Faculty Bibliography

BACKGROUND:Despite advances in technology, graft rupture rates reported in the literature following anterior cruciate ligament (ACL) surgery range from 1.8% to 18%. Recent anatomical studies have identified a lateral structure, the anterolateral ligament (ALL), as a potential source of residual pivoting following ACL reconstruction. The purpose of this report is to review the history surrounding the ALL and recent anatomic studies, identify its biomechanical and clinical implications, and develop a practical approach to utilizing it during ACL reconstruction. METHODS:An extensive review of the historical and current literature surrounding the identification of the ALL, its biomechanical function, reconstruction, and outcomes of ALL reconstruction was performed. DISCUSSION/CONCLUSIONS:After the storm of media coverage surrounding the "new ligament" known as the ALL, much attention was focused on cadaveric dissection, biomechanical analysis, and reconstruction of this structure. Several techniques have been described, and currently studies are being performed both retrospectively and prospectively to evaluate the added benefit of ALL reconstruction to the rotational stability of the knee and outcomes after ACL reconstruction. CONCLUSION/CONCLUSIONS:The ALL is a lateral-based structure that provides rotational stability to the knee in the presence of ACL deficiency. Reconstruction of this ligament may provide added benefit to stability and outcomes following ACL reconstruction in certain patient populations. Further randomized controlled trials are needed to elucidate the true benefit of ALL reconstruction and those patients who should undergo this added procedure.

Anterior instability of the glenohumeral joint is a common and functionally limiting shoulder condition, particularly in young and active patients. In this population, non-operative management has been increasingly demonstrated to be associated with recurrent instability and increased long-term morbidity. Surgical treatment options include both arthroscopic and open techniques. In appropriately indicated patients, surgical treatment of first-time anterior shoulder instability is a cost-effective and successful treatment option.

PURPOSE/OBJECTIVE:Characterize the clinical utility of diagnostic shoulder imaging modalities commonly used in the outpatient workup of shoulder pain. MATERIALS/METHODS/METHODS:Retrospective review of adults imaged for outpatient shoulder pain from 1/1/2013 to 9/1/2015. To be categorized as "useful", a study had to meet one of the following criteria: change the clinical diagnosis or treatment plan, provide a final diagnosis, or guide definitive treatment. A utility score was assigned to each study based on the number of utility criteria met (range 0-4). A score of 1 was considered low utility; a score of greater than or equal to 2 was considered high utility. Statistical analysis included binary logistic regression and generalized estimating equations. RESULTS:210 subjects (65% male); mean age 47 (range 18-84), underwent 302 imaging studies (159 X-ray, 137 MRI, 2 CT, 4 ultrasound) during the study period. 92.1% of all studies met minimum criteria for utility (score >1). Most commonly, diagnostic studies obtained during the outpatient workup of shoulder pain were found to guide definitive treatment (70.5%) or provide a final diagnosis (53%). Most X-rays were categorized as no or low utility (85.5%). 97.8% of the MRI studies were categorized as useful with most being high utility (73%). Overall, MRI was the most useful modality in all clinical scenarios (P = 0.002) and more likely to be high utility (P < 0.001) compared to X-rays. None of the investigated patient or injury characteristics were significant predictors of useful imaging. CONCLUSION/CONCLUSIONS:Our study suggests that both radiographs and MRI are useful in the evaluation of adult unilateral shoulder pain in the outpatient setting. MRI appears to be the most useful imaging modality in terms of helping guide diagnosis and treatment selection. This serves as a potential first step towards the development of evidence based imaging algorithms that can be used and tested in future studies.

Introduction: Posttraumatic arthritis (PTA) is a common sequela of proximal humerus fractures that is commonly managed with anatomic or reverse total shoulder arthroplasty (TSA). TSA for PTA is more challenging than that performed for primary osteoarthritis and frequently leads to worse patient outcomes. CPT uniformly classifies all cases of primary TSA, irrespective of procedural complexity and resource utilization. This study analyzes intraoperative differences and 30-day outcomes for anatomic and reverse TSA performed in the posttraumatic shoulder.
Method(s): Patients undergoing TSA from 2008 to 2015 were selected from the National Surgical Quality Improvement Program database and stratified according to concurrent procedures and administrative codes indicating posttraumatic diagnoses. Perioperative parameters and 30-day complications were recorded; multivariate analyses were performed to determine whether PTA was a risk factor for poor outcomes.
Result(s): A total of 8508 primary and 243 posttraumatic TSAs were identified. Posttraumatic TSA patients were slightly younger (P =.003), more likely to be female (P <.001), smokers (P =.029), and diabetic (P =.003). Diagnosis of PTA was an independent risk factor for prolonged operative times >=160 minutes (>=1 standard deviation above the mean, P =.003; odds ratio [OR]: 1.718; 95% confidence interval [CI]: 1.204-2.449) and increased bleeding requiring transfusion (P <.001; OR: 2.719; 95% CI: 1.607-4.600). Although posttraumatic TSA had a tendency for longer hospital admissions, 30-day readmissions were not significantly different between cohorts.
Conclusion(s): Compared with primary osteoarthritis, a preoperative diagnosis of PTA is an independent risk factor for prolonged operative times and postoperative transfusion in anatomic or reverse TSA patients; such patients may be less than optimal candidates for same-day discharges or outpatient shoulder arthroplasty.
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OBJECTIVE:The purpose of this study is to familiarize the radiologist with knee arthroscopy, including the setup, equipment, and standard procedure used. This is followed by a discussion of the strengths and weaknesses of knee MRI and arthroscopy and presentation of images showing normal knee anatomy and pathologic findings. CONCLUSION/CONCLUSIONS:By having an understanding of basic arthroscopic principles as well as the strengths and limitations of MRI and arthroscopy in the diagnosis of knee abnormalities, radiologists will improve image interpretation and add value to interactions with the consulting orthopedic surgeon.

