Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose of the current study is to systematically review the current evidence in the literature to ascertain rates of return to play following ACLR with extra-articular augmentation (EA). METHODS:A literature search was performed based on the PRISMA guidelines. Studies were included if they evaluated and reported on return to play following ACLR + EA, case studies and review articles were excluded. The outcomes measured focused on 1) return to play, 2) return to play at the same or higher level, and 3) timing of return to play. Qualitative analysis and quantitative analysis were performed using SPSS. RESULTS:Overall, 19 studies met our inclusion criteria. Among those undergoing primary ACLR, 82.8%-100% were able to return to play, with 64%-100% able to return at the same/higher level of play. All professional athletes were able to return to play and 85.7%-100% able to return to the same level of pre-operative play. The mean time to return was 5-11 months in those undergoing primary ACLR + EA. Among those undergoing revision ACLR, 50-88.4% were able to return to play, with 41.5%-77.8% able to return at the same/higher level of play. None of the included 5 studies comparing rate of return to play between ACLR + EA or ACLR found a significant difference between them. However, among the 6 studies comparing rate of return to play at the same level ACLR + EA or ACLR, 2 studies found a significant difference in rate of return to play at the same/higher level in those undergoing ACLR + EA. CONCLUSION/CONCLUSIONS:ACLR + EA resulted in high levels of return to play in those undergoing either primary or revision ACLR. Additionally, comparative studies of patients undergoing primary ACLR with or without EA reported similar high rates of return to play.

IMPORTANCE/OBJECTIVE:Cadaveric and MRI findings have demonstrated significantly less labral separation and displacement when the shoulder is placed in external rotation as compared with internal rotation. OBJECTIVE:The purpose of the current study is to meta-analyse the randomised controlled trials in the literature to compare immobilisation in external versus internal rotation after first-time anterior shoulder dislocation. EVIDENCE REVIEW/METHODS:A literature search of MEDLINE, EMBASE and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials comparing immobilisation in external rotation versus internal rotation for first-time anterior shoulder dislocation were included. FINDINGS/RESULTS:Nine randomised controlled trials with 795 patients were included. The mean age of included patients was 29 years, 82.4% were male and the mean follow-up was 25.5 months. As compared with immobilisation in internal rotation, compliance was significantly higher (74.5% vs 67.4%, p=0.01), and the rate of recurrent dislocations was significantly lower (22.2% vs 33.4%, p=0.02) with immobilisation in external rotation. Additionally, in patients 20-40 years old the rate of recurrent dislocations was significantly lower in those treated with immobilisation in external rotation than internal rotation (12.1% vs 31.4%, p=0.006). Immobilisation in external rotation also resulted in a higher rate of return to preinjury level of play (60.1% vs 42.6%, p=0.0001). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Immobilisation of the shoulder in external rotation after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilisation in internal rotation. LEVEL OF EVIDENCE/METHODS:Level I.

BACKGROUND/UNASSIGNED:It is unclear whether leukocyte-poor (LP) or leukocyte-rich (LR) varieties of platelet-rich plasma (PRP) as an adjuvant to arthroscopic rotator cuff repair (ARCR) result in improved tendon healing rates. PURPOSE/UNASSIGNED:To perform a network meta-analysis of the randomized controlled trials in the literature to ascertain whether there is evidence to support the use of LP- or LR-PRP as an adjunct to ARCR. METHODS/UNASSIGNED:The literature search was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Randomized controlled trials comparing LP- or LR-PRP with a control alongside ARCR were included. Clinical outcomes, including retears and functional 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/UNASSIGNED:There were 13 studies (868 patients) included, with 9 studies comparing LP-PRP with a control and 4 studies comparing LR-PRP with a control. LP-PRP was found to significantly reduce the rate of retear and/or incomplete tendon healing after fixation, even among medium-large tears; it also improved outcomes on the visual analog scale for pain, Constant score, and University of California Los Angeles score. LP-PRP had the highest P-score for all treatment groups. LR-PRP did not result in any significant improvements over the control group, except for visual analog scale score for pain. However, post hoc analysis revealed that LP-PRP did not lead to significant improvements over LR-PRP in any category. CONCLUSION/UNASSIGNED:The current study demonstrates that LP-PRP reduces the rate of retear and/or incomplete tendon healing after ARCR and improves patient-reported outcomes as compared with a control. However, it is still unclear whether LP-PRP improves the tendon healing rate when compared with LR-PRP.

