Faculty Bibliography

OBJECTIVES/OBJECTIVE:An isolated medial patellofemoral ligament (MPFL) reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient-reported outcomes. METHODS:A retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, gender, and follow-up time. Recurrent instability (including redislocation and subluxation), visual analogue scale (VAS) score, Kujala score, and satisfaction were evaluated. RESULTS:There were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow-up time. The mean age was 25.0 years, 76.3% were female, and the mean follow-up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p = 0.311) or revision surgeries (10.2% vs. 10.2%) between groups. CONCLUSION/CONCLUSIONS:Matched patients undergoing MPFLR with TTO compared with isolated MPFLR demonstrate no statistically significant difference in patient-reported outcomes, levels of pain, and satisfaction postoperatively. Furthermore, the addition of a TTO does not increase the risk of further surgery or complications. LEVEL OF EVIDENCE/METHODS:III, retrospective comparative study.

PURPOSE/OBJECTIVE:To evaluate the variation in tibial tubercle sagittal alignment in patients with and without patellofemoral (PF) cartilage wear. METHODS:This was a single-centre, retrospective review of patients that underwent a cartilage restoration procedure for isolated PF cartilage wear from 2014 to 2020. Patients were matched in a 1:2 ratio for age, sex and BMI to partial meniscectomy patients as controls. The sagittal TT-TG (sTT-TG) distance was measured on preoperative axial T2 magnetic resonance imaging (MRI) and was defined as the distance between a point at the nadir of the trochlear cartilage and the most anterior point of the tibial tubercle. RESULTS:One hundred and forty patients (47 cartilage restoration, 94 meniscectomy) were included. Mean age, BMI, and height for the total cohort were 34.01 ± 8.7, 26.6 ± 6.4, and 173.0 ± 17.7 respectively, with 78 males (55%) and 63 females (45%). There were no significant differences between groups for age, BMI or sex (n.s). The cartilage restoration group (- 2.5 mm ± 5.9) was found to have a significantly more posterior (negative) sTT-TG compared to the meniscectomy group (1.72 mm ± 6.7) (p < 0.001). Interrater reliability was excellent (ICC = 0.931, p < 0.001). Patients with less than - 3.4 mm sTT-TG were 2.74 times more likely to have a cartilage restoration procedure compared to those with greater than - 3.4 mm (OR 2.7, 95% CI 1.3-5.85). Patients with < - 10 mm posterior translation were 13.7× (CI 1.6-111.1) more likely to have a cartilage restoration procedure. CONCLUSION/CONCLUSIONS:Patients that underwent isolated cartilage restoration procedures had a significantly more posterior tibial tubercle than partial meniscectomy controls based on the sagittal TT-TG. The more posterior the tubercle, the more likely the patient had a cartilage restoration procedure. Surgeons should consider the sTT-TG measurement in patients presenting with anterior knee pain, particularly patellofemoral lesions. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND/UNASSIGNED:Performing open subpectoral biceps tenodesis in overhead athletes with a superior labrum anterior to posterior (SLAP) tear may affect their ability to return to overhead sports. PURPOSE/UNASSIGNED:To investigate clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex. STUDY DESIGN/UNASSIGNED:Case series; Level of evidence, 4. METHODS/UNASSIGNED:value of <.05 was considered to be statistically significant. RESULTS/UNASSIGNED:The current study included 44 overhead athletes. The mean age was 34.9 years (range, 16-46 years), 79.5% were male, and the mean follow-up was 49.0 months (range, 18-107 months). Overall, 81.8% of patients returned to play their overhead sport after biceps tenodesis, and 59.1% of patients returned to the same or higher level of play. It took patients, on average, 8.7 months to return to play after biceps tenodesis. The mean SLAP-RSI score was 69.4, and 70.5% of patients passed the SLAP-RSI threshold of 56. The mean ASES score, VAS score, SSV, and satisfaction were 92.0, 0.8, 80.6, and 87.9%, respectively. No patients in our cohort required revision surgery. CONCLUSION/UNASSIGNED:This study found that athletes undergoing biceps tenodesis for the treatment of a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery.

