Faculty Bibliography

Although anterior cruciate ligament reconstruction (ACLR) is a generally successful procedure, failure is still relatively common. An increased posterior tibial slope (PTS) has been shown to increase the anterior position of the tibia relative to the femur at rest and under load in biomechanical studies. Increased PTS has also been shown to increase forces on the native and reconstructed ACL. Clinical studies have demonstrated elevated PTS in patients with failed ACLR and multiple failed ACLR, compared with control subjects. Anterior closing-wedge osteotomies have been shown to decrease PTS and may be indicated in patients who have failed ACLR with a PTS of ≥12°. Available clinical data suggest that the procedure is safe and effective, although evidence is limited to case series. This article presents the relevant biomechanics, clinical observational data on the effects of increased PTS, and an algorithm for evaluating and treating patients with a steep PTS.

PURPOSE/OBJECTIVE:Medial patellofemoral ligament reconstruction (MPFLR) is often indicated in athletes with lateral patellar instability to prevent recurrence and allow for a successful return to play. In this patient population, the ability to return to play is one of the most important clinical outcomes. The purpose of the current study was to analyze the characteristics of patients who were unable return to play following MPFL reconstruction. METHODS:A retrospective review of patients who underwent MPFL reconstruction and subsequently did not return to play after a minimum of 12-months of follow-up was performed. Patients were evaluated for their psychological readiness to return to sport using the MPFL-Return to Sport after Injury (MPFL-RSI) score, which is a modification of the ACL-RSI score. A MPFL-RSI score > 56 is considered a passing score for being psychologically ready to return to play. Additionally, reasons for not returning to play including Visual Analog Scale for pain (VAS), Kujala score, satisfaction, and recurrent instability (including dislocations and subluxations) were evaluated. RESULTS:The study included a total of 35 patients who were unable to return to play out of a total cohort of 131 patients who underwent MPFL reconstruction as treatment for patellar instability. Overall, 60% were female with a mean age of 24.5, and a mean follow-up of 38 months. Nine patients (25.7%) passed the MPFL-RSI benchmark of 56 with a mean overall score of 44.2 ± 21.8. The most common primary reasons for not returning to play were 14 were afraid of re-injury, 9 cited other lifestyle factors, 5 did not return due to continued knee pain, 5 were not confident in their ability to perform, and 2 did not return due to a feeling of instability. The mean VAS score was 1.9 ± 2.3, the mean Kujala score was 82.5 ± 14.6, and the mean satisfaction was 76.9%. Three patients (8.7%) reported experiencing a patellar subluxation event post-operatively. No patient sustained a post-operative patellar dislocation. CONCLUSION/CONCLUSIONS:Following MPFL reconstruction, patients that do not return to play exhibit poor psychological readiness with the most common reason being fear of re-injury. LEVEL OF EVIDENCE/METHODS:IV.

PURPOSE/OBJECTIVE:The purpose of the current study is to systematically review and network meta-analyze the current evidence in the literature to ascertain if there is a superior lateral extra-articular augmentation technique in conjunction with anterior cruciate ligament (ACL) reconstruction (ACL.R) with respect to knee stability, re-rupture rates and functional outcomes. METHODS:The literature search was performed based on the PRISMA guidelines. Cohort studies comparing ACL.R to ACL.R + lateral extra-articular augmentation were included. Lateral extra-articular techniques included were anterolateral ligament reconstruction (ALL.R), Cocker-Arnold, Lemaire, Losee, Maraccaci, and McIntosh. Clinical outcomes were compared between ACL.R alone and the different lateral extra-articular augmentation techniques using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score. RESULTS:Twenty-eight studies with a total of 2990 patients were included. ACL.R + Cocker-Arnold technique had the highest P-Score for ACL re-ruptures and residual pivot-shift. ACL.R + Cocker-Arnold, Lemaire, and ALL.R all significantly reduced the rate of ACL re-rupture, and residual pivot-shift, compared to ACL.R alone. There was no significant difference between any of the lateral extra-articular augmentation techniques and ACL.R alone. ALL.R had the highest P-Score for return to play, and return to play at pre-injury level. CONCLUSION/CONCLUSIONS:This study established that ACL.R + Cocker-Arnold, Lemaire and ALL.R resulted in significantly lower ipsilateral ACL re-ruptures, as well as reduced pivot-shift, compared to ACL.R alone. Whereas, the other lateral extra-articular augmentation techniques did not reduce pivot-shift and re-rupture. Additionally, functional outcomes and return to play were comparable between those who underwent ACL.R and lateral extra-articular augmentation and ACL.R alone. LEVEL OF EVIDENCE/METHODS:III.

