Search

To perform an updated systematic review comparing the clinical outcomes of autograft versus nonirradiated allograft for anterior cruciate ligament reconstruction (ACLR).A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of primary ACLR with autograft versus nonirradiated allograft with a minimum 2-year follow-up. The search terms used were: "anterior cruciate ligament" AND autograft AND allograft AND (irradiation OR non-irradiated). Patients were evaluated based on graft failure rates, the Objective International Knee Documentation Committee (IKDC) score, anteroposterior laxity, and patient-reported outcomes (Subjective IKDC score, the visual analog scale [VAS], the Cincinnati Knee Rating System, Lysholm, and Tegner scores). Risk of bias was assessed using the ROBINS-I and Cochrane Collaboration's risk of bias tool for non-randomized and randomized studies, respectively.Sixteen studies (3 Level I, 7 Level II, 6 Level III) met inclusion criteria, including a total of 15,502 patients undergoing ACLR with autograft and 1,577 with nonirradiated allograft. The average follow-up ranged from 24.0 to 132.0 months. Graft failure ranged from 0% to 9.4% of patients in the autograft group and 0% to 26.5% in the allograft group. Two studies showed greater failure rates among younger patients in the allograft group. There were no significant differences between the Objective IKDC score, anteroposterior laxity, or patient-reported outcomes between the groups within any of the included studies (Autograft and nonirradiated allograft for primary ACLR demonstrate similar patient-reported outcomes and graft failure rates.III, systematic review of level I-III studies.

To compare the outcomes of patients undergoing treatment of focal chondral defects (FCDs) of the knee joint with chondroplasty versus bone marrow aspirate concentrate (BMAC) and cartilage-derived matrix (CDM) implantation.A retrospective chart review was performed for patients diagnosed with Outerbridge grade 3-4 FCDs. Patients were included if they were treated arthroscopically with BMAC/CDM implantation or chondroplasty alone between March 2016 and May 2019 and had more than 1-year follow-up. Postoperative outcomes included the visual analog scale (VAS) for pain; University of California, Los Angeles (UCLA) activity scores; Knee Outcome Survey (KOS) Activities of Daily Living (ADL) and Sports subscores; postoperative corticosteroid or hyaluronic acid injections; subsequent surgeries; and conversion to total knee arthroplasty.A total of 98 patients were identified with a mean follow-up in BMAC/CDM of 24 months (range 13-41 months) and in chondroplasty of 44 months (range 34-55 months). A subanalysis was performed to control for significant differences in age, which yielded 39 patients, ages 40-60 years. Within the subanalysis group, mean VAS scores were significantly lower in the BMAC/CDM group (1.7 vs 4.4;Patients with grade 3-4 FCDs of the knee had improved postoperative outcomes when treated with BMAC/CDM implantation versus chondroplasty alone, as evidenced by a significant improvement in VAS and UCLA scores and significantly greater postoperative KOS ADL, and KOS Sport subscores.IV, therapeutic case series.

In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.

Background: Previous studies have demonstrated various groin-related nerve and soft tissue complications in patients undergoing hip arthroscopy with a perineal post. Purpose: To prospectively compare groin-related nerve and soft tissue complications between patients undergoing hip arthroscopy with and without the use of a perineal post. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective single-surgeon cohort study was performed on all patients undergoing hip arthroscopy by the senior author between January 2020 and March 2022. A post-free hip distraction system was used at 1 center in which the senior author operates, and a system with a large padded perineal post was used at another surgical location. Patients completed a survey at the first postoperative visit (7-10 days) to determine if they had experienced any groin-related complications after surgery (groin numbness, sexual/urinary dysfunction, skin tears). Patients with a positive survey response repeated the survey at each follow-up visit (6 weeks, 3 months, 6 months) until the symptoms resolved. The rate and duration of groin-related complications were then compared between the groups. Results: A total of 87 patients were included in the study who underwent hip arthroscopy: 53 with a perineal post and 34 without. No differences were found between the post and postless groups in terms of age at surgery, sex, body mass index, or traction time. We found that 16 patients (30%) in the perineal post group experienced groin numbness versus 0 (0%) in the postless group ( P < .0001). On average, groin numbness lasted 5 ± 3 days (mean ± SD) in the perineal post group. Three patients in the perineal post group experienced sexual dysfunction for a mean 7 days, as compared with none in the postless group. Seventeen patients (32%) in the perineal post group experienced foot numbness versus 4 (12%) in the postless group ( P = .04). One patient in the perineal post group reported a superficial skin tear. Conclusion: Postless hip arthroscopy resulted in no risk of groin-related complications as compared with traditional hip arthroscopy with a perineal post.

Lateral epicondylitis is a commonly encountered and persistent problem in the active, middle-aged population, with a reported annual incidence as high as 3.4%. Lateral epicondylitis is often treated successfully with conservative measures but may necessitate surgical intervention in refractory cases. Most of the review literature has failed to definitively identify arthroscopic or open debridement as the superior surgical approach. We favor the arthroscopic approach because it allows for the examination and treatment of concomitant intra-articular pathologies, which may be underappreciated on magnetic resonance imaging, and for minimal disruption of the superficial extensors to access the pathologic structures. In addition, this approach often allows for a quick resolution of symptoms and expeditious return to work and sport with a low rate of complications or revisions. For surgeons who are not experienced in elbow arthroscopy, the option of open debridement remains a reasonable approach. However, our preferred management of surgically indicated tennis elbow is arthroscopic repair of the affected extensor tendons along with addressing any concomitant pathology, when present. In our opinion, this leads to optimized long-term outcomes.

