Faculty Bibliography

Purpose of Review: Discoid lateral meniscus (DLM) is a well-known meniscus variant, and comprises excess and thickened meniscal tissue, altered collagen ultrastructure, and peripheral instability. This article presents a comprehensive review on current knowledge of DLM, focusing on pathology in parallel with surgical techniques and outcomes. Recent Findings: A paradigm shift in surgical management of DLM is taking place as knee surgeons are seeing more patients with long-term sequelae of partial lateral meniscectomy, the standard treatment for DLM for many years. Surgical treatment has evolved alongside the understanding of DLM pathology. A new classification system has been proposed and optimal surgical techniques described in recent years. This article highlights up-to-date evidence and techniques in management of both acute DLM tears and joint restoration following subtotal meniscectomy for DLM. Summary: Surgical management of DLM must be tailored to individual pathology, which is variable within the diagnosis of DLM. We present an algorithm for management of DLM and discuss future directions for the understanding and treatment of this debilitating condition.

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

PURPOSE/OBJECTIVE:To establish mean distance or identify intersection between tibial tunnels for posterior meniscal root repair in the setting of anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction. METHODS:-test. RESULTS: = .028) meniscal root tunnels were significantly closer to the PCL tunnel when drilled from the contralateral side of the tibia. CONCLUSION/CONCLUSIONS:This study demonstrates that posterior meniscal root repair tunnels are often placed within a few millimeters and can even intersect cruciate ligament reconstruction tunnels in the proximal tibia. CLINICAL RELEVANCE/CONCLUSIONS:The information in this study may assist surgeons in planning for cruciate ligament reconstruction with concomitant posterior meniscal root repair.

BACKGROUND:Graft-tunnel mismatch is an avoidable complication in anterior cruciate ligament (ACL) reconstruction. Patient height and sex may be predictors of patellar tendon length (PTL) and intra-articular ACL length (IAL). Understanding these relationships may assist in reducing graft-tunnel mismatch during ACL reconstruction with bone-patellar tendon-bone (BTB) autograft. PURPOSE/OBJECTIVE:To determine the association of patient height and sex with PTL and IAL. STUDY DESIGN/METHODS:Cross-sectional study; Level of evidence, 3. METHODS:Magnetic resonance imaging (MRI) studies were obtained on the healthy knees of 100 male and 100 female patients. Patients with prior surgery, open physes, significant degenerative changes, ACL rupture, or extensor mechanism injury were excluded. Three independent readers measured PTL, IAL, and Caton-Deschamps Index (CDI) on MRI. Bivariate and linear regression analysis was performed to detect the association of anthropometric data with anatomic parameters measured on MRI studies. RESULTS:< .001 for all). Results of the linear regression analysis demonstrated that both height and female sex were predictive of longer PTL. Further, height was independently predictive of IAL but sex was not. CONCLUSION/CONCLUSIONS:PTL was correlated more with patient sex than height. IAL was also correlated with patient sex. Longer BTB grafts are expected to be harvested in female patients compared with male patients of the same height despite shorter IAL. These associations should be considered during BTB ACL reconstruction to minimize graft-tunnel mismatch.

PURPOSE/OBJECTIVE:The primary outcome is to compare post-operative outcomes between opioid naïve patients and patients with a history of pre-operative opioid usage undergoing hip arthroscopy. The secondary outcome is to determine if pre-operative opioid users consumed more oral morphine milligram equivalents than opioid naïve patients following surgery. METHODS:This is a single-center, retrospective analysis comparing outcomes and postoperative opioid usage between patients with and without a history of pre-operative opioid use. Inclusion criteria included patients ≥ 18 years, Tonnis grade 0 or 1, imaging consistent with FAI or labral pathology, and a diagnosis of symptomatic FAI requiring hip arthroscopy. Patient outcomes were compared throughout a 2-year follow up using the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS) and Visual Analog Scale (VAS). RESULTS:17 patients were evaluated in each cohort. The mean age of the study cohort and control cohort were 52.0 ± 9.4 years and 51.2 ± 12.2 years, respectively. Females were 58.8% (n=10) of both cohorts. Non-naïve patients had a lower pre-operative NAHS score (p= 0.05) and a higher VAS at their 6-month and 1-year (p <0.001) postoperative visits. Naïve patients reported higher mHHS scores 2 years postoperatively (p <0.001). The study cohort was prescribed higher levels of oral morphine equivalents (OME) at the postoperative 1-year visit (p=0.05). Opioid naïve patients were more likely to reach MCID and PASS of VAS at a faster rate. At the 2-year follow-up, 11.8% of opioid naïve patients continued to take opioids compared to 58.8% from the non-naïve group for persistent hip pain (p <0.001). CONCLUSION/CONCLUSIONS:We have determined that preoperative opioid usage in patients undergoing hip arthroscopy is associated with inferior outcomes compared to opioid naïve patients. Additionally, pre-operative opioid users are likely to continue the use of opioid medications postoperatively and at higher doses than opioid naïve patients.

