Faculty Bibliography

CASE:A 71-year-old man presented with extreme anterior knee pain. His history, physical examination, and imaging were consistent with prepatellar bursitis, but his pain seemed out of proportion for these findings. The patient eventually underwent marginal excision of the inflamed prepatellar bursa which histopathology identified as a glomangioma. Postoperatively, he has complete resolution of his pain and has returned to his daily activities. CONCLUSION:Glomus tumors are a rare cause of severe knee pain that completely resolves after excision. In the patient with extreme, localized knee sensitivity, it is important to consider this pathology even if no mass is identified on imaging.

PURPOSE:To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes. METHODS:A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable. RESULTS:Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. CONCLUSIONS:Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use. LEVEL OF EVIDENCE:Level II, systematic review and meta-analysis of RCTs.

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.

INTRODUCTION/BACKGROUND:It is important to understand the current characteristics of orthopaedic surgery program leadership, especially in the current climate of modern medicine. The purpose of this report was to describe the demographic, academic, and geographic characteristics of current orthopaedic chairs and program directors (PDs). METHODS:Orthopaedic surgery residency programs were obtained from the Accreditation Council for Graduate Medical Education website and cross-referenced with the Electronic Residency Application Service, identifying 161 residency programs for the 2018 to 2019 cycle. All data were collected in January 2020 to best control for changes in leadership. Demographic and academic information were collected from public websites. For geographic analysis, the United States was divided into five regions, and training locations were categorized as appropriate. RESULTS:A total of 153 chairs and 161 PDs were identified. 98.0% of chairs were men versus 88.8% of PDs (P = 0.001). Chairs had been in practice and in their current position for longer than PDs (26.4 vs 16.8 years [P < 0.005] and 9.1 vs 7.1 years [P = 0.014], respectively). Chairs had more publications and were more likely to be professors than PDs. PDs were more likely to remain at both the same region and institution that they trained in residency. The most common subspecialty was sports among chairs and trauma among PDs, although when compared with national averages orthopaedic trauma and orthopaedic oncology were the most overrepresented subspecialties. CONCLUSION/CONCLUSIONS:Orthopaedic chairs are more likely to be men, have had longer careers, and have more academic accomplishments than their PD counterparts. Geography appears to have an association with where our leaders end up, especially for PDs. Subspecialization does not notably influence leadership positions, although orthopaedic trauma and orthopaedic oncology surgeons are more commonly represented than expected. This report serves to identify the current state of orthopaedic leadership and may provide guidance for those who seek these leadership positions.

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.

PURPOSE/OBJECTIVE:The purpose of this study is to survey the members of North American and European shoulder surgery & sports medicine societies to evaluate their criteria for deciding when an athlete can safely return to play (RTP) following shoulder stabilization surgery. METHODS:A survey was sent to the members of the American Shoulder and Elbow Surgeons (ASES), American Orthopaedic Society for Sports Medicine (AOSSM), European Society for Sports & Knee Arthroscopy (ESSKA), and European Society for Surgery of the Shoulder and the Elbow (SECEC). Surgeons were asked which criteria they used to determine when an athlete can RTP following the arthroscopic Bankart repair and Latarjet procedures, with additional questions on how time from surgery and participation in collision sports affect return. RESULTS:Overall, 317 surgeons responded to the survey. Following arthroscopic Bankart repair, the most common criteria used were time (98.7%), strength (74.8%), and range of motion (70%). The most commonly-reported time point was 4 months (43.8%), and the majority used an additional time period, most commonly 2 months (38.2%), before allowing a collision athlete to RTP (75.4%). Interestingly, the addition of a Remplissage procedure did not affect decision-making regarding RTP in most cases (92.1%). Following the Latarjet procedure, the most common criteria used were time (98.4%), strength (67.5%), and range of motion (65.9%). Less than half reported using imaging to assess for radiographic union before allowing patients to RTP (47%), and the most common modality was plain radiography (80%). The most common time point was 4 months (33.1%), and the majority reported waiting an additional period of time, most commonly by 2 months (25.9%), before allowing a collision athlete to RTP (59.6%). CONCLUSION/CONCLUSIONS:Despite the absence of evidence-based guidelines on when athletes can safely return to play following shoulder stabilization surgery, there exists minimal variability in recommendations between North American and European shoulder surgeons. Further research is required to better define criteria for return to play after the arthroscopic Bankart repair and Latarjet procedures.

