Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:This manuscript reviews relevant prior literature regarding management of immunosuppressants in patients with rheumatic diseases around the time of orthopedic surgery, highlighting important considerations specifically regarding arthroscopy. RECENT FINDINGS/RESULTS:Utilization rates of arthroscopic surgery in patients with rheumatic diseases are on the rise, as immunosuppressive treatment options enable them to lead more active lives and hence experience more injuries. Physicians regularly manage patients' glucocorticoids and conventional synthetic and biologic disease modifying antirheumatic drugs around the time of orthopedic surgery, aiming to minimize infection risk while optimizing disease control. However, there is a paucity of randomized controlled trial data for orthopedic surgery-and specifically nothing in the literature pertaining to arthroscopic surgery. Recent guidelines for rheumatic disease patients undergoing elective total hip and knee arthroplasty recommend that most immunosuppressive medications should be held perioperatively, citing the high-risk profile of arthroplasty cases and arthroplasty patients. While 2017 societal guidelines for perioperative immunosuppression during arthroplasty currently serve as a guide for physicians, they may not be applicable to arthroscopy. The less aggressive arthroscopic surgeries span a broader range of patient ages and risk profiles, indications for surgery, and procedural complexity and associated risks. Given these considerations, the majority of routine arthroscopic patients may not require holding of their immunosuppressive medications in the perioperative period.

PUPROSE/UNASSIGNED:The purpose of this study is to systematically review the literature and evaluate patient-reported outcomes and complication/revision rates of bone-block augmentation in the treatment of posterior shoulder instability (PSI). METHODS:PUBMED was searched according to PRIMSA guidelines to find clinical studies evaluating patient-report outcomes, revision and complication rates in posterior bone block for posterior shoulder instability. A literature search of MEDLINE, EMBASE and The Cochrane Library, was performed based on the PRISMA guidelines. Clinical studies reporting on the complications following posterior bone block were included. RESULTS:Overall, 11 (LOE III: 2, LOE IV: 9) studies met inclusion criteria, with 225 shoulders. Recurrent instability after the posterior bone block was found to be 9.8%. The overall complication rate was 13.8%, with 0.89% having graft complications, 11.1% having hardware complications, 0.4% having wound complications, 0.4% having nerve complications, and 0.89% having other complications. Residual pain was found in 11.6% of shoulders operated on. Patient-reported outcomes were evaluated most commonly by Rowe (81.4), Constant (84.6), and Walch - Duplay (81.6). CONCLUSION/CONCLUSIONS:There is a moderate rate of recurrence following posterior bone block for PSI. However, the patient-reported outcomes are high despite there being commonly reported persistent shoulder pain postoperatively. LEVEL OF EVIDENCE/METHODS:Level IV; Systematic Review.

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.

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.