Faculty Bibliography

BACKGROUND/UNASSIGNED:As platelet-rich plasma injection for knee osteoarthritis (OA) has increased in popularity, it has become more important to assess its effectiveness and satisfaction with its use in the context of its high cost. The purpose of this study was to determine satisfaction, commercial appeal, and effectiveness of platelet-rich plasma (PRP) for the treatment of knee OA. METHODS/UNASSIGNED:A retrospective review of patients who underwent PRP injection in the knee from 2016 to 2019 was performed. Satisfaction with the PRP injection (out of 100), whether the patient would want to undergo PRP injection again, whether they would recommend the injection and whether they felt that the injection was worth the cost was collected. VAS pain scores were collected and measured out of 100. RESULTS/UNASSIGNED:Overall, 114 patients were included. The mean pre-injection pain score was 70.4, and the mean pain level decreased after injection to 36.8. Patients rated their satisfaction on average at 49.2, 50.9% stated that they would get the PRP injection again, 60.5% would recommend to a friend, and 50.9% felt the injection was worth the cost. Younger age and improved post-injection pain correlated with increasing likelihood of desiring further PRP injection. CONCLUSIONS/UNASSIGNED:Patients on average rated satisfaction slightly below average, indicating net indifference skewing towards dissatisfaction with their injection, and only half indicated that it was worth the cost and that they would receive it again. Younger age and pain relief increased desire for further injection, but efficacy did not correlate with patients saying that the injection was worth the cost.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the mid-term results of posterior medial meniscal root tear (PMMRT) repair through assessment of functional outcome scores and magnetic resonance imaging (MRI). METHODS:This was a single-center, retrospective study evaluating patients that had undergone a PMMRT. This was a follow-up to a previously published 2-year outcome study (all original patients were invited to participate). Clinical outcomes included pre- and postoperative International Knee Documentation Committee (IKDC) and Lysholm scores. Root healing, meniscal extrusion, and cartilage degeneration via International Cartilage Repair Society Scale (ICRS) grades were assessed on MRI by two musculoskeletal fellowship-trained radiologists. RESULTS:10 of the original study's 18 patients were able to participate. Mean age and BMI was 48.4 ± 12.0 years and 29.5 ± 4.5, respectively, with mean follow-up 65.5 ± 8.3 months (range 52.0-75.8) (60% female). The IKDC significantly increased from 43 ± 13 preoperatively to 75 ± 16 at 5-year follow-up (p < 0.001). There was no significant change in IKDC score between 2-year and 5-year follow-up [75 ± 16 vs 73 ± 20, (n.s)]. The Lysholm also significantly increased between preoperative and 5-year follow-up (49 ± 7 vs 84 ± 11, p < 0.001). There was no significant change between Lysholm score at 2-year and 5-year follow-up [84.0 ± 11 vs 82 ± 13, (n.s)]. Mean extrusion did not significantly change from the preoperative state to 5-year follow-up [4.80 mm ± 1.9 vs 5.0 mm ± 2.5, (n.s.)]. Extrusion also did not significantly change between 2-and 5-year follow-up [6.1 ± 3.2 mm vs 5.0 mm ± 2.5, (n.s.)]. No patients with > 3 mm of extrusion on preoperative MRI had < 3 mm of extrusion on postoperative MRI. Both medial femoral condyle and medial tibial plateau ICRS grades significantly increased from preoperative to 2-year follow-up (p = 0.038, p = 0.023, respectively). Medial femoral condyle and medial tibial plateau ICRS grades again significantly increased between 2-year and 5-year follow-up (p = 0.014, p = 0.034). CONCLUSION/CONCLUSIONS:Patients treated with the transtibial suture pullout technique with two locking cinch sutures had maintenance of clinical outcome improvements at 5-year follow-up. However, extrusion was widely prevalent, with worsening progression of femoral and tibial chondral disease. LEVEL OF EVIDENCE/METHODS:Level 4.