Background:Previous studies have demonstrated the risks of pudendal nerve and/or soft tissue complications due to the use of a perineal post during hip arthroscopy. Recently, various postless hip arthroscopy techniques have been described in the literature.Purpose:To assess the current international trends in the use of postless hip arthroscopy among hip preservation specialists.Study Design:Cross-sectional study.Methods:An anonymous 11-item survey was sent by email to all members of the International Society for Hip Arthroscopy (ISHA) in January 2022. Surgeons were asked various questions regarding their current use of post-assisted or postless hip arthroscopy, if they had changed their setup technique during their career and the reason for that change, and their perceived rate of pudendal nerve and/or perineal soft tissue injuries using their current technique. Descriptive statistics were used to report the results of each question. The Student t test was used to compare the number of years in practice between post-assisted and postless users. Fisher exact tests were performed to compare categorical rates of pudendal nerve and soft tissue complications between post-assisted and postless users.Results:A total of 126 surveys were completed from 431 ISHA members (29.2%). Sixty-one percent of the surgeons currently use a perineal post, while 33% use a postless technique. Seventy-five percent of the perineal post users and 98% of the postless users self-reported a rate of pudendal nerve and/or soft tissue injury of Conclusion:Although use of a perineal post is still a more common setup technique among hip arthroscopists, approximately one-third of surgeons use a postless technique. Surgeons who have switched to a postless technique often did so because of perineal complications, with the majority noticing a subjective decrease in these complications with the use of postless hip arthroscopy.

Background: The extent to which concomitant cartilage repair provides an improvement in clinical outcomes after osteotomy is unclear. Purpose: To compare studies reporting clinical outcomes after isolated osteotomy with or without cartilage repair for osteoarthritis (OA) or focal chondral defects (FCDs) of the knee joint. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, Cochrane Library, and Embase databases. The search was done to identify comparative studies that directly compared outcomes between isolated osteotomy—high tibial osteotomy or distal femoral osteotomy—and osteotomy with concomitant cartilage repair for OA or FCDs of the knee joint. Patients were evaluated based on reoperation rate, magnetic resonance observation of cartilage repair tissue score, macroscopic International Cartilage Regeneration & Joint Preservation Society score, and patient-reported outcomes. Results: In total, 6 studies—level 2 evidence (n = 2);, level 3 evidence (n = 3);, and level 4 evidence (n = 1)—met the inclusion criteria, including a total of 228 patients undergoing osteotomy alone (group A) and 255 patients undergoing osteotomy with concomitant cartilage repair (group B). The mean patient age was 53.4 and 54.8 years, respectively, and the mean preoperative alignment was 6.6° and 6.7° of varus in groups A and B, respectively. The mean follow-up time was 71.5 months. All studies assessed medial compartment lesions with varus deformity. One study compared osteotomy alone for patients with medial compartment OA versus osteotomy with autologous chondrocyte implantation for patients with FCDs of the medial compartment. Three other studies included a heterogeneous cohort of patients with OA and FCDs in both groups. Only 1 study isolated its comparison to patients with medial compartment OA and 1 study isolated its comparison to patients with FCDs. Conclusion: There is limited evidence with substantial heterogeneity between studies on clinical outcomes after osteotomy alone versus osteotomy with cartilage repair for OA or FCDs of the knee joint. At this time, no conclusion can be made regarding the role of additional cartilage procedures in treating medial compartment OA or FCDs. Further studies are needed that isolate specific disease pathology and specific cartilage procedures.

Background: Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy. Purpose: To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption. Study Design: Systematic review. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was “hip arthroscopy fascia iliaca randomized.” Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption. Results: Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, –0.2 [95% CI, –1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities. Conclusion: In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.

To perform a systematic review of postoperative rehabilitation protocols for third-generation autologous chondrocyte implantation (ACI) of the knee joint.A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials that described a rehabilitation protocol following third-generation ACI of the knee joint. The search terms used were: "autologous" AND "chondrocyte" AND "randomized". Data extracted from each study included various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, the use of continuous passive motion (CPM), the time to return to sports, and physical therapy (PT) modalities used and the timing of their initiation.Twenty-five studies (22 Level I, 3 Level II) met inclusion criteria, including a total of 905 patients undergoing treatment with ACI. The average patient age ranged from 29.1 to 54.8 years, and the mean follow-up time ranged from 3 months to 10.0 years. The average lesion size ranged from 1.9 to 5.8 cmBased on the included studies, most rehabilitation protocols for third-generation ACI initiate CPM within 24 hours postoperatively and allow partial WB immediately following surgery with progression to full WB within 12 weeks. There is variation of the PT modalities used as well as the timing of their initiation.Level II, systematic review of Level I-II studies.

