Browsing by Author "Wittstein, Jocelyn R"

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    ItemOpen Access
    Females have Lower Knee Strength and Vertical Ground Reaction Forces During Landing than Males Following Anterior Cruciate Ligament Reconstruction at the Time of Return to Sport.
    (International journal of sports physical therapy, 2022-01) Sullivan, Zachary B; Sugarman, Barrie S; Faherty, Mallory S; Killelea, Carrie; Taylor, Dean C; Le, Daniel; Toth, Alison P; Riboh, Jonathan C; Diehl, Lee H; Wittstein, Jocelyn R; Amendola, Annunziato; Sell, Timothy C

    Purpose

    There is a high rate of second anterior cruciate ligament (ACL) injury (ipsilateral graft or contralateral ACL) upon return-to-sport (RTS) following ACL reconstruction (ACLR). While a significant amount of epidemiological data exists demonstrating sex differences as risk factors for primary ACL injury, less is known about sex differences as potential risk factors for second ACL injury. The purpose of this study is to determine if there are sex-specific differences in potential risk factors for second ACL injury at the time of clearance for RTS.

    Methods

    Ten male and eight female athletes (age: 20.8 years ±6.3, height: 173.2 cm ±10.1, mass: 76.6 kg ±18.3) participated in the study following ACLR at time of RTS (mean 10.2 months). Performance in lower extremity isokinetic and isometric strength testing, static and dynamic postural stability testing, and a single leg stop-jump task was compared between the sexes.

    Results

    Normalized for body weight, males had significantly greater isokinetic knee flexion (141±14.1 Nm/kg vs. 78±27.4 Nm/kg, p=0.001) and extension strength (216±45.5 Nm/kg vs. 159±53.9 Nm/kg, p=0.013) as well as isometric flexion (21.1±6.87% body weight vs. 12.5±5.57% body weight, p=0.013) and extension (41.1±7.34% body weight vs. 27.3±11.0% body weight, p=0.016) strength compared to females. In the single-leg stop jump task, males had a greater maximum vertical ground reaction force during landing (332±85.5% vs. 259±27.4% body weight, p=0.027) compared to females.

    Conclusions

    Based on these results, there are significant differences between sexes following ACLR at the time of RTS. Lower knee flexion and extension strength may be a potential risk factor for second ACL injury among females. Alternatively, the increased maximum vertical force observed in males may be a potential risk factor of second ACL injury in males. Although these results should be interpreted with some caution, they support that rehabilitation programs in the post-ACLR population should be individualized based on the sex of the individual.

    Level of evidence

    Level 3.
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    ItemOpen Access
    Immune cell profiles in synovial fluid after anterior cruciate ligament and meniscus injuries.
    (Arthritis research & therapy, 2021-11) Kim-Wang, Sophia Y; Holt, Abigail G; McGowan, Alyssa M; Danyluk, Stephanie T; Goode, Adam P; Lau, Brian C; Toth, Alison P; Wittstein, Jocelyn R; DeFrate, Louis E; Yi, John S; McNulty, Amy L

    Background

    Anterior cruciate ligament (ACL) and meniscus tears are common knee injuries. Despite the high rate of post-traumatic osteoarthritis (PTOA) following these injuries, the contributing factors remain unclear. In this study, we characterized the immune cell profiles of normal and injured joints at the time of ACL and meniscal surgeries.

    Methods

    Twenty-nine patients (14 meniscus-injured and 15 ACL-injured) undergoing ACL and/or meniscus surgery but with a normal contralateral knee were recruited. During surgery, synovial fluid was aspirated from both normal and injured knees. Synovial fluid cells were pelleted, washed, and stained with an antibody cocktail consisting of fluorescent antibodies for cell surface proteins. Analysis of immune cells in the synovial fluid was performed by polychromatic flow cytometry. A broad spectrum immune cell panel was used in the first 10 subjects. Based on these results, a T cell-specific panel was used in the subsequent 19 subjects.

    Results

    Using the broad spectrum immune cell panel, we detected significantly more total viable cells and CD3 T cells in the injured compared to the paired normal knees. In addition, there were significantly more injured knees with T cells above a 500-cell threshold. Within the injured knees, CD4 and CD8 T cells were able to be differentiated into subsets. The frequency of total CD4 T cells was significantly different among injury types, but no statistical differences were detected among CD4 and CD8 T cell subsets by injury type.

    Conclusions

    Our findings provide foundational data showing that ACL and meniscus injuries induce an immune cell-rich microenvironment that consists primarily of T cells with multiple T helper phenotypes. Future studies investigating the relationship between immune cells and joint degeneration may provide an enhanced understanding of the pathophysiology of PTOA following joint injury.
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    ItemOpen Access
    Isometric Knee Strength is Greater in Individuals Who Score Higher on Psychological Readiness to Return to Sport After Primary Anterior Cruciate Ligament Reconstruction.
    (International journal of sports physical therapy, 2022-01) Sugarman, Barrie S; Sullivan, Zach B; Le, Daniel; Killelea, Carolyn; Faherty, Mallory S; Diehl, Lee H; Wittstein, Jocelyn R; Riboh, Jonathan C; Toth, Alison P; Amendola, Annunziato; Taylor, Dean C; Sell, Timothy C

    Background

    Anterior cruciate ligament (ACL) injury is extremely common among athletes. Rate of second ACL injury due to surgical graft rupture or contralateral limb ACL injury is approximately 15-32%. Psychological readiness to return to sport (RTS) may be an important predictor of successful RTS outcomes. Psychological readiness can be quantified using the ACL Return to Sport after Injury (ACL-RSI) questionnaire, with higher scores demonstrating greater psychological readiness.