PURPOSE/OBJECTIVE:The purpose of the current study is to perform a systematic review of the literature and evaluate maximum medical improvement and minimal clinically important difference (MCID) of different injectables in the treatment of symptomatic knee osteoarthritis. METHODS:A systematic review was performed to evaluate maximum medical improvement and MCID in patients undergoing injections of different modalities for knee osteoarthritis. Demographic factors of the patients being reviewed were analyzed, with patient-reported outcomes as reported by visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) being used to evaluate the clinical trajectory of patients receiving intra-articular injections. RESULTS:Overall, 79 (level of evidence I: 79) studies met inclusion criteria, with 8761 patients. Corticosteroid (CS) injections, middle molecular weight hyaluronic acid (MMW-HA), and leukocyte-rich platelet rich plasma (LR-PRP) injections reached their maximum pain control at 4 to 6 weeks after injection, as measured by VAS. The lowest VAS scores were reached for low molecular weight hyaluronic acid (LMW-HA), high molecular weight hyaluronic acid (HMW-HA), and leukocyte-poor platelet rich plasma (LP-PRP) by 3 months after injection. Similarly, the WOMAC scores were lowest at 4 to 6 weeks after CS and MMW-HA injections, and at 3 months after HMW-HA and LP-PRP injections. LR-PRP demonstrated the most prolonged pain relief relative to the other injection types, with the lowest VAS score of all groups measured at final follow-up. LP-PRP showed the lowest WOMAC scores at final follow-up, one year post-injection. CONCLUSION/CONCLUSIONS:PRP injections provide continued pain relief at up to 1 year after injection. Corticosteroids and hyaluronic acid have good efficacy and are suitable for many patients but lack this longevity. LEVEL OF EVIDENCE/METHODS:Level I, a systematic review of Level I studies.

BACKGROUND:The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair. METHODS:Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability. RESULTS:Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%). CONCLUSIONS:Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

PURPOSE/OBJECTIVE:The purpose of this study was to analyze patients that did not return to play (RTP) following arthroscopic Bankart repair (ABR) compared to those who did RTP, and analyze factors associated with not returning to play. METHODS:A retrospective review of patients who underwent ABR, and subsequently did not RTP after a minimum of 24-month follow-up was performed. Additionally, these were pair matched in a 3:1 ratio for age, gender, sport and level of pre-operative play with a control group who RTP. Patients were evaluated for their psychological readiness to return to sport using the SIRSI score. Multivariate regression models were used to evaluate factors affecting RTP. RESULTS:The study included a total of 52 patients who were unable to RTP and 156 who returned to play. Ten patients (19.2 %) who did not RTP passed the SIRSI benchmark of 56 with a mean overall score of 39.8 ± 24.6, in those who returned 73.0 % passed the SIRSI benchmark of 56 with a mean overall score of 68.9 ± 22.0 (p < 0.0001 for both). The most common primary reasons for not returning were 27 felt physically unable to return, whilst 21 felt it was a natural end to their career or their lifestyle had changed. Multi-logistic regression revealed that 4 of the 12 components of the SIRSI score (p < 0.05 for all) and SSV (p = 0.0049), were the factors that were associated with RTP. CONCLUSION/CONCLUSIONS:Following ABR, those that do not return to play exhibit poor psychological readiness to return to play, with multi-linear regression revealing the SIRSI questions associated with fear of re-injury were associated with a lower rate of RTP. Additionally, functional limitations were found to be associated with a lower rate of RTP. LEVEL OF EVIDENCE/METHODS:Level III; Retrospective Comparative Cohort Study.