Purpose To systematically review the literature to compare the adductor canal block (ACB) with the femoral nerve block (FNB) following primary anterior cruciate ligament reconstruction (ACLR) in terms of early postoperative analgesic requirements and postoperative quadriceps strength. Methods A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to August 2019 to identify randomized controlled trials that compared postoperative pain and functional outcomes in patients following primary ACLR with ACB versus FNB. The search phrase used was: adductor canal femoral nerve anterior cruciate ligament. Patients were evaluated based on analgesic consumption and quadriceps muscle strength. Study quality and risk of bias were evaluated with the Modified Coleman Methodology Score and Cochrane risk-of-bias tool respectively. Results Five studies (all Level I evidence) were identified that met inclusion criteria, including 221 patients undergoing primary ACLR with ACB (mean age 26.8 years, 68.3% male) and 221 with FNB (mean age 28.2 years, 67.0% male). Statistical assessment for heterogeneity found for opioid consumption of ACB versus FNB groups was I2 = 97% (P Conclusions In patients undergoing ACLR, the ACB may provide similar analgesic requirements, and the included studies suggest a potential advantage in preserving muscle strength at short-term (24-48 hours) follow-up when compared with FNB. However, the differences in muscle strength assessments between studies do not allow for strong conclusions. Level of Evidence I, systematic review and meta-analysis of Level I studies.

Background: Core muscle injury (CMI), often referred to as a sports hernia, is a common cause of groin pain in athletes characterized by concomitant injury to the insertion of the adductor longus and the rectus abdominis muscles. Currently, the literature on CMI is sparse with no standardized physical examination tests used in the diagnosis of this type of injury. Purpose: To determine the diagnostic accuracy of various physical examination tests in the diagnosis of CMI. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: A consecutive series of patients evaluated by the senior author with symptoms consistent with CMI were included. Four physical examination tests were routinely performed in these patients by the senior author and were noted in each patient’s chart as positive or negative: (1) pain with resisted cross-body sit-up in figure-of-4 position, (2) pain with straight-leg sit-up, (3) pain with resisted hip flexion in external rotation (external rotation Stinchfield test), and (4) the presence of an adductor contracture. CMI was independently diagnosed by a reference standard (magnetic resonance imaging [MRI]). All MRI scans were read by a musculoskeletal fellowship-trained radiologist. The sensitivity and specificity of each physical examination test alone and in combination were calculated based on this reference standard. Results: A total of 81 patients were included in this study. MRI was positive for a CMI in 39 patients (48%) overall. Both the cross-body sit-up test and the presence of an adductor contracture were found to have a sensitivity of 100% (specificity, 3% for both). The external rotation Stinchfield test was found to have the highest specificity of 60% (sensitivity, 15%). The sensitivity of all 4 physical examination tests in combination was found to be 100% (specificity, 0%). Conclusion: Certain physical examination maneuvers can be used to assist in the diagnosis of a CMI. The cross-body sit-up test and the presence of an adductor contracture are highly sensitive but nonspecific tests for CMI and therefore should be used in conjunction with diagnostic imaging before deciding on an appropriate treatment course.

To compare early postoperative pain in patients undergoing hip arthroscopy with versus without the pericapsular nerve group (PENG) block.A retrospective chart review of prospectively collected data was performed to identify patients who underwent hip arthroscopy at a single institution between May 2019 and October 2021. Patients were included if they received general anesthesia and were opioid naive. Patients who received the PENG block were compared with patients who did not. Opioid, benzodiazepine, and antiemetic medication administration was recorded both intraoperatively and for the duration of the patient's stay in the postanesthesia care unit (PACU). Opioids administered were converted to morphine milligram equivalents (MMEs). Pain was assessed with a visual analog scale. Time to discharge (in minutes) and complications were recorded.A total of 53 patients were identified for inclusion, of whom 28 received the PENG block and 25 did not. Opioid consumption was significantly lower in the PENG block group both intraoperatively (16.9 ± 14.1 MMEs vs 40.6 ± 18.3 MMEs, P.001) and in the PACU (14.4 ± 11.4 MMEs vs 31.2 ± 20.1 MMEs, P.001). The highest recorded PACU pain score was significantly greater in the no-PENG block group (7.0 ± 1.9 vs 5.3 ± 2.1, P = .004). Within the PENG block group, fewer patients required antiemetics (0 vs 4, P = .043). There was a greater time to discharge in the no-PENG block group (161 ± 50 minutes vs 129 ± 34 minutes, P = .008). No complications, including postoperative falls, were noted in either group.The PENG block improves perioperative outcomes by decreasing pain, opioid consumption, time to discharge, antiemetic requirements, and benzodiazepine requirements after hip arthroscopy.Level III, retrospective comparative therapeutic trial.

Background: The extent to which concomitant osteotomy provides an improvement in clinical outcomes after cartilage repair procedures is unclear. Purpose: To review the existing literature to compare clinical outcomes of patients undergoing cartilage repair of the tibiofemoral joint with versus without concomitant osteotomy. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify studies that directly compared outcomes between cartilage repair of the tibiofemoral joint alone (group A) versus cartilage repair with concomitant osteotomy (high tibial osteotomy [HTO] or distal femoral osteotomy [DFO]) (group B). Studies on cartilage repair of the patellofemoral joint were excluded. The search terms used were as follows: osteotomy AND knee AND (“autologous chondrocyte” OR “osteochondral autograft” OR “osteochondral allograft” OR microfracture). Outcomes in groups A and B were compared based on reoperation rate, complication rate, procedure payments, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale [VAS] for pain, satisfaction, and WOMAC). Results: Included in the review were 5 studies (1 level 2 study, 2 level 3 studies, 2 level 4 studies) with 1747 patients in group A and 520 patients in group B. The mean patient ages were 34.7 and 37.5 years in groups A and B, respectively, and the mean lesion sizes were 4.0 and 4.5 cm2, respectively. The mean follow-up time was 44.6 months. The most common lesion location was the medial femoral condyle (n = 999). Preoperative alignment averaged 1.8° and 5.5° of varus in groups A and B, respectively. One study found significant differences between groups in KOOS, VAS, and satisfaction, favoring group B. The reoperation rates were 47.4% and 17.3% in groups A and B, respectively ( P < .0001). Conclusion: Patients undergoing cartilage repair of the tibiofemoral joint with concomitant osteotomy might be expected to experience greater improvement in clinical outcomes with a lower reoperation rate compared with those undergoing cartilage repair alone. Surgeons preparing for cartilage procedures of the knee joint should pay particular attention to preoperative malalignment of the lower extremity to optimize outcomes.