BACKGROUND/UNASSIGNED:Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year. PURPOSE/UNASSIGNED:To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes. STUDY DESIGN/UNASSIGNED:Systematic review and meta-analysis. METHODS/UNASSIGNED:A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate. RESULTS/UNASSIGNED:< .05). No benefit was found in any of the studies evaluating subacromial infusions. CONCLUSION/UNASSIGNED:Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.

INTRODUCTION:There has been controversy regarding whether headgear use in women's lacrosse will affect the rate of head and musculoskeletal injuries. The purpose of this study was to investigate the effect of mandated headgear use on the rate of head and musculoskeletal injuries in high school women's lacrosse. METHODS:This was a prospective cohort study of eight high school women's lacrosse teams and their game op-ponents who were mandated to wear F3137 headgear for the 2017 and 2018 seasons. Athletic trainers documented all injuries that occurred as a result of participation on the lacrosse teams. Injury rates in the headgear cohort were compared to a retrospective (control) cohort from the High School Reporting Information Online injury data reports. RESULTS:Over the study period, 17 total injuries were reported in the headgear cohort during 22,397 exposures for an injury rate of 0.76 injuries per 1,000 athlete-exposures. The headgear cohort demonstrated significant decreases in rates of in-game head and face injury (RR 0.141, 95% CI [0.004, 0.798]), in-game concussion (RR 0.152, 95% CI [0.004, 0.860]), and practice trunk and extremity injury (RR 0.239, 95% CI [0.049, 0.703]) when compared to the control cohort. CONCLUSION:Mandated use of headgear was shown to be effective at lowering the rate of head or face injury and concussions in women's lacrosse. Additionally, mandated headgear use was also shown to lower the rate of injury to body locations other than the head or face during practice. To our knowledge, this is the first study to demonstrate a decrease in injury rates associated with ASTM approved headgear in women's lacrosse.

BACKGROUND:The aim of this study was to describe associated injuries in cases of distal biceps femoris avulsions (DBFA) as well as the incidence of neurological injury and radiographic abnormalities of the common peroneal nerve (CPN). METHODS:A retrospective chart review was conducted of patients presenting to our office or trauma center with DBFA injuries. Demographic data was obtained as well as mechanism of injury. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. The CPN was evaluated for signs of displacement or neuritis. RESULTS:Sixteen patients were identified (mean age-at-injury 28.6 years, 87.5% male) with DBFA. Three patients (18.8%) sustained their injuries secondary to high energy trauma while 13 (81.3%) had injuries secondary to lower energy trauma. Nine patients (56.3%) initially presented with CPN palsy. All patients presenting with CPN palsy of any kind were found to have a displaced CPN on MRI and no patient with a normal nerve course had a CPN palsy. CONCLUSIONS:This case series demonstrates a strong association between DBFA and CPN palsy as well as multi-ligamentous knee injury (MLKI). These injuries have a higher rate of CPN palsy than that typically reported for MLKI. Furthermore, these findings suggest that CPN displacement on MRI may be a clinically significant indicator of nerve injury. LOE: IV.

AIM/OBJECTIVE:There is a shortage of high-level evidence regarding periarticular fractures affect outcomes after MLKIs. The purpose of this study was to determine whether concomitant periarticular fractures with mutliligament knee injuries (MLKIs) predict worse patient-reported outcomes (PROMs) when compared to MLKIs without concomitant periarticular fractures after surgical repair and/or reconstruction. MATERIALS AND METHODS/METHODS:Medical records of patients who sustained MLKIs from January 1, 2009 to June 1, 2014 were retrospectively reviewed. All patients aged 18-65 years with grade III injuries of two or more knee ligaments and 1-year minimum follow-up were included. Patients with injuries or surgeries to either knee before their MLKIs were excluded. Radiographs and computed tomography imaging obtained at the time of injury were used to detect concomitant periarticular fractures. Patients with and without concomitant periarticular fractures were matched on a 1:2 basis, respectively. Multiple PROMs were collected, including the IKDC Subjective Knee Form (IKDC-SKF), and Knee Injury and Osteoarthritis Outcome Score (KOOS). The independent t-test was used to compare PROMs between patients with and without periarticular fractures. RESULTS:Eighteen patients (10 males, 8 females) with a mean follow-up of 4.0 years (range 1.1-8.6 years) were included in the final analysis, with six patients having MLKIs and concomitant periarticular fractures. Compared to patients with isolated ligamentous MLKIs (n   =  12), patients with concomitant periarticular fracture (n = 6) demonstrated significantly worse outcomes on the IKDC-SKF (54.2 ± 13.3 vs. 74.0 ± 19.6, p = 0.04) and KOOS-Sports and Recreation subscale (41.2 ± 32.4 vs. 70.8 ± 19.4, p = 0.03). CONCLUSION/CONCLUSIONS:The presence of a periarticular fracture predicted significantly worse clinical outcomes in the setting of MLKI. These findings may be useful in determining the prognosis of MLKI with concomitant periarticular fractures treated with surgical repair and/or reconstruction.