The Latarjet-Patte procedure has a long and storied history that predates shoulder arthroscopy, but its popularity has increased over the past two decades as a treatment for anterior glenohumeral instability with bone loss. Transfer of the coracoid process and conjoint tendon to the anteroinferior glenoid creates a triple-blocking effect that is both static and dynamic, lending it biomechanical superiority over alternative bone block techniques. Patients undergoing the Latarjet-Patte procedure have low rates of recurrent instability compared to arthroscopic soft-tissue stabilization procedures, particularly in the setting of glenoid- and humeral-sided bone loss. A number of technical innovations have been developed in recent years to improve the efficacy of this procedure and to reduce its potential complications, although their associated learning curves and potential for widespread adoption remain unclear. In this article, we review the history, indications, outcomes, and future of this surgical technique.

Background/UNASSIGNED:The Latarjet procedure is indicated in patients with risk factors for postoperative recurrence, including collision and competitive athletes. However, the factors that prevent athletes from being able return to play (RTP) after the open Latarjet procedure are still unclear and have not been fully elucidated in the literature. Purpose/UNASSIGNED:To evaluate patient-reported outcomes and psychological and psychosocial factors associated with athletes who did not RTP after the open Latarjet procedure compared with patients who did RTP. Study Design/UNASSIGNED:Cohort study; Level of evidence, 3. Methods/UNASSIGNED:We conducted a retrospective review of athletes who underwent the open Latarjet procedure and subsequently did not RTP after a minimum of 12 months. These patients were pair matched in a 2:1 ratio for age, sex, sport, and level of preoperative play with a control group who returned to play. Patients were evaluated for their psychological readiness to return to sport using the Shoulder Instability-Return to Sport after Injury (SIRSI); other measures included the visual analog scale (VAS) for pain and Subjective Shoulder Value (SSV). Multivariate regression models were used to evaluate factors affecting RTP. Results/UNASSIGNED:< .05). Conclusion/UNASSIGNED:Patients who did not RTP after open Latarjet exhibited poor psychological readiness to RTP and worse pain VAS and SSV scores compared with patients who did RTP.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the outcomes of patients 5-years post-operatively following arthroscopic superior-labrum anterior-posterior (SLAP) repair, and to evaluate factors associated with satisfaction. METHODS:A retrospective review of patients who underwent SLAP repair with a minimum of 5-year follow-up was performed. Recurrence, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, satisfaction, whether they would undergo the same surgery again, and the rate, level and timing of return to play (RTP) were evaluated. Multi-linear regression models were used to evaluate factors affecting postoperative satisfaction. RESULTS:Overall, 122 patients who underwent SLAP repair were included, with a mean age of 33.4 years. 81% were males, and 58.2% were participating in sport pre-operatively. The mean follow-up was 86.4 ± 14.4 months. At final follow up, the mean satisfaction was 87.7%, and the mean SSV was 82.9. Overall, the rate of RTP was 85.9%, with 64.8% returning at the same level at a mean of 10.5 ± 8 months. Ultimately, 13 (10.7%) patients had a further surgery, including 10 (8.2%) patient that had a biceps tenodesis. VAS during sport (p = 0.025), SSV (p < 0.001), and time to RTP (p = 0.0056), were associated with higher satisfaction. CONCLUSION/CONCLUSIONS:There was a high rate of satisfaction at 5-year follow-up, with excellent patient reported outcomes but with a tenth of patients requiring revision surgeries. Additionally, while there was an overall high rate of RTP, there was only a modest rate of RTP at their pre-injury level and overhead athletes took longer to RTP.

PURPOSE/OBJECTIVE:The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. METHODS:A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS:The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. CONCLUSION/CONCLUSIONS:Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. LEVEL OF EVIDENCE/METHODS:Level V, expert opinion.

PURPOSE/OBJECTIVE:The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability. METHODS:A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS:The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors. CONCLUSION/CONCLUSIONS:Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization. LEVEL OF EVIDENCE/METHODS:Level V, expert opinion.

PURPOSE/OBJECTIVE:The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. METHODS:A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS:The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. CONCLUSION/CONCLUSIONS:Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. LEVEL OF EVIDENCE/METHODS:Level V, expert opinion.