Faculty Bibliography

PURPOSE/OBJECTIVE:Osteoarthritis (OA) is a debilitating joint disease characterized by progressive loss of articular cartilage. Intra-articular injections are a mainstay of nonoperative treatment, however, there is controversy as to the optimal injectable for these patients. The purpose of the current study is to perform a network meta-analysis of the randomized control trials in the literature to ascertain whether there is a superior injectable nonoperative treatment for knee OA. METHODS:The literature search was conducted based on the PRISMA guidelines. Randomized control trials (RCTs) evaluating intra-articular injectables in osteoarthritic knees were included. Data was extracted and Visual Analogue Scale (VAS) scores and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, where available were analyzed at 1, 3, 6 and 12 months. 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:Seventy-nine RCTs with 8761 patients were included in this review. Intra-articular injectables evaluated included autologous conditioned serum (ACS), bone marrow aspirate concentrate (BMAC), botulinum toxin, corticosteroids (CS), hyaluronic acid (HA), mesenchymal stem cells (MSC), ozone, saline placebo, platelet-rich plasma (PRP), plasma rich in growth factor (PRGF), and stromal vascular fraction (SVF). At 4-6 weeks and 3 months of follow-up, the treatment with the highest P-Score for WOMAC score was high molecular weight (HMW) HA + CS [P-Score = 0.9500 and 8503, respectively]. At 6-months follow-up, the treatment with the highest P-Score for WOMAC score was PRP [P-Score = 0.7676]. At all post-injection time points, the treatment with the highest P-Score for VAS score [P-Score Range = 0.8631-9927] and Womac score at 12 Months [P-Score = 0.9044] was SVF. CONCLUSIONS:The current evidence shows that SVF injections result in the greatest improvement in pain and functional outcomes in patients with knee OA at up to 1 year of follow-up.

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.

CASE:A 41-year-old man presented with a transverse patella fracture and proximal patellar tendon avulsion after a fall from standing. Disruption of the extensor mechanism of the knee at multiple points is rare. He was treated operatively for his patella fracture and patellar tendon avulsion but experienced early failure of the patellar tendon fixation requiring reoperation. Both components of injury ultimately healed, and he returned to function. CONCLUSION:This case describes a rare presentation of an uncommon injury pattern affecting the extensor mechanism. This is the first report to describe multifocal failure of the extensor chain from a low-energy mechanism.

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.

OBJECTIVE:The purpose of the current study is to evaluate the clinical and radiographic outcomes at early to midterm follow-up between fresh precut cores versus hemi-condylar osteochondral allograft (OCAs) in the treatment of symptomatic osteochondral lesions. DESIGN/METHODS:A retrospective review of patients who underwent an OCA was performed. Patient matching between those with OCA harvested from an allograft condyle/patella or a fresh precut allograft core was performed to generate 2 comparable groups. The cartilage at the graft site was assessed with use of a modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system and patient-reported outcomes were collected. RESULTS:= 0.93). CONCLUSIONS:This study found that there was no difference in patient-reported clinical outcomes or MOCART scores following OCA implantation using fresh precut OCA cores or size matched condylar grafts at early to midterm follow-up.

PURPOSE/OBJECTIVE:The purpose of this study is to evaluate the short-term complication rate following the open and arthroscopic Latarjet procedures and to meta-analyze the studies comparing the 2 approaches. METHODS:PubMed was searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to find clinical and biomechanical studies comparing complication rates in open and arthroscopic Latarjet procedures. A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the PRISMA guidelines. Clinical studies reporting on the complications following the open or arthroscopic Latarjet were included. Meta-analysis was performed for comparative studies using Review Manager, version 5.3. A P value of <.05 was considered statistically significant. RESULTS:Overall, 89 studies (Level of Evidence [LOE] I: 2, LOE II: 2, LOE III: 24, LOE IV: 61) met inclusion criteria, with 7175 shoulders. Following the open Latarjet procedure, the overall complication rate was 6.1%, with a 1.9% occurrence of graft-related complications, 1.1% hardware, 1.1% wound, 0.9% nerve, and 1.2% other complications. Following the arthroscopic Latarjet procedure, the overall complication rate was 6.8%, with a 3.2% occurrence of graft-related complications, 1.9% hardware, 0.5% wound, 0.7% nerve, and 0.5% other complications. Complications were reported in 7 studies comparing 379 patients treated with the open Latarjet and 531 treated with the arthroscopic Latarjet, with no statistically significant difference between the two (P = .81). CONCLUSION/CONCLUSIONS:Our study established that the overall complication rate following the Latarjet procedure was 6%-7%, with the most common complication being graft-related. Furthermore, based on the current evidence, there is no significant difference in the complication rate between the open and arthroscopic Latarjet procedures.

Purpose/UNASSIGNED:To evaluate outcomes for a combined osteoligamentous reconstruction technique for Neer Type IIB clavicle fractures. Methods/UNASSIGNED:Patients with Neer Type IIB clavicle fractures treated with combined clavicular locking plate and coracoclavicular ligament suture reconstruction were identified. Demographics, clinical outcomes, and radiographic outcomes were collected. Results/UNASSIGNED:Twenty-four patients with mean 13 months of follow-up were included. Bony union and normal radiographic coracoclavicular relationship were achieved in 23 (96%) patients. The mean UCLA Shoulder score was 33.3. Three (13%) complications occurred. Discussion/UNASSIGNED:The combined osteoligamentous reconstruction approach as described is a successful option for treating Neer Type IIB clavicle fractures.

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:Telemedicine has increasingly been considered as a viable alternative to traditional office-based health care, including postoperative follow-up visits. The purpose of the present study was to determine if patient satisfaction with overall care is equivalent for telemedicine follow-up (i.e., synchronous face-to-face video) and office-based follow-up after arthroscopic meniscectomy and repair. METHODS:Patients were prospectively enrolled from August 1, 2019, to March 1, 2020. Patients were included who were ≥18 years old, consented to isolated arthroscopic meniscal repair or meniscectomy, and were able to properly utilize telemedicine software on a computer, tablet, or smartphone with a built-in camera. Patient demographic data, including complication events and postoperative satisfaction data, were recorded and analyzed for significance. RESULTS:One hundred and fifty patients were enrolled in the study, of whom 122 (81.3%) were included in the final analysis. There were no significant differences between groups in terms of patient demographics or satisfaction scores. Patient satisfaction with overall care was equivalent based on the results of two 1-sided t-test analysis for equivalence (9.77 ± 0.60 in the office-based group versus 9.79 ± 0.53 in the telemedicine group; p < 0.001). When patients were asked to indicate their preferred follow-up type with the options listed as the type they received versus an alternative, 58 patients (84.1%) in the office-based group preferred their received type of follow-up, whereas 42 (79.2%) in the telemedicine group preferred their received follow-up (p = 0.493). There were no significant differences between groups in terms of complications (p > 0.05). CONCLUSIONS:The present study showed that patient satisfaction with overall care is equivalent between telemedicine and office-based follow-up in the immediate postoperative period following an arthroscopic meniscal surgical procedure, and should be considered a reasonable alternative to the traditional in-office modality. LEVEL OF EVIDENCE/METHODS:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.