OBJECTIVE:To assess MRI appearance of the dermal allograft and its correlation with clinical outcome following superior capsular reconstruction (SCR). MATERIALS AND METHODS/METHODS:This is a retrospective study of patients who underwent SCR between 2015 and 2018. Patients with postoperative MRI and clinical follow-up were included. Exclusion criteria were preoperative shoulder instability, advanced glenohumeral arthritis, and lack of postoperative MRI or clinical follow-up. Radiographs and MRIs were evaluated for graft integrity and position, acromiohumeral interval, superior subluxation distance (SSD), and glenohumeral cartilage loss. Correlation between imaging and clinical outcome measures were assessed. RESULTS:24 shoulders (23 patients) met the inclusion criteria at a mean clinical and MRI follow-up of 9.1 months. There were 12 intact grafts (50%) and 12 torn grafts (50%), most commonly at the glenoid attachment (8/12). Patients with graft tear had greater SSD (mean 10.5 ± 6.1 mm) than those without tear (mean 6.1 ± 3.8 mm) (p = 0.028). SSD > 7.9 mm had a 79% sensitivity and 91% specificity for graft tear. The intact grafts were more commonly covering the superior humeral head (91.7%) compared with the torn grafts (41.7%) (p = 0.027). There was improvement of clinical outcome measures including American Shoulder and Elbow Surgeons score (p = 0.005) and forward elevation (p = 0.021) although there was no correlation between clinical outcome and integrity of the graft. CONCLUSION/CONCLUSIONS:SCR results in significant short-term clinical improvement even in the presence of graft tear on postoperative MRIs on current study. Gap between graft and the anchors, non-superior position of the graft, and humeral head superior subluxation can be associated with tear.

INTRODUCTION/BACKGROUND:Partial thicknessrotator cuff tears(PTRCT) have low healing potential and tend to progress over time if not addressed surgically. There is a relative paucity of literature discussing optimal treatment for symptomatic PTRCT as compared to full thicknessrotator cuff tears. The available data supports a treatment course of debridement with or without acromioplasty for symptomatic patients with tears less than 50% in thickness combined with the use of repair (conversion to full thickness or transtendinous) for symptomatic patients with tears greater than 50% in thickness. The aim of this study was to evaluate functional and radiographic outcomes following surgical implantation of a collagen-based bioinductive implant for PTRCT. METHODS:Patients with PTRCT who underwent implantation of a collagen-based bioinductive implant over the bursal surface of the rotator cuff were identified. Patients who had an implant placed to augment a standard full thickness repair were excluded from analysis. We administered questionnaires to patients with a minimum of 6 months since surgery and collected patient data including demographics, preoperative and postoperative American Shoulder and Elbow Society (ASES) scores, preoperative and postoperative visual analog scale (VAS) pain scores, complications, and satisfaction level. Magnetic resonance imaging (MRI) was obtained as needed, at 6 months, or at 12 months postoperatively, and tendon thickness was measured on coronal views. RESULTS:Thirty patients were identified who met the inclusion and exclusion criteria. Twenty-four patients (80% response rate) were available for follow-up; 19 were male and five were female. Mean age and body mass index were 54.5 ± 11.6 years and 28.6 ± 5.9 kg/m2 , respectively. Mean tear thickness as measured intraoperatively was 56.6%. There were 16 (66.7%) articular-sided, five (20.8%) bursal-sided, and three (12.5%) intrasubstance tears. Mean survey follow-up time was 19.1 months. Mean ASES scores increased significantly from 45.6 preoperatively to 68.1 postoperatively (p = 0.001). Mean VAS pain scores decreased significantly from 8.3 preoperatively to 3.8 postoperatively (p < 0.001). Mean patient satisfaction level was 7.5. Ten patients had both a preoperative and postoperative MRI available for comparison. Tendon thickness at the tear site increased significantly from 5.7 mm preoperatively to 6.5 mm at mean 9.9 months follow-up (p = 0.007). There were no implant-related complications. One patient suffered a traumatic re-tear 4 months postoperatively. CONCLUSION/CONCLUSIONS:Highly porous collagen-based bioinductive implants are safe and effective forreducing pain and improving shoulderfunction in patientswith PTRCT of approximately 50%, with radiographic evidence of new tissue formation. Randomized controlled trials are needed to assess efficacy relative to debridement and standard repair techniques.