OBJECTIVES/OBJECTIVE:The purpose of this study was to determine whether a preoperative video-based opioid education reduced narcotics consumption after arthroscopic rotator cuff repair in opioid-naive patients. METHODS:This was a single-center randomized controlled trial. Preoperatively, the control group received our institution's standard of care for pain management education, whereas the experimental group watched an educational video on the use of opioids. Patients were discharged with 30 × 5 mg/325 mg oxycodone-acetaminophen prescribed: 1 to 2 tablets every 4 to 6 hours. They were contacted daily and asked to report opioid use and visual analog scale pain. A chart review at 3 months post-op was used to analyze for opioid refills. RESULTS:A total of 130 patients completed the study (65 control and 65 experimental). No statistically significant differences were noted in patient demographics between groups (P > 0.05). Patients in the education group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (14.0 pills experimental versus 13.7 pills control, P = 0.60). No statistically significant differences were noted between groups at follow-regarding the rate of prescription refills (P > 0.05). CONCLUSION/CONCLUSIONS:This study suggests that preoperative video-based opioid education may have no effect on reducing the number of narcotic pills consumed after arthroscopic rotator cuff repair. CLINICAL RELEVANCE/CONCLUSIONS:Data exist to suggest that preoperative video-based opioid education has an effect on postoperative consumption; however, the effect of this education in the setting of already-limited opioid-prescribing is not known. CLINICALTRIALS. GOV IDENTIFIER/UNASSIGNED:NCT04018768.

Objectives: Tranexamic acid (TXA) is a commonly used medication in orthopaedic procedures, reducing perioperative bleeding and need for transfusion. The purpose of this double-blind randomized controlled study was to evaluate if IV TXA for primary anterior cruciate ligament (ACL) reconstruction with bone-patella tendon-bone (BTB) could reduce perioperative blood loss or postoperative intra-articular hemarthrosis without postoperative drains.
Method(s): A controlled, randomized, double-blinded trial was conducted in 110 patients who underwent ACLR with BTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-gram boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated, and the volume of blood (ml) was recorded. Additionally, perioperative blood loss (ml); Visual Analog Scale (VAS) on postoperative days (POD) 1-7 and post-operative weeks (POW) 1, 6 and 12; postoperative opioid consumption POD 1-7; range of motion (ROM) and ability to straight leg raise (SLR) at POW 1, 6, 12; and pre and postoperative thigh circumference ratio (TCR).
Result(s): There was no significant difference in perioperative blood loss between the experimental and control groups (32.5ml v. 35.6ml, p=0.47). The experimental group had 23 knees aspirated; control group had 26 knees aspirated (p=0.56). No significant difference seen in postoperative hemarthrosis volume with IV TXA (26.7ml v. 37.3ml, p=0.12). There was no significant difference in VAS score between the two groups (p=0.15), additionally, there was no difference in postoperative opioid consumption (p=0.33). There was no significant difference in ROM or ability to SLR, or pre- nor post-operative TCR (p > 0.05 for all).
Conclusion(s): IV TXA in patients who undergo ACLR with BTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early post-operative recovery regarding ROM or quadriceps reactivation

Objectives: Patients with a superior labral anterior to posterior (SLAP) tear of the shoulder are often initially treated non-operatively, but many do not respond and require surgery. Identifying patients who are likely to fail non-operative management and would benefit from early surgical intervention can shorten time of disability and limit resources utilized on unsuccessful treatments. The purpose of this study is to create a clinical prediction model to determine which patients are likely to fail non-operative treatment of SLAP tears and require surgical intervention.
Method(s): This was a case-control study consisting of patients treated at a single institution for isolated, non-degenerative SLAP tears. Patients with concomitant rotator cuff tears were excluded from this analysis. Patients were retrospectively surveyed using the Research Electronic Data Capture (REDCap) system regarding clinical features of their shoulder injury, non-operative treatments that they received, and key functional outcomes during their post-injury period. Responders underwent additional medical record review to identify other variables related to the clinical presentation and treatment of their shoulder injury. In order to simplify the predictive model and optimize its interpretability, the lasso (least absolute shrinkage and selection operator) method of penalized logistic regression analysis was used to identify the characteristics that were most closely associated with failure of nonoperative treatment. The data was randomly split into a training set and test set. Using the training set, the value of lambda which minimized cross-validation prediction error rate was determined (Figure 1). The final lasso model was then computed. The predictive accuracy of the final model was assessed using the test data set.
Result(s): Overall, 189 patients were contacted and included in the analysis. The mean age of included patients was 29.9 +/- 6.7 years. Thirty-eight patients (20.1%) were female. One hundred and six patients (56.1%) failed non-operative management and required surgical intervention. The final lasso model identified a total of 9 variables that were significantly associated with failure of non-operative management of SLAP tears (Table 1). These predictors included pre-injury overhead sports participation, presence of specific symptoms, severity of pain, and the type of non-operative treatment modalities used. Injury to the dominant extremity, history of prior shoulder injury, patient age, use of NSAIDs, and occupation involving manual labor or overhead work were not associated with failure of nonoperative treatment. The predictive accuracy of the model was 70.3% (95% CI 53.0%, 84.1%). Sensitivity of the model was 81.0% and specificity was 56.3%.
Conclusion(s): A clinical prediction model consisting of variables describing patient characteristics, specific symptoms, and the type of non-operative treatment modalities utilized was found to predict failure of non-operative management of SLAP tears with moderate accuracy. Further refinements of this prediction model, including the inclusion of additional physical examination and imaging variables, will be required before future iterations are tested in clinical practice