Background: Some studies have suggested that running increases the risk of knee osteoarthritis (OA), while others believe it serves a protective function. Purpose: To perform an updated systematic review of the literature to determine the effects of running on the development of knee OA. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies evaluating the effect of cumulative running on the development of knee OA or chondral damage based on imaging and/or patient-reported outcomes (PROs). The search terms used were “knee AND osteoarthritis AND (run OR running OR runner).” Patients were evaluated based on plain radiographs, magnetic resonance imaging (MRI), and PROs (presence of knee pain, Health Assessment Questionnaire-Disability Index, and the Knee injury and Osteoarthritis Outcome Score). Results: Seventeen studies (6 level 2 studies, 9 level 3 studies, and 2 level 4 studies), with 7194 runners and 6947 nonrunners, met the inclusion criteria. The mean follow-up time was 55.8 months in the runner group and 99.7 months in the nonrunner group. The mean age was 56.2 years in the runner group and 61.6 years in the nonrunner group. The overall percentage of men was 58.5%. There was a significantly higher prevalence of knee pain in the nonrunner group ( P < .0001). Although 1 study found a significantly higher prevalence of osteophytes in the tibiofemoral (TF) and patellofemoral (PF) joints within the runner group, multiple studies found no significant differences in the prevalence of radiographic knee OA (based on TF/PF joint-space narrowing or Kellgren-Lawrence grade) or cartilage thickness on MRI between runners and nonrunners ( P > .05). One study found a significantly higher risk of knee OA progressing to total knee replacement among nonrunners (4.6% vs 2.6%; P = .014). Conclusion: In the short term, running is not associated with worsening PROs or radiological signs of knee OA and may be protective against generalized knee pain.

To systematically review randomized controlled trials to compare clinical outcomes of microfracture (MFx) versus third-generation autologous chondrocyte implantation (ACI) for the treatment of focal chondral defects (FCDs) of the knee joint.A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials comparing minimum 2-year clinical outcomes of patients undergoing MFx versus third-generation ACI for FCDs of the knee joint. The search terms used were: "knee" AND "microfracture" AND "autologous chondrocyte" AND "randomized." Patients were evaluated based on treatment failure rates, magnetic resonance imaging, International Cartilage Repair Society scores, and patient-reported outcome scores (Lysholm, Tegner, Knee Injury and Osteoarthritis Outcome Score, modified Cincinnati Knee Rating System, 12-item Short Form Health Survey Physical and Mental, and the EuroQol 5 Dimensions Visual Analog Scale score).Six studies (5 Level I, 1 Level II) met inclusion criteria, including a total of 238 patients undergoing MFx and 274 undergoing ACI. Two studies had an overlapping cohort of patients and therefore the study with longer follow-up was used in all analyses. The average follow-up among patients ranged from 2.0 years to 6.0 years. Average lesion size ranged from 1.8 cmAt short-term follow-up, third-generation ACI demonstrates a lower failure rate and greater improvement in patient-reported outcomes compared with MFx for FCDs of the knee joint.II, systematic review of Levels I-II studies.

Recurrent patellofemoral instability is a common cause of knee pain and functional disability in adolescent and young adult patients, resulting in loss of time from work and sports. There are numerous factors that contribute to recurrent patellofemoral instability; these factors include tear of the medial patellofemoral ligament (MPFL), weakening or hypoplasia of the vastus medialis obliquus (VMO), trochlear dysplasia, increased tibial tuberosity-trochlear groove (TT-TG) distance (>20 mm), valgus malalignment, increased Q angle, malrotation secondary to internal femoral or external tibial torsion, patella alta, and generalized ligamentous laxity. A detailed history and a thorough physical examination are crucial to clinch an early, accurate diagnosis. Imaging studies play an important role to confirm the clinical diagnosis and also help to identify concomitant intra-articular pathologies. Initially, nonoperative management (including the use of physical therapy, patellar taping or brace) is offered to patients with acute, first-time patellar dislocations and most patients respond well to this mode of treatment. Surgical treatment is indicated for patients who have post-trauma osteochondral fracture or loose body; predisposing anatomical risk factors; recurrent, symptomatic instability; and who have failed an adequate trial of nonoperative management. Surgical treatments include MPFL reconstruction, proximal or distal realignment procedures, and trochleoplasty. Lateral release is often performed in combination with other procedures and seldom performed as an isolated procedure. An individualized case-by-case approach is recommended based on the underlying anatomical risk factors and radiographic abnormality.