Background/UNASSIGNED:Patellar tendon tears impart potentially debilitating sequelae among professional basketball athletes. Hypothesis/UNASSIGNED:Professional basketball athletes with patellar tendon tears have decreased return-to-play performance in seasons after injury compared with preinjury statistics. Study Design/UNASSIGNED:Case series; Level of evidence, 4. Methods/UNASSIGNED:Patellar tendon tears among National Basketball Association (NBA) athletes from the 1999-2000 to 2014-2015 seasons were identified. Player performance statistics for players who underwent operative patellar tendon repair were compared from 1 season before injury to 1 season after injury and 2 seasons before injury to 2 seasons after injury using the primary outcome of player efficiency rating (PER). Secondary performance outcomes were also analyzed. Results/UNASSIGNED:= .045) decreased in comparisons of 2 seasons before and after injury. Conclusion/UNASSIGNED:Patellar tendon tears were not associated with diminished efficiency-adjusted performance, as measured by PER, games played, minutes per game played, points per 36 minutes, and rebounds per 36 minutes. However, decreases in total minutes played were observed following patellar tendon tear. Orthopaedic surgeons may be better prepared to counsel basketball athlete patients with patellar tendon tear given these findings.

PURPOSE: The purpose of the current study was to evaluate the short-term results of meniscal root repair surgery, assessing clinical and radiographic outcomes, utilizing MRI to assess root healing and extent of post-operative extrusion. METHODS: This was a single-center, retrospective study evaluating patients who had undergone a medial meniscus posterior root repair using a transtibial pullout technique with two locking cinch sutures. Demographic data were collected from patient charts. Clinical outcomes were assessed with pre- and post-operative IKDC and Lysholm scores. Pre-op scores were taken at the patients' initial clinical visit, mean 1.55 months prior to surgery (+/- 1.8 months, min 0.3, max 7.3). Radiographic outcomes were assessed with MRI evaluation of root healing, meniscal extrusion, and cartilage degeneration using ICRS criteria. Tunnel placement was evaluated and compared to the anatomic footprint. RESULTS: Eighteen patients (47.2 years +/- 11.9) were evaluated at mean follow-up of 24.9 months (+/- 7.2, min 18.4, max 35.6). The IKDC score significantly increased from 45.9 (+/- 12.6) pre-operatively to 76.8 (+/- 14.7) post-operatively (p < 0.001). Lysholm scores also increased from 50.9 (+/- 7.11) to 87.1 (+/- 9.8) (p < 0.001). Mean tunnel placement was 5.3 mm (+/- 3.5, range 0-11.8) away from the anatomic footprint. Mean extrusion increased from 4.74 mm (+/- 1.7) pre-operatively to 5.98 (+/- 2.8) post-operatively (p < 0.02). No patients with > 3 mm of extrusion on pre-operative MRI had < 3 mm of extrusion on post-operative MRI. Both medial femoral condyle and medial tibial plateau ICRS grades worsened significantly (p < 0.02 and p < 0.01, respectively). On MRI, one root appeared completely healed, 16 partially healed, and one not healed. CONCLUSION: Patients treated with the transtibial suture pull-out technique with two locking cinch sutures had improved clinical outcomes, but only partial healing in the majority of cases, increased extrusion, and progression of medial compartment cartilage defect grade on follow-up MRI. Patients should be counseled that although clinical outcomes in the short term may be optimistic, long-term outcomes regarding progression to degenerative arthritis may not be as predictable. CLINICAL LEVEL OF EVIDENCE: III.

PURPOSE OF REVIEW/OBJECTIVE:The purposes of this review are to (1) discuss the epidemiology and workup of the rare posterior cruciate ligament (PCL) avulsion fracture, (2) review the indications for nonoperative and operative management of patients with PCL avulsion fractures, (3) examine surgical outcomes in this patient population, and (4) discuss the authors' preferred management algorithm and surgical approach. RECENT FINDINGS/RESULTS:In accordance with the rarity of these injuries, the literature is sparse regarding surgical outcomes. Many of these injuries are in the setting of a multi-ligamentous injury. Most authors suggest that