PURPOSE/OBJECTIVE:The purpose of the current study is to compare the outcomes of open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under the age of 30 years. METHODS:A retrospective review of patients under the age of 30 years who underwent either isolated BT or AR for a diagnosis of a SLAP tear between 2011 and 2019 was performed. Patients were included if they were >16 years old at the time of surgery, had an isolated SLAP tear involving instability of the biceps-labral anchor (types II-IV), were skeletally mature, and had a minimum follow-up of 12 months. The American Shoulder & Elbow Surgeons score, visual analog scale, Subjective Shoulder Value, patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A P value of <.05 was considered statistically significant. RESULTS:Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, and the mean follow-up duration was 60 months. At final follow-up, there was no difference between treatment groups in any of the functional outcome measures assessed (P > .05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; P = .53), timing of RTP (BT: 8.8 months, AR: 9.4 months; P = .61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; P > .99). Among those undergoing AR, 9 required a revision procedure (11.5%) compared to none treated with BT (P = .11). CONCLUSIONS:In patients under the age of 30 years with a symptomatic isolated SLAP tear, BT may be a reliable alternative to AR. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

STUDYDESIGN/UNASSIGNED:Retrospective-comparative; LOE-3. OBJECTIVE:The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following 1-or-2-level lumbar fusion has on Hospital-Consumer-Assessment-of-Healthcare-Providers-and-Systems-(HCAHPS)-survey results. SUMMARY OF BACKGROUND DATA/BACKGROUND:Prior research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction. METHODS:A retrospective review of prospectively-collected data was conducted on patients who underwent 1-or-2-level lumbar fusions L3-S1 between October 2014-October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions > 2 levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram-morphine-equivalents (MME). RESULTS:330 patients met inclusion criteria, 259 pre-protocol, 71 post-protocol. There were 256 1-level fusions and 74 2-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (p > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7%(95) pre-protocol, to 59.2%(42) post-protocol; p < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL; p = 0.003. Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3%; p < 0.001. Average opioids prescribed on discharge in the pre-protocol period was was 534 ± 425 MME, compared to after initiation of the protocol it was 320 ± 174 MME; P < 0.001. There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol vs 4.51 ± 0.82 post-protocol; p = 0.986. CONCLUSION/CONCLUSIONS:A reduction in opioids prescribed at discharge after 1-or-2-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

PURPOSE/OBJECTIVE:The purpose of this study was to perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature in order to assess the evidence defining the optimal combination of surgical technique single row repair (SRR), double-row repair (DRR), or transosseous-equivalent/suture-bridge (TOE/SB) arthroscopic rotator cuff repair (ARCR) and postoperative rehabilitation (early or late) protocol for ARCR. METHODS:The literature search was performed based on the PRISMA guidelines. Randomized SSR-Early trials (RCT) comparing SRR vs DRR vs TOE/SB ARCR techniques were included, as well as early versus late postoperative ROM. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score. RESULTS:28 studies comprising 2,181 total shoulders met the inclusion criteria. TOE/SB-late (OR 0.19 [0.08;0.46) and DRR-late (OR 0.25 [0.12;0.52) were found to significantly reduce the rate of re-tear, with TOE/SB-late resulting in the highest P-score for the American Shoulder & Elbow Surgeons (ASES) (P Score: 0.7911) score and re-tear rate (P Score: 0.8725). DRR-early did not result in any significant improvements over the SRR-early group, except in internal rotation. There was no significant difference in forward flexion between groups, with almost equivalent P-Scores. Furthermore, TOE/SB-early and TOE/SB-late trended toward worsening external rotation compared to the control. CONCLUSION/CONCLUSIONS:The current study suggests that rotator cuff repair using the transosseous-equivalent/suture-bridge technique and late postoperative mobilization yields the highest functional outcomes and lowest re-tear rate in the arthroscopic management of symptomatic rotator cuff tears.