    Purpose

    The purpose of this study was to investigate differences in functional performance and psychological readiness to return to sport among athletes who have undergone primary ACL reconstruction (ACLR).

    Study design

    Descriptive cohort study.

    Methods

    Eighteen athletes who had undergone primary ACLR were tested at time of RTS clearance. The cohort was divided into two groups, high score (HS) and low score (LS), based on median ACL-RSI score, and performance on static and dynamic postural stability testing, lower extremity isokinetic and isometric strength testing, and single leg hop testing was compared between the groups using an independent samples t-test.

    Results

    The median ACL-RSI score was 74.17. The average ACL-RSI score was 83.1±6.2 for the HS group and 61.8±8.0 for the LS group. High scorers on the ACL-RSI performed significantly better on isometric knee flexion as measured via handheld dynamometry (22.61% ±6.01 vs. 12.12% ±4.88, p=0.001) than the low score group.

    Conclusion

    The findings suggest that increased knee flexion strength may be important for psychological readiness to RTS after primary ACLR. Further research is indicated to explore this relationship, however, a continued emphasis on improving hamstring strength may be appropriate during rehabilitation following ACLR to positively impact psychological readiness for RTS.

    Level of evidence

    III.
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    ItemOpen Access
    Meniscus-Derived Matrix Bioscaffolds: Effects of Concentration and Cross-Linking on Meniscus Cellular Responses and Tissue Repair.
    (International journal of molecular sciences, 2019-12-19) Lyons, Lucas P; Hidalgo Perea, Sofia; Weinberg, J Brice; Wittstein, Jocelyn R; McNulty, Amy L
    Meniscal injuries, particularly in the avascular zone, have a low propensity for healing and are associated with the development of osteoarthritis. Current meniscal repair techniques are limited to specific tear types and have significant risk for failure. In previous work, we demonstrated the ability of meniscus-derived matrix (MDM) scaffolds to augment the integration and repair of an in vitro meniscus defect. The objective of this study was to determine the effects of percent composition and dehydrothermal (DHT) or genipin cross-linking of MDM bioscaffolds on primary meniscus cellular responses and integrative meniscus repair. In all scaffolds, the porous microenvironment allowed for exogenous cell infiltration and proliferation, as well as endogenous meniscus cell migration. The genipin cross-linked scaffolds promoted extracellular matrix (ECM) deposition and/or retention. The shear strength of integrative meniscus repair was improved with increasing percentages of MDM and genipin cross-linking. Overall, the 16% genipin cross-linked scaffolds were most effective at enhancing integrative meniscus repair. The ability of the genipin cross-linked scaffolds to attract endogenous meniscus cells, promote glycosaminoglycan and collagen deposition, and enhance integrative meniscus repair reveals that these MDM scaffolds are promising tools to augment meniscus healing.
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    ItemOpen Access
    Patellar Tendon Orientation and Strain Are Predictors of ACL Strain In Vivo During a Single-Leg Jump.
    (Orthopaedic journal of sports medicine, 2021-03) Englander, Zoë A; Lau, Brian C; Wittstein, Jocelyn R; Goode, Adam P; DeFrate, Louis E

    Background

    There is little in vivo data that describe the relationships between patellar tendon orientation, patellar tendon strain, and anterior cruciate ligament (ACL) strain during dynamic activities. Quantifying how the quadriceps load the ACL via the patellar tendon is important for understanding ACL injury mechanisms.

    Hypothesis

    We hypothesized that flexion angle, patellar tendon orientation, and patellar tendon strain influence ACL strain during a single-leg jump. Specifically, we hypothesized that patellar tendon and ACL strains would increase concurrently when the knee is positioned near extension during the jump.

    Study design

    Descriptive laboratory study.

    Methods

    Models of the femur, tibia, ACL, patellar tendon, and quadriceps tendon attachment sites of 8 male participants were generated from magnetic resonance imaging (MRI). High-speed biplanar radiographs during a single-leg jump were obtained. The bone models were registered to the radiographs, thereby reproducing the in vivo positions of the bones, ligament, and tendon attachment sites. Flexion angle, patellar tendon orientation, patellar tendon strain, and ACL strain were measured from the registered models. ACL and patellar tendon strains were approximated by normalizing their length at each knee position to their length at the time of MRI. Two separate bivariate linear regression models were used to assess relationships between flexion angle and patellar tendon orientation and between ACL strain and patellar tendon strain. A multivariate linear regression model was used to assess whether flexion angle and patellar tendon strain were significant predictors of ACL strain during the inflight and landing portions of the jump.