PURPOSE/OBJECTIVE:In recent years, meniscal allograft transplantation (MAT) has been established as an effective option for young patients with symptomatic meniscus insufficiency with goals of functional improvement and joint preservation. Currently, there is little available information on return-to-play among patients in this cohort. The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return-to-play guidelines, and subsequent rates of return-to-play following MAT. METHODS:MEDLINE, EMBASE and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on MAT. Studies were included if they reported return-to-play data or rehabilitation protocols. The rate and timing of return-to-play was assessed. The rehabilitation protocols were recorded, including time to start range of motion (ROM), full ROM, partial weight bearing (WB), and full WB. RESULTS:Overall, 67 studies met the inclusion criteria. Eleven studies, including 624 patients, reported 483 out of 624 patients (77.4%) returning to play, with 326 out of a reported 475 patients (68.6%) returning to the same/higher level, at a mean time to return of 9.0 months. There was significant variability in the reported rehabilitation protocols, but the most commonly reported time to begin ROM exercises was within the first week by 42 out of 60 studies (70.0%) and full ROM at 8 weeks by 18 out of 46 studies (39.1%). Partial weight bearing was most commonly begun in the fourth week by 20 out of 46 studies (43.5%), and for full WB the sixth week by 43 out of 65 studies (66.1%). Time elapsed following surgery was the most commonly reported criteria for return-to-play by 44 out of 48 studies (91.6%), with 6 months being the most common time point utilized by 17 out of 45 studies (37.8%). A small proportion of studies, 16 out of 48 (33.3%), advised against returning to competitive/collision sports altogether following MAT. CONCLUSIONS:In conclusion, there is a high rate of return-to-play following MAT, with the majority of patients returning to the same level of play. However, there is significant variability in reported rehabilitation protocols, and poor-quality reporting in return-to-play criteria in the literature indicates a need for further study and the development of an evidence-based consensus statement for this patient population. The results from this study can be used to better inform patients on their expected outcomes and provide a more informed consent process. LEVEL OF EVIDENCE/METHODS:IV.

INTRODUCTION/BACKGROUND:The purpose of the current study was to evaluate resident, fellow, and attending perspectives on the use of e-learning as part of orthopaedic surgery education. METHODS:A survey was created evaluating (1) overall attitudes toward e-learning, (2) multi-institutional e-learning/e-conferences, (3) national/regional e-conferences, and (4) future directions with e-learning. The survey was distributed to all the orthopaedic surgery residency program directors in the United States, and they were asked to circulate the survey to their program's faculty and trainees. RESULTS:A total of 268 responses were collected, including 100 attendings and 168 trainees. Overall satisfaction with e-learning compared with in-person learning was higher among trainees than attending faculty, with 51.4% of trainees favoring e-learning, as opposed to 32.2% of attendings (P = 0.006). Both groups felt they were more likely to pay attention with in-person learning (P = 0.89). During the COVID-19 pandemic, 85.7% of residents have used e-learning platforms to join a conference in their specialty of interest while off-service. Most attendings and trainees felt e-learning should play a supplemental role in standard residency/fellowship education, with a low number of respondents feeling that it should not be used (86.6% versus 84%, and 2.1% versus 0.6%, respectively, P = 0.28). CONCLUSION/CONCLUSIONS:E-learning has been an important modality to continue academic pursuits during the disruption in usual education and training schedules during the COVID-19 pandemic. Most trainees and attendings surveyed felt that e-learning should play a supplementary role in resident and fellow education moving forward. Although e-learning does provide an opportunity to hold multi-institutional conferences and makes participation in meetings logistically easier, it cannot fully replicate the dynamic interactions and benefits of in-person learning.