PURPOSE/OBJECTIVE:The purpose of this study was to identify if the location of posterolateral corner (PLC) injury was predictive of clinical common peroneal nerve (CPN) palsy. METHODS:A retrospective chart review was conducted of patients presenting to our institution with operative PLC injuries. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. A fellowship-trained musculoskeletal radiologist reviewed the PLC injury and categorized it into distal, middle and proximal injuries with or without a biceps femoral avulsion. The CPN was evaluated for signs of displacement or neuritis. RESULTS:Forty-seven operatively managed patients between 2014 and 2019 (mean age-at-injury 29.5 ± 10.7 years) were included in this study. Eleven (23.4%) total patients presented with a clinical CPN palsy. Distal PLC injuries were significantly associated with CPN palsy [9 (81.8%) patients, (P = 0.041)]. Nine of 11 (81.8%) patients with CPN palsy had biceps femoral avulsion (P = 0.041). Of the patients presenting with CPN palsy, only four (36.4%) patients experienced complete neurologic recovery. Three of 7 patients (43%) with an intact CPN had full resolution of their clinically complete CPN palsy at the time of follow-up (482 ± 357 days). All patients presenting with a CPN palsy also had a complete anterior cruciate ligament (ACL) rupture in addition to a PLC injury (P = 0.009), with or without a posterior cruciate ligament (PCL) injury. No patient presenting with an isolated pattern of PCL-PLC injury (those without ACL tears) had a clinical CPN palsy. CONCLUSION/CONCLUSIONS:Distal PLC injuries have a strong association with clinical CPN palsy, with suboptimal resolution in the initial post-operative period. Specifically, the presence of a biceps femoris avulsion injury was highly associated with a clinical CPN palsy. Additionally, CPN palsy in the context of PLC injury has a strong association with concomitant ACL injury. Furthermore, the relative rates of involvement of the ACL vs. PCL suggest that specific injury mechanism may have an important role in CPN palsy. LEVEL OF EVIDENCE/METHODS:IV.

BACKGROUND:Graft failure following anterior cruciate ligament reconstruction (ACLR) is a devastating complication. Risk factors such as patient characteristics and tunnel positions are well described. The relationship between graft dimension and failure rates has been investigated mainly in soft tissue grafts. Less studied are the effects of patella tendon (PT) dimensions on the risk of graft failure following patella tendon autograft (PTA) reconstructions. PURPOSE/OBJECTIVE:The purpose of the current study was to investigate if patellar tendon thickness measured on preoperative magnetic resonance imaging (MRI) predicts failure after ACLR using PTA. METHODS:This was an institutional review board approved, single-center, retrospective case-control study comparing patients' preoperative patellar tendon thickness between July 2005 and January 2017. Sixteen patients (mean age 21.2 ± 5.0 years) with PTA failure requiring revision surgery were identified and compared to 34 control patients who had undergone primary ACLR with PTA without failure with a minimum of 2-years follow-up. Patients with failure were matched at approximately 1:2 based on age, sex, height, weight, associated meniscus injury, and associated meniscal surgery. Patellar tendon dimensions were measured at the inferior pole of the patella (IPP), tibial tubercle insertion (TT), and longitudinal midpoint (MP) on preoperative axial and sagittal cut MRIs. Interclass correlation coefficeint (ICC) and Bland-Altman analyses were evaluated to determine inter-observer reliability. The two cohorts were compared using independent samples t-tests and analysis of variance. RESULTS:All ACLR failures occurred after a non-contact, pivot type injury. There were no significant differences in age, sex, height, weight, meniscal injury, or meniscal surgery between the two groups. Mean time between primary ACLR and revision was 2.6 ± 2.6 years and mean follow-up time was 3.1 ± 1.0 years in the control group. Patellar tendon length and width were not significantly different between the two groups. The average thickness at both the inferior pole and longitudinal midpoint was significantly higher in the failure group compared to controls (IPP: 5.04 ± 1.1 mm versus 4.33 ± 0.7 mm, p = 0.01; MP: 4.60 ± 0.7 mm versus 4.22 ± 0.5 mm, p = 0.03). Additionally, ICC was high across all measurements, with all values > 0.978. Similarly, all values demonstrated bias of less than ± 0.05. CONCLUSION/CONCLUSIONS:Patella tendon autograft anterior cruciate ligament reconstruction failures had significantly thicker patellar tendons at the inferior pole and longitudinal midpoint of the patella tendon.