    Results

    Both flexion angle and patellar tendon strain were significant predictors (P < .05) of ACL strain. These results indicate that elevated ACL and patellar tendon strains were observed concurrently when the knee was positioned near extension.

    Conclusion

    Concurrent increases in patellar tendon and ACL strains indicate that the quadriceps load the ACL via the patellar tendon when the knee is positioned near extension.

    Clinical relevance

    Increased ACL strain when the knee is positioned near extension before landing may be due to quadriceps contraction. Thus, landing with unanticipated timing on an extended knee may increase vulnerability to ACL injury as a taut ligament is more likely to fail.
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    ItemOpen Access
    Representation of Female Speakers at the American Academy of Orthopaedic Surgeons Annual Meetings Over Time.
    (The Journal of the American Academy of Orthopaedic Surgeons, 2023-03) Nwosu, Chinemerem; Wittstein, Jocelyn R; Erickson, Melissa M; Schroeder, Nicole; Santiesteban, Lauren; Klifto, Christopher; Jiang, Yue; Shapiro, Lauren

    Background

    In the United States, women comprise 16% of orthopaedic surgery residents, 4% of fellows, and 6% of practicing orthopaedic surgeons. The underrepresentation of women in surgical subspecialties may be because of lack of early exposure to female mentors. Conference speaker roles are important for visibility. This study aims to evaluate the representation of women in speaker roles and responsibilities at the American Academy of Orthopaedic Surgeons (AAOS) meetings over time.

    Methods

    The names of speakers and session titles at the annual AAOS meetings were obtained from conference programs for the years 2009, 2014, and 2019. Each speaker was classified based on sex and role. Sessions discussing scientific or surgical topics were classified as technical and those that did not were classified as nontechnical. Descriptive statistics are provided, as well as individual-year odds ratios (ORs) and confidence intervals (CIs) examining sex versus technical session status and sex versus speaker role; combined results controlling for year are calculated using the Cochran-Mantel-Haenszel method.

    Results

    Overall, 3,980 speaking sessions were analyzed; 6.8% of speaking sessions were assigned to women. Women were more likely than men to participate in nontechnical speaking roles (OR 3.85; 95% CI, 2.79 to 4.78). Among talks given by women, the percentage that were nontechnical increased (25.5% in 2009, 24.3% in 2014, and 44.1% in 2019). Among moderator roles, the percentage assigned to women increased (4.5% in 2009, 6.0% in 2014, 14.5% in 2019).

    Discussion

    Our findings demonstrate an increase in female speakers at AAOS meetings from 2009 to 2019. The percentage of female moderators and nontechnical sessions given by women increased since 2009. A need for a shift in the distribution of speaker role exists, which promotes inclusivity and prevents professional marginalization. Representation of women as role models increases visibility and may address the leaky pipeline phenomenon and paucity of women in orthopaedics.
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    Venous Thromboembolism Prophylaxis and Hormonal Contraceptive Management Practice Patterns in the Perioperative Period for Anterior Cruciate Ligament Reconstruction.
    (Arthroscopy, sports medicine, and rehabilitation, 2022-04) Christian, Robert A; Lander, Sarah T; Bonazza, Nicholas A; Reinke, Emily K; Lentz, Trevor A; Dodds, Julie A; Mulcahey, Mary K; Ford, Anne C; Wittstein, Jocelyn R

    Purpose

    To evaluate the venous thromboembolism (VTE) prophylaxis practices of surgeons performing anterior cruciate ligament reconstruction (ACLR) in female patients using hormonal contraceptives.

    Methods

    Our research team designed an investigational survey using branching logic that was made available to the AANA membership. The survey was designed to identify clinical decision making regarding VTE prophylaxis after ACLR in patients without risk factors for VTE, the counseling of patients about VTE risk associated with hormonal contraceptives, and the use of VTE prophylaxis after ACLR in patients taking hormonal contraceptives.

    Results

    Ninety-four respondents completed the survey. Eighty-nine respondents identified their gender (63% male and 37% female respondents). Respondents reported performing the following number of ACLRs annually: more than 50 (40%), 30 to 50 (29%), 15 to 30 (29%), and fewer than 15 (2%). Of the respondents, 62 (67%) reported that VTE developed after ACLR in their patients (male patients only, 32%; female patients only, 24%; and both male and female patients, 34%). Sixty-seven percent used chemoprophylaxis after ACLR. Surgeons who asked about hormonal contraceptive use were more likely to be women (P = .01; odds ratio [OR], 4.2). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to be women (P = .02; OR, 2.8). Surgeons who asked about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .03; OR, 2.9). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .001; OR, 4.6).

    Conclusions

    There is no standard of care for VTE prophylaxis after ACLR. A surgeon's own gender and prior clinical experience with VTE after ACLR may influence his or her likelihood to consider a patient's hormonal contraceptive use regarding VTE risk after ACLR.

    Clinical relevance

    The use of hormonal contraception is a risk factor for VTE in female patients undergoing ACLR. It is important to identify current practice patterns and the need for a standard of care.