Rotator cuff tear (RCT) and cervical spinal stenosis (CSS) are common pathologies in the elderly. Both conditions may present with lateral shoulder pain and weakness or numbness of the upper extremity, potentially affecting patients' ability to live independently. Few data are available on the incidence of CSS among patients with concurrent RCT. The purpose of this study was to investigate the incidence of CSS among RCT patients, demographics, and surgical management using a national insurance database. The Medicare database was used to identify patients with RCT and concomitant CSS by ICD-9 codes from 2005-2014. Trends based on age, gender, and body mass index (BMI) were assessed. Utilization of open and arthroscopic rotator cuff repair (RCR) was compared. A total of 86,501 patients were identified. The number of patients diagnosed with RCT and CSS significantly increased (p0.0001). The incidence of CSS in patients with RCT increased from 9% to 13% (p0.05). Females64 years were more likely to exhibit combined pathology than age-matched males (OR 1.15, 95% CI 1.12 to 1.18) or females65 years (OR 1.64, 96% CI 1.61 to 1.67). A BMI of 30-40 kg/m2 demonstrated the highest incidence (43%, p0.0001). Arthroscopic RCR increased by 2% (p = 0.03) in RCT-CSS. The incidence of CSS in RCT patient is increasing. Orthopedic surgeons should maintain high clinical suspicion for concurrent CSS pathology in patients with RCT, particularly in obese female patients65 years with several medical comorbidities. Further investigation into the influence of these concurrent pathologies on patient outcomes is warranted.

Background: The use of mesenchymal stem cells (MSCs) for the treatment of knee osteoarthritis (OA) has gained recent interest in the orthopaedics community. Purpose: To review the literature to evaluate the efficacy of umbilical cord–derived MSCs in the treatment of OA of the knee joint. Study Design: Systematic review; Level of evidence, 4. Methods: We searched the PubMed, Cochrane Library, and Embase databases to identify studies with evidence levels from 1 to 4 that evaluated the clinical efficacy of human umbilical cord–derived MSC (hUC-MSC) injections for knee OA. The search phrase used was “umbilical cord knee osteoarthritis.” In the studies reviewed, patients were assessed based on the macroscopic International Cartilage Regeneration & Joint Preservation Society (ICRS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and the subjective International Knee Documentation Committee (IKDC) score. Results: A total of 7 studies met inclusion criteria, including 385 patients undergoing injection of hUC-MSCs (mean age, 59.7 years). The mean follow-up was 23.4 months. Weighted averages of the WOMAC, macroscopic ICRS, subjective IKDC, and VAS scores all showed improvement from before to after treatment. No severe adverse reactions were recorded. Conclusion: Patients undergoing treatment of knee OA with hUC-MSCs might be expected to experience improvements in clinical outcomes. Additional high-quality randomized studies are needed to better determine the efficacy of hUC-MSC for the treatment of knee OA.

Athletes with medial epicondyle nonunions typically present with medial elbow pain, an elbow flexion contracture, and the inability to compete. The purpose of this study was to evaluate the clinical outcomes of patients who underwent medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair for symptomatic medial epicondyle non-unions. Four patients with a mean age of 15 years (range, 11–19 years) diagnosed with symptomatic medial epicondyle nonunions were evaluated. All were treated with medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair. Two of the patients were followed for 12 months, whereas the other 2 patients were followed for 18 months. All patients returned to their preinjury level of sports without difficulty. Two patients with preoperative flexion contracture had residual flexion contractures of 4° and 5° postoperatively, respectively, as measured by a goniometer. All other patients regained full elbow motion equal to that of the contralateral extremity at final follow-up. The patients with preoperative ulnar nerve symptoms had complete resolution postoperatively at a mean follow-up of 18 months. In overhead and upper extremity weight-bearing athletes who have symptomatic medial epicondyle nonunions, fragment excision with flexor-pronator mass repair can yield satisfactory results. [ Orthopedics . 2021;44(3):e337–e342.]

Lateral knee endoscopy can approach the cysts of the lateral knee, distal part of the iliotibial band, the proximal tibiofibular joint, and the fibular head and it can be used for creation of the posterior portals for posterior knee arthroscopy. Endoscopic resection of cyst of the knee is a feasible minimally invasive approach for symptomatic cystic lesion of the lateral knee. It is particularly useful for multi-loculated cysts. Pre-operative magnetic resonance imaging is important to confirm the diagnosis and study the multi-loculation of the cyst and its relationship to surrounding important structures. The proximal tibiofibular joint can be considered as the fourth compartment of the knee to explain subtle knee problems. Endoscopic approach to proximal tibiofibular joint can reach adjacent capsulo-ligamentous structures including biceps femoris tendon, lateral collateral ligament, popliteofibular ligament, fibular head, and posterolateral corner of the knee. Distal iliotibial (IT) band syndrome is a disorder characterized by pain over the lateral aspect of the knee and is commonly diagnosed in a wide array of athletes, most frequently runners and cyclists. Most cases subside with conservative measures. Operative treatment is considered in chronic, recurrent, or refractory cases that persist for more than 6 months and include open or arthroscopic distal IT band lengthening, resection of the lateral synovial recess, transection of the posterior fibers of the IT band, and bursectomy. In this chapter, the endoscopic techniques are outlined.