Objectives: Socioeconomic factors have been shown to impact patient care in many surgical fields; however, their effects have not been thoroughly evaluated in the context of anterior cruciate ligament reconstruction (ACLR) outcomes. The purpose of this study is to investigate the effects of socioeconomic factors on time to surgery, knee function, and subjective outcomes measures following ACLR.
Method(s): A retrospective query of primary ACLR surgeries at a single institution performed from 2011 to 2015 with minimum twoyear follow-up was conducted. Patient demographics, insurance type, worker's compensation status, surgical variables, IKDC score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups.
Result(s): 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group). The Medicaid group demonstrated lower annual income (p<0.01) and a lower level of completed education compared to the non- Medicaid group (p<0.01). Medicaid patients had a greater duration between time of initial knee injury and surgery compared to the non-Medicaid group (11.8 +/- 16.3 months versus 6.1 +/- 16.5 months, p = 0.04). At the time of follow-up, patients in the non- Medicaid group had a significantly greater IKDC score compared to Medicaid patients (82.5 +/- 13.8 versus 75.3 +/- 20.8, p = 0.03).
Conclusion(s): Socioeconomic factors impacted care in the setting of ACL injury. Medicaid insurance patients were seen significantly later after initial injury when compared to non-Medicaid carriers, and had worse outcomes compared to their non-Medicaid peers. Higher annual income brackets had significantly higher clinical outcomes scores at a minimum of two years postoperatively. Education level did not affect outcomes

Objectives: Medial patellofemoral ligament reconstruction (MPFLR) using allograft tissue has several potential benefits including the absence of donor site morbidity, ability to predict graft parameters, and decreased operative time. The purpose of this study was to evaluate the outcomes of patients following MPFLR with allograft. Our hypothesis was that there would be a low rate of recurrent instability, and excellent clinical outcomes reported.
Method(s): A retrospective review of athletes who underwent MPFL Reconstruction, with a minimum of 12-month follow-up was performed. Recurrent instability (including re-dislocation and subluxation), Visual Analogue Scale (VAS) score, Kujala score, satisfaction, and whether they would undergo the same surgery again, were evaluated.
Result(s): Overall, follow up was attained for 131 patients with 141 knees (73.4%). The mean patient age of 25.0 years, 67.4% females, and mean time to follow-up was 46.8 months (12-111). At final follow up, the mean VAS score was 1.4 +/- 2.0, the mean Kujala score was 84.8 +/- 15.6, the mean satisfaction score was 84% +/- 26.0, and 117 (83.0%) would undergo the same procedure again if required. There was 17 (12.0%) patients that had recurrent instability, with 2 being re-dislocations (1.4%). A further procedure was performed in 14 patients (9.9%). There were no intra-operative complications in our series.
Conclusion(s): There was a low rate of recurrent instability following MPFLR with allograft, with excellent patient reported outcomes, and a low complication rate

Objectives: Superior-labrum anterior-posterior (SLAP) tears are common among athletic populations and may require surgical treatment. Return to play post-operatively may be complicated by a number of factors, including psychological readiness to return. The purpose of this study was to evaluate the use of the SLAP Return to Sport Index (SLAP-RSI) score to quantify psychological readiness to return to play following operative management of SLAP tears.
Method(s): A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 12-month follow-up was performed. Patients were evaluated for their psychological readiness to return to sport using the SLAP-RSI score. The SLAP-RSI score was created by adapting the terms in the Anterior (ACL-RSI score) with terms related to SLAP tears. A SLAP-RSI score > 56 is considered a passing score for being psychologically ready to return to play.
Result(s): The study included 174 athletes who underwent operative management of SLAP tears. Overall, 73.5% percent of patients were able to return to play, and the mean SLAP-RSI score in this cohort was 74.1+/-20.9, as compared to 46.7+/-27.7 in those who were unable to return (p<0.0001). Of those who returned, 82.1% passed the SLAP-RSI benchmark of 56, while of those who did not return, 33.3% passed the SLAP-RSI benchmark of 56. Additionally, a significant difference was found in each component of the SLAP-RSI score between the two cohorts (p<0.05). No individual component of the SLAP-RSI score was below 56 in patients who were able to return to play, while none was above 56 in those who were unable to return. Among patients who were unable to return, ones who cited lifestyle reasons had a higher SLAP-RSI score (77.4 +/- 21.8) than those who cited residual pain (28.2 +/- 15.1) or fear of re-injury (42.6 +/- 23.6) (p<0.0001).
Conclusion(s): Following the operative management of SLAP repair, patients that are unable to return to play exhibit poor psychological readiness to return which may be due to residual pain or fear of re-injury