Purpose/UNASSIGNED:To systematically review the literature and assess the reported rehabilitation protocols, return-to-play guidelines, and reported rates of return-to-play after meniscal repair. Methods/UNASSIGNED:MEDLINE, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on meniscal repair. Studies were included if return-to-play data and/or rehabilitation protocols were reported. The rate and timing of return-to-play was assessed. The rehabilitation protocols were documented, in addition to when to start range of motion (ROM), full ROM, partial weight-bearing (WB), and full WB. Results/UNASSIGNED:Overall, 88 studies met our inclusion criteria. Thirteen studies, including 507 patients, cited a range of 71.2% to 100% of return-to-play, with 53.9% to 92.6% returning to the same/greater level, ranging between 3.3 and 10 months. There was considerable variability in the reported rehabilitation protocols, but the most frequently reported time to begin ROM exercises was within the first week (78.9%) and full ROM at 6 weeks (33.3%). Partial WB was typically begun during the first week (61.0%), and full WB between the fourth and sixth week (65.6%) postoperatively. Following surgery, time elapsed was the most commonly cited criteria for return-to-play (97.0%), with 6 months being the most common time point applied (46.9%). No study advised against returning to competitive or contact sports after meniscal repair. Conclusions/UNASSIGNED:In conclusion, there was a high rate of return-to-play following meniscal repair, with 60% of patients returning to the same level of play. However, there was considerable diversity in the reported rehabilitation protocols and insufficient reporting on return-to-play criteria in the literature. This demonstrates the need for further research and formulation of an evidence-based consensus statement for this patient population. Level of Evidence/UNASSIGNED:Level IV, systematic review of Level I to IV studies.

Purpose/UNASSIGNED:To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids after arthroscopic shoulder capsulolabral (Bankart) repair for recurrent anterior shoulder instability. Methods/UNASSIGNED:This was a single-center, prospective, randomized controlled study. Patients aged 18 to 65 years indicated for arthroscopic shoulder capsulolabral repair for recurrent anterior shoulder instability were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) 30 ibuprofen (600 mg every 6 to 8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg every 6 hours as needed for breakthrough pain) or (2) 30 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 24, 48, and 96 hours and 1 week after surgery, which included questions about analgesic medication usage, visual analog scale (VAS) pain score, incidence of adverse events, and patient satisfaction. Results/UNASSIGNED: = .05) compared with patients in the NSAID group. Of patients in the NSAID group, 17.5% experienced adverse effects, compared with 35% in the opioid-only group. Conclusions/UNASSIGNED:Use of oral NSAIDs with limited breakthrough opioids results in significantly less opioid use after arthroscopic Bankart repair in the first postoperative week compared with opioids only. Both groups used limited amounts of opioids to control postoperative pain. There were no differences in pain levels at any time point postoperatively or satisfaction between patient groups. Level of Evidence/UNASSIGNED:II, nonblinded randomized control trial.

The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions. Cite this article: Bone Joint J 2021;103-B(2):207-212.

PURPOSE/OBJECTIVE:The purpose of this double-blinded randomized controlled trial was to evaluate the use of intravenous (IV) tranexamic acid (TXA) in patients undergoing primary bone-patella tendon-bone (BTB) ACLR with regard to post-operative hemarthrosis, pain, opioid consumption, quadriceps atrophy and activation. METHODS:A controlled, randomized, double-blinded trial was conducted in 110 patients who underwent ACLR with BTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-gram boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated, and the volume of blood (ml) was recorded. Additionally, perioperative blood loss (ml); Visual Analog Scale (VAS) on postoperative days (POD) 1-7 and post-operative weeks (POW) 1, 6 and 12; postoperative opioid consumption POD 1-7; range of motion (ROM) and ability to straight leg raise (SLR) at POW 1, 6, 12; and pre and postoperative thigh circumference ratio (TCR). RESULTS:There was no significant difference in perioperative blood loss between the TXA and control groups (32.5ml v. 35.6ml, p=0.47). The TXA group had 23 knees aspirated; control group had 26 knees aspirated (p=0.56). No significant difference seen in postoperative hemarthrosis volume with IV TXA compared to those without (26.7ml v. 37.3ml, p=0.12). There was no significant difference in VAS score between the two groups (p=0.15), additionally, there was no difference in postoperative opioid consumption (p=0.33). There was no significant difference in ROM or ability to SLR, or post-operative TCR (p > 0.05 for all). CONCLUSION/CONCLUSIONS:IV TXA in patients who undergo ACLR with BTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early post-operative recovery regarding ROM or quadriceps reactivation.