Background: Posttraumatic osteoarthritis (PTOA) after injury to the anterior cruciate ligament (ACL) is common. Purpose: To perform a systematic review of basic science and animal studies to determine the effect of doxycycline treatment on the prevention of PTOA after ACL rupture/transection. Study Design: Systematic review. Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify basic science and animal studies evaluating the effect of doxycycline treatment on the prevention of PTOA of the knee joint after ACL/cranial cruciate ligament (CCL) injury. The search phrase used was “doxycycline cruciate ligament.” Inclusion criteria were basic science and animal studies evaluating the effect of oral administration of doxycycline in ACL/CCL-deficient animals with or without a control group. Results: Seven studies met inclusion criteria and were included in this systematic review. Five studies were performed in dogs, 1 in rabbits, and 1 in mice. Overall, the effects of doxycycline treatment on the prevention of PTOA after ACL/CCL rupture/transection were mixed. In dogs, no significant effects of doxycycline treatment were found in terms of matrix metalloproteinase (MMP) activity, while a mouse study found significantly lower MMP-13 expression on the tibia in doxycycline-treated animals, suggesting that doxycycline may protect against proteoglycan loss and decrease osteoarthritis progression. Cartilage nitric oxide concentrations were lower in doxycycline-treated dogs compared with untreated dogs, suggesting decreased cartilage degradation among doxycycline-treated dogs, although there were no significant effects on cartilage stromelysin levels with no significant effects in terms of physiological remodeling or catabolism of cartilage. Bone formation or resorption was not found to be affected by doxycycline treatment. One study demonstrated a substantial beneficial effect of doxycycline on gross morphology of the medial femoral condyle. Doxycycline was found to conserve bone strain energy density and appeared to limit subchondral bone loss in 1 study. Conclusion: Based on the limited available animal studies, doxycycline appears to demonstrate some benefits in the prevention of PTOA after ACL/CCL rupture/transection. Additional studies are needed to further characterize the potential benefits, side effects, dosage, and duration of this treatment after ACL injury in human patients.

Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy.We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity.Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P.001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study.Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis.

Chondral defects of the knee are prevalent and often encountered during arthroscopic procedures. Despite the limited healing potential of chondral defects, several treatment options have been proposed. However, microfracture, osteochondral autograft (or allograft) transfer, autologous chondrocyte implantation, and matrix-induced autologous chondrocyte implantation are all associated with their respective shortcomings. As such, the optimal treatment for chondral defects of the knee remains unclear. Recently, many authors have advocated treating chondral defects with biological therapies and scaffold-based treatments. Bone marrow aspirate concentrate, a cell-based injection, has gained particular attention because of its differentiation capacity and potential role in tissue regeneration. In addition, scaffold cartilage treatments have emerged and reached clinical practice. BioCartilage is one form of scaffold, which consists of extracellular matrix, and has been claimed to promote the regeneration of hyaline-like cartilage. This article presents our technique of arthroscopic chondral defect repair using BMAC and BioCartilage.

Purpose To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption. Methods A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was “core muscle injury” OR “sports hernia” OR “athletic pubalgia” OR “inguinal disruption.” The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported. Results Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was “athletic pubalgia,” followed by “sports hernia.” Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication. Conclusions A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location. Level of Evidence Level V, systematic review of Level I to V studies.

Total knee arthroplasty (TKA) is one of the most commonly performed yet costly surgical procedures in orthopaedics. With national trends and reimbursements moving in favor of shorter hospital length-of-stay (LOS), it is important to understand the complications associated with discharging patients earlier. This is particularly more challenging in a teaching institution due to complexity and variety of layers of care. Therefore, the purpose of this study was to evaluate the 90-day postoperative outcomes among those who were discharged on postoperative day 2 (POD-2) and compare them to a cohort whom had a LOS ≥ 3 days. A retrospective review of all patients who underwent a primary TKA from at a single-teaching institution from 2015 to 2017 was performed. During this time, an accelerated discharge protocol was designed and implanted in our institution. We identified 485 patients who were then substratified into two groups: patients who were discharged on POD-2 (n = 91) with the accelerated protocol and those who were discharged ≥ 3 days (n = 394). Outcomes evaluated included (1) demographics, (2) readmission rates, (3) emergency room (ER) visits, and (4) complication rates within 90 days of TKA. The POD-2 cohort was significantly younger than patients with ≥ 3-day LOS (64 vs. 69 years; p = 0.0001). There were no differences in gender ratios between the 2-day and 3-day cohorts (women, 67 vs. 72%; p = 0.34). Readmission rates (2 vs. 5%; p = 0.31) and ER visits were similar between cohorts (9 vs. 6%; p = 0.4). Medical and surgical complication rates did not differ between the two cohorts, with an overall complication rate of 5.5% in POD-2 versus 5.6% in >3 days LOS (p = 0.97). Patients discharged on POD-2 from TKA did not demonstrate an increased risk of complications, ER visits, or readmissions within 90 days in a teaching institution. However, older patients tended to have a longer LOS.

Recurrent patella instability is a common condition that may potentiate substantial knee dysfunction resulting in loss of time from work and sports. There are numerous factors that contribute to recurrent patella instability including tearing of the medial patellofemoral ligament (MPFL), shallow trochlea, valgus alignment, externally rotated tibia tubercle, ligamentous laxity, elevated Q angle, and increased tibial tuberosity trochlear groove distance. Reconstruction of the MPFL has been shown to restore patella stability where concomitant pathology is within acceptable limits. Major complications include recurrence from inadequate MPFL reconstruction or failure to address other pathology, patella femoral pain from over constrained MPFL or unaddressed cartilage defects to the patella femoral compartment, or patella fracture. This technique provides a reproducible method of restoring patella stability through MPFL reconstruction while minimizing stress risers in the patella by using suture anchor fixation that creates a ligamentous footprint instead of tendon healing into a socket on the patella.

Background: Patients with recurrent lateral patellar dislocations are often treated with reconstruction of the medial patellofemoral ligament (MPFL). Purpose: To perform a systematic review to evaluate clinical outcomes and the risk of recurrent patellar dislocation after MPFL reconstruction (MPFLR) with autograft versus allograft. Study Design: Systematic review; Level of evidence, 4. Methods: The authors conducted a search of PubMed, the Cochrane Library, and Embase to identify studies comparing outcomes of MPFLR with autograft versus allograft. The inclusion criteria were full-text studies that directly compared clinical outcomes and/or risk of recurrent patellar instability between patients undergoing MPFLR with autograft versus allograft. A quality assessment was performed using the modified Coleman Methodology Score, and risk-of-bias assessment was performed using the Risk Of Bias In Non-randomized Studies–of Interventions and the Cochrane Collaboration tools. Results: Seven studies (1 evidence level 2, 3 level 3, 3 level 4) that met inclusion criteria were identified and included a total of 150 patients who underwent MPFLR with autograft and 193 with MPFLR with allograft. One study found a significantly higher failure rate among patients with autograft, and another study found a trend toward a significantly higher failure rate among patients with autograft. One study demonstrated no significant difference between postoperative tibial tubercle–trochlear groove distance (measured on magnetic resonance imaging scans) in failed versus successful grafts. One study found that patellar tilt angle improved significantly from preoperatively to postoperatively ( P < .001) but there was no difference between the groups. Kujala scores significantly improved for both autograft and allograft groups across studies. Two studies found significant differences in postoperative Kujala scores between the 2 groups, 1 of which found better scores in the allograft group ( P = .0032) and another in which scores were better in the autograft group ( P = .02). Conclusion: Patients undergoing MPFLR with either autograft or allograft can expect to experience improvement in clinical outcomes. Subjective outcomes improved to a similar degree in both groups. Graft failure was more frequently observed in patients with autograft. Allograft may be a better option for MPFLR owing to lower failure rate.

Background: Recent evidence suggests that there may be an increased risk of infection for patients undergoing a corticosteroid injection before, during, or after knee arthroscopy. Purpose: To systematically review the literature to evaluate the risk of postoperative infection in patients undergoing intra-articular corticosteroid injections (CSI) before, during, or after knee arthroscopy. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies that evaluated the rate of postoperative infection in patients undergoing knee arthroscopy who received an intra-articular CSI during the perioperative period. The search phrase used was “knee AND arthroscopy AND injection AND (infection OR revision).” A subanalysis was also performed to analyze infection rates based on the timing of the corticosteroid injection in relation to arthroscopy. Results: Four studies met the inclusion criteria, representing 11,925 patients undergoing knee arthroscopy with an intra-articular CSI administered during the perioperative period (mean follow-up, 5.3 months) and 247,329 patients without a corticosteroid injection during the perioperative period (mean follow-up, 5.9 months). Patients who received an injection experienced a statistically significantly higher rate of postoperative infection (2.2%) when compared with patients who did not receive an injection (1.1%; P < .001). When analyzed by the timing of the injection, patients receiving an injection preoperatively or intraoperatively experienced a statistically significantly higher rate of postoperative infection (3% and 2.6%, respectively) when compared with patients receiving an injection postoperatively (1.4%; P = .001 for both). Conclusion: Patients undergoing knee arthroscopy who receive an intra-articular CSI during the perioperative period can be expected to experience significantly higher postoperative infection rates when compared with patients not receiving an injection. Furthermore, patients receiving a corticosteroid injection pre- or intraoperatively may experience significantly higher rates of postoperative infection when compared with patients receiving an injection postoperatively.

Manipulation under anesthesia (MUA) can help patients regain an adequate range of motion (ROM) following total knee arthroplasty (TKA). Although there are studies reporting that MUA can assist in improving ROM, there is a paucity of studies regarding whether requiring an MUA is associated with an increased risk of revision. The purpose of this study was to assess the: (1) incidence of revision TKA and (2) outcomes of those undergoing MUA and compare it with a matched cohort who did not require MUA. A prospectively collected database of two high-volume institutions was assessed for patients who required a single MUA following TKA between 2005 and 2011. We found a total of 138 knees with a mean 8.5-year follow-up post-MUA. We compared this with a matched cohort (1:1) who underwent TKA during this same time period but did not require an MUA. Incidence of revision surgery and clinical outcomes were compared between the two cohorts. Within the MUA cohort, nine knees underwent revision, which was similar to the matched cohort that had seven revisions (93 vs. 95%; p = 0.6). The mean KSS-functional (88 vs. 90 points; p = 0.15) and clinical scores (87 vs. 89 points; p = 0.1) were similar between the two cohorts. Undergoing an MUA was not associated with an increased risk of revision TKA. If patients require MUA, they may still achieve satisfactory outcomes. This information can be used in educating patients so they may be able to formulate their expectations following their MUA.

