ski jumping (SJ) athletes have a high prevalence of chronic hip pathology, which may lead to altered knee and ankle biomechanics. Purpose: The purpose of this study was to determine the relationship among athlete-reported lower extremity outcomes in a proximal-to-distal sequence. Study Design/Level of Evidence: cross-sectional study, Level IV. Methods: Elite SJ and NC athletes who competed at the national and international levels were prospectively recruited to complete a survey eliciting information about their Hip Disability and Osteoarthritis Outcome Score (HOOS), International Knee Demographic Committee (IKDC) score, and Foot and Ankle Outcome Score (FAOS). Univariate linear regressions modeling IKDC scores and FAOS subscores were performed for each of the following independent variables: age, sex, body mass index, Nordic event (NC or SJ), HOOS subscore, and FAOS subscore or IKDC score, respectively. Results: A total of 22 athletes were included in the study. HOOS symptoms subscores were significantly lower (worse) among SJ athletes compared with NC athletes ( P = .002). HOOS quality of life subscores were lower for female athletes compared with male athletes (54 ± 21, 73 ± 4.0; P = .029) in the entire cohort. An increase in the HOOS pain subscore (0.54 ± 0.20, P = .016) and HOOS sports subscore (0.40 ± 0.17, P = .042) was associated with a significant increase in the IKDC score. An increase in the HOOS symptoms subscore (0.63 ± 0.21, P = .011) was associated with a significant increase in the FAOS symptoms subscore. Conclusion: Elite NC and SJ athletes are at high risk of hip pain, which increases their risk of developing knee and ankle pain as well. These findings strongly suggest that training targeted at hip strength and conditioning may optimize knee and ankle outcomes in elite NC and SJ athletes. Clinical Relevance: The results of this study may help guide physicians, allied health personnel, and coaches to alter lower extremity training regimens to decrease the risk of injury.

Purpose: The purpose of this study is to assess the association between sagittal tibial tuberosity‐trochlear groove (sTT‐TG) distance and patellofemoral chondral lesion size in patients undergoing cartilage restoration procedures.Methods: A retrospective cohort analysis of patients who underwent an osteochondral allograft transplantation or matrix‐induced autologous chondrocyte implantation in the patellofemoral compartment, from 2010 to 2020, were included if they had patellofemoral high‐grade lesions, magnetic resonance imaging (MRI) and minimum 2‐year follow‐up. The preoperative sTT‐TG distance was measured independently on axial T2‐weighted MRI sequences by two authors, each at least two weeks apart. Intraoperative lesion size was reported according to operative report measurements by the attending surgeon. An interclass correlation coefficient (ICC) was calculated to assess intra‐ and inter‐rater reliability, and categorical data analysis and linear regression models were used to assess the relationship between sTT‐TG and lesion size.Results: A total of 80 patients (50 females) with a mean age of 31.5 ± 10.4 years, body mass index of 27.0 ± 5.9 kg/m² and follow‐up of 61.5 ± 21.4 months were included. A total of 107 lesions were present: 63 patients with unipolar (patella = 41, trochlea = 22) and 22 with bipolar lesions. The mean MRI defect size was 1.6 ± 1.0 cm² and the mean intraoperative defect size was 3.8 ± 2.4cm². Intra‐ (ICC: 0.99,0.98) and inter‐rater reliability (ICC: 0.96) were excellent for both MRI defect size and sTT‐TG measurements. The mean sTT‐TG was −4.8 ± 4.9 mm and was significantly inversely related to MRI defect size (−0.45, p < 0.01), intraoperative patellar lesion size (−0.32, p = 0.01), total lesion area (−0.22, p = 0.04), but not trochlear lesion size (−0.09, p = 0.56). Multivariable regression demonstrated a more negative sTT‐TG remained an independent variable correlated with larger MRI‐measured patellofemoral defect sizes and intraoperative patellar lesions.Conclusion: A more negative sTT‐TG was an independent variable correlated with larger patellofemoral lesions in patients undergoing patellofemoral cartilage restoration.Level of Evidence: Level III, Diagnostic.

Background: The use of telerehabilitation after sports medicine procedures such as an arthroscopic rotator cuff repair (ARCR) and anterior cruciate ligament reconstruction (ACLR) has rapidly increased in recent years; however, the functional outcomes and patient satisfaction with telerehabilitation compared to in-person rehabilitation remain unclear. The purpose of this study was to compare the functional outcomes and patient satisfaction with telerehabilitation to in-person rehabilitation in a randomized controlled trial after two common sports procedures, ARCR and ACLR. Methods: Two randomized controlled trials were conducted involving patients scheduled to undergo ARCR or ACLR by one of six fellowship-trained sports medicine surgeons between October 2020 and November 2021. Each trial had an enrollment goal of 60 patients. Subjects were randomized 1:1 to receive telerehabilitation or in-person rehabilitation postoperatively. Functional outcome and satisfaction metrics were collected at baseline and at post-operative visits and compared between groups. Results: In total, 16 ACLR patients were enrolled, of whom 10 (62.5%) were assigned to in-person rehabilitation and 6 (37.5%) to telerehabilitation. Additionally, 32 ARCR patients were enrolled, of whom 20 (62.5%) were assigned in-person rehabilitation and 12 (37.5%) were assigned telerehabilitation. In total, of the 30 patients assigned to in-person rehabilitation, none reported a crossover to telerehabilitation. Of the 18 patients initially assigned to telerehabilitation, 12 (67%) completed the final follow-up survey, of which 11 (92%) reported a crossover; 9 patients completed in-person rehabilitation and 2 patients completed hybrid in-person and telerehabilitation. Conclusions: Patients preferred in-person rehabilitation compared to telerehabilitation after ACLR and ARCR, as evidenced by the nearly ubiquitous crossover from telerehabilitation to in-person rehabilitation in both studies. Our findings suggest that telerehabilitation protocols still need to be perfected, and that there may be a role for a hybrid in-person and tele-rehab model.

Background: The purpose of this study was to compare opioid analgesic use and patient-reported outcomes (PROs) after anterior cruciate ligament reconstruction (ACLR) between patients with and without cannabis use disorder (CUD). Hypothesis: We hypothesized that patients with CUD would have greater postoperative opioid usage with comparable improvement in PROs. Study Design: Retrospective matched-cohort study. Level of Evidence: Level 3. Methods: We identified patients with CUD who underwent primary ACLR at a single center and had minimum 3-month follow-up. Patients with CUD were propensity score matched 1:1 to non-CUD controls with respect to age, sex, and follow-up time. Total refills, days supply, and morphine milligram equivalents (MMEs) of opioid analgesics prescribed were calculated for up to 1 year postoperatively. Patient-Reported Outcome Information System (PROMIS) instruments were used to assess PROs. Opioid use and outcomes were compared between CUD and control groups using Mann-Whitney U test and Fisher’s exact test. P values <0.05 were considered significant. Results: A total of 104 patients with CUD were matched to 104 controls. Both groups were majority male (65.4% male, 34.6% female). The CUD group had a mean age of 29.9 years and mean follow-up time of 16.1 months. There was no significant intergroup difference in opioid prescription rates (CUD 82.7% vs control 83.7%, P ≥ 0.99). Among patients prescribed opioids, there were no significant intergroup differences in total days supply ( P = 0.67), total MMEs ( P = 0.71), or MMEs per day ( P = 0.65). There were no significant differences in pre- to postoperative improvement in PROMIS Pain Intensity ( P = 0.51), Pain Interference ( P = 0.81), Mobility ( P = 0.90), Mental Health ( P = 0.74), or Physical Health ( P = 0.94). Conclusion: There were no significant differences detected in opioid usage or PRO improvement after ACLR between patients with CUD and those without. However, because a sample size was not determined a priori, a larger sample may show a difference. Clinical Relevance: CUD does not appear to correlate with inferior outcomes after ACLR.

Objectives: Cannabis use disorder (CUD), also known as marijuana use disorder, is prevalent yet underdiagnosed psychiatric condition among the U.S. population. Epidemiologic studies have identified a high rate of comorbidity between CUD and chronic pain and other psychiatric disorders. There is a concern among orthopedic surgeons that patients with CUD who undergo elective procedures, such as anterior cruciate ligament reconstruction (ACLR), may be at higher risk for long-term opioid use and poorer outcomes following surgery. The aim of this study was to compare opioid use and patient- reported outcomes (PROs) following ACLR between patients with CUD versus controls. Methods: We conducted a retrospective review of patients with an active diagnosis of CUD who underwent primary ACLR surgery at a single center from 2011-2021 with minimum 3-month follow-up. Patients with CUD were identified using ICD-10 code F12 and its associated sub-codes. CUD patients were matched to controls on age, sex, and follow-up time using greedy nearest-neighbor propensity score matching. Analgesic prescriptions up to one year postoperative were abstracted from medical records and all opioid analgesic doses were converted to morphine milligram equivalents (MMEs). Pre- and post-operative Patient-Reported Outcome Information System (PROMIS) scores, 90-day readmissions, and 90-day revisions were also abstracted from medical records. Outcomes were compared between CUD and control groups using Mann-Whitney U test and Fisher’s exact test. P-values <0.05 were considered significant. Results: 104 CUD patients were matched to 104 controls. Sex demographics were the same in both groups (65.4% male, 34.6% female) and there were no significant differences in mean age (CUD 29.9 vs control 29.2 years; p=0.57), BMI (CUD 25.5 vs control 25.5 years; p=0.95), or follow-up time (CUD 16.1 vs control 15.1 months; p=0.65). Both groups were prescribed postoperative opioids at similar rates (CUD 82.7% vs control 83.7%; p=1.00). Among those prescribed opioids, there were no significant differences in total days supplied (CUD 12.5 vs control 10.8; p=0.67), total MMEs (CUD 558 vs control 445; p=0.71), or MMEs per day (CUD 47.5 vs control 46.3; p=0.65). Likewise, there were no significant differences in pre-to-postoperative improvement in PROMIS Pain Intensity (CUD -5.8 vs control -5.1; p=0.51), Pain Interference (CUD -8.3 vs control -7.6; p=0.81), Mobility (CUD 10.9 vs control 11.1; p=0.90), Mental Health (CUD 0.03 vs control 0.54; p=0.74), or Physical Health (CUD 3.9 vs control 4.2; p=0.94). Conclusions: Patients with CUD do not appear to consume opioid analgesics at a higher frequency or duration than their counterparts without CUD following ACLR surgery. Furthermore, both groups experience similar improvements in patient-reported outcomes following ACLR and these improvements are not diminished among CUD patients. While orthopedic surgeons should continue to screen patients for cannabis use as part of a thorough preoperative assessment, cannabis abuse or dependence in itself is not cause for concern for worse post-ACLR outcomes.

Objectives: The COVID-19 pandemic led to increased sedentary behavior and BMIs during 2020, which may decondition musculotendinous units and lead to increased risk for injury. Our hypothesis is as patients return to pre-COVID levels of activity, we hypothesize that there will be a resultant rebound increase in tendon ruptures. Methods: The electronic medical record was queried for current procedural terminology codes for tendon ruptures (Achilles, patella, quadriceps, hamstring, distal biceps, triceps, and pectoralis major) from January 2017 to December 2021 at a single academic urban center. Data was reviewed to ensure only acute tendon rupture repairs were included. The years 2017 – 2019 was used as a proxy for pre- COVID rates, 2020 as a proxy for the COVID quarantine, and 2021 as a proxy for “Post-COVID” activity. Univariate analysis was performed for comparative data. Results: A total of 1879 patients (82.8% male, mean age 47.8 years) who sustained tendon injuries and underwent surgical repair were identified. There were 589 (31.3%) Achilles tendon repairs, 181 (9.6%) patella tendon repairs, 414 (22.0%) quadriceps tendon repairs, 100 (5.3%) hamstring tendon repairs, 397 (21.1%) distal biceps repairs, 105 (5.6%) triceps repairs, and 93 (4.9%) pectoralis tendon repairs. The total number of tendon injuries per year was: 2017 – 357 (19.0%), 2018 – 380 (20.2%), 2019 – 380 (20.2%), 2020 – 308 (16.4%), 2021 – 454 (24.2%). The rates in 2017, 2018, and 2019 were within 1% of each other, but there was a 3.8% decrease in rate of tendon injuries from 2019 to 2020, and a 7.8% increase in rate of tendon injuries from 2020 to 2021 (Figure 1). When analyzed by quarter, linear regression model demonstrated a statistically significant increase in case counts over the period from Q2 2020 to Q2 2021 (β = 21.20; 95% CI = 13.62 - 28.78, p-value < 0.01). Conclusions: A “COVID rebound” of tendon rupture repairs in 2021 from a prolonged period of inactivity during 2020 occurred at a single academic center. As patients return to pre-COVID levels of activity that may be unsuitable to their deconditioned state, health care providers, should counsel patients appropriately on return to activity or sport following long periods of induced inactivity. : This study presents important epidemiologic information on musculotendinous injury rates during the COVID-19 pandemic, that can help providers counsel patients when returning to their former baseline levels of physical activity.

Objectives: Expansion of chondral defect size and clinical outcomes in patients with cartilage lesions are thought to be modulated by several risk factors. Previous studies suggest that time delay until implantation may be a risk factor for an increase in the number and size of chondral lesions at the time of implantation. Reports on the effect of time delay on clinical outcomes, however, remain limited. Therefore, the purpose of this study was to evaluate the effect of time delay from cartilage biopsy to implantation on patient satisfaction, return to sport (RTS), and clinical outcomes following autologous chondrocyte implantation. Methods: A retrospective review was performed among patient who underwent autologous chondrocyte implantation (ACI) and matrix-associated autologous chondrocyte implantation (MACI) at a single institution between the years 2012 to 2020 with minimum 2-year clinical follow-up. Clinical outcomes were measured using the Visual Analog Scale (VAS) for pain and satisfaction and the Knee Injury and Osteoarthritis Outcome Score (KOOS; subscores: symptoms, pain, sport, and quality of life (QOL)). Time delay was calculated as the elapsed time between cartilage biopsy and implantation. Cartilage lesions were categorized based on the Outerbridge classification of chondral lesions. The number of high-grade lesions (Outerbridge grade 3 or 4) and size of lesions were analyzed at time of biopsy and implantation. T-tests or non-parametric tests and Chi-squared tests were used to analyze continuous variables and categorical variables, respectively. A one-way ANOVA was used to compare outcomes based on RTS status, using a post-hoc Tukey’s HSD test for multiple comparisons. Bivariate linear regression was used to determine the impact of the time interval from biopsy to implantation on the change in size of the largest high-grade lesion and RTS. Results: A total of 36 patients, mainly female (55.6%) aged 29.25 (± 9.49) with a mean follow-up of 6.51 ± 2.5 years were included in our analysis. Thirteen patients (36.1%) did not RTS. Of the 23 patients (63.9%) who returned to sport, 11 (30.6%) returned at their preoperative level or higher, and 12 (33.3%) returned at a lower level. VAS pain scores were significantly higher in patients who did not RTS vs those who did (42.85 vs. 9.35, p 2; however, this correlation did not reach significance (p=0.09). The number of high-grade lesions at time of implantation were significantly higher in those that returned to sport at a lower level than those who did not return (1.67 vs. 1.23, p=0.02). The average surface area of the defect at biopsy and implantation were 3.13 cm² and 4.38 cm² respectively. The number of patients who had an increase in the number of high-grade lesions from biopsy to implantation was significantly higher in those who returned to sport at a lower level compared to those who did not return (4 vs. 1, p=0.05). Logistic regression demonstrated no significant relationship between time interval and rate of return to sport (p=3.59). No other associations were observed between time from biopsy to implantation and clinical outcomes. Conclusions: An increase in time delay from biopsy to graft implantation is associated with worse pain after surgery. Both the number of high-grade lesions at the time of implantation and an increase in time delay were not associated with lower rates of return to sport. Further studies are needed to evaluate the effects of time delay until implantation and its potential role as a risk factor for worse clinical outcomes in patients undergoing autologous chondrocyte implantation procedures. [Table: see text]