Various techniques for piriformis muscle release have been published previously. However, it is imperative we continue to improve on existing techniques as well as develop new ones that may further optimize outcomes. Therefore, we aimed to describe an endoscopic technique for the release of the piriformis muscle in those with symptoms of sciatic nerve compression. Using the posterolateral portal, we are able to perform a complete release of the piriformis from the greater trochanter and the piriformis fossa with care to protect the external rotators and the sciatic nerve. It is our belief that this technique can be easily replicated by practitioners who read this technical note.

HIV is prevalent worldwide and numerous patients with this diagnosis ultimately may become candidates for TKA. Although some studies have suggested that complications are more common in patients with HIV who undergo TKA, these studies largely were done before the contemporary era of HIV management; moreover, it is unclear whether patients with HIV achieve lower patient-reported outcome scores or inferior implant survivorship. We asked whether there were any differences in the outcomes of patients with HIV without hemophilia who undergo TKA compared with a matched control cohort in terms of: (1) patient-reported outcomes; (2) implant survivorship; and (3) complication rates. Forty-five patients with HIV who had undergone 50 TKAs at three institutions with a minimum followup of 4 years between 2005 and 2011 were identified. An additional three patients were lost to followup before the fourth-year annual visit. All patients with HIV underwent thorough preoperative optimization with their primary care physician and infectious disease specialist. There were 31 men and 14 women with a mean age of 57 years and mean followup of 6 years (range, 4–10 years). These patients were compared with a matched cohort of 135 patients (one-to-three ratio) who did not have HIV and who had undergone a primary TKA by the same surgeons during this same period using the same implant. Matching criteria included patient age (within 2 years), BMI (within 2 kg/m2), surgeon performing TKA, followup (within 6 months), minimum followup of 4 years, sex ratio, and primary diagnosis (degenerative joint disease versus osteonecrosis). Approximately 10% of patients in the matching group had not returned for followup after their sixth annual visit. Outcomes evaluated included The Knee Society objective and function scores, University of California, Los Angeles (UCLA) activity scores, overall implant survivorship (free of revision) using Kaplan-Meier analysis, and complications. With the numbers available, there were no differences in preoperative Knee Society score or UCLA activity scores among the cohorts. With the numbers available, there were no differences in the mean Knee Society objective scores between patients with HIV (89 ± 11 points) and the matching cohort (91 ± 14 points) (95% CI, −7 to 3; p = 0.38). There were no differences among the Knee Society functional component as well (88 ± 12 points versus 90 ± 13 points; 95% CI, −6 to 2; p = 0.36) at latest followup. Similarly, there were no differences with the numbers available in the UCLA activity scores (6 ± 5 points [range, 4–7] versus 6 ± 7 points [range, 4–8]; p = 0.87) between the cohorts. With the numbers available, Kaplan-Meier analysis showed no significant difference in the overall implant survivorships between patients with HIV (98%; 95% CI, 94%–99%) compared with the matching group (99%; 95% CI, 98%–100%; p = 0.89). Postoperative complications were also comparable between the two groups. With the numbers available, we found that patients with HIV had no differences in clinical scores and implant survivorship compared with patients without the disease at mid-term followup. We believe practitioners should not be reluctant to perform TKA on this patient population. However, we believe the preoperative optimization process is crucial to achieving good outcomes and minimizing the risk of complications. Future comparative studies should have longer followup and a larger sample size with greater power to determine if there are differences in complications and implant survivorship. Level III, therapeutic study.

Background: Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA Purpose: To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD. Study Design: Narrative review. Methods: A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase borderline hip dysplasia. Results: The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented. Conclusion: Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.

Recently, with the Medicare bundled payments initiative for total knee arthroplasty (TKA), there has been a move by many institutions to further streamline costs associated with the entire operative and perioperative process. One of these cost-saving strategies has been to favor discharging patients to home with outpatient services as opposed to discharging to the relatively more expensive rehabilitation facilities. Our aim was to determine the success of a teaching institute's initiative in discharging patients to home instead of a rehabilitation facility. Specifically, we evaluated if there were differences in discharge disposition based off of (1) surgeon/patient preference, (2) length of stay, (3) demographics, and (4) postoperative complications. A retrospective review of all patients who had a TKA from 2015 to 2017 at a single teaching institution was performed and assessed discharge to home or to a rehabilitation facility. If they were not discharged to home, we evaluated why that did not happen, stratified the reason they were discharged to a rehabilitation facility into four groups based on (1) physician and occupational health team assessment, (2) patient preference, (3) physician preference, and (4) family or caretaker preference. A total of 229 patients were enrolled in this initiative, with 107 patients (47%) discharged to home with outpatient physical therapy services and 122 (53%) discharged to a rehabilitation facility. Of these, 35 patients (29%) went to these facilities because of physician and occupational health team assessment. However, 31 (25%) patients were due to patient preference, 32 (26%) were because of surgeon's preference, and 24 (20%) were not discharged to home because of family or caretaker preference. There were no differences in length of stay, gender, or complication rates between cohorts. Many patients can be safely discharged to home following TKA at a community teaching institution; however, there continues to be a strong prejudice by patients, physicians, and caretakers to be discharged to a rehabilitation facility despite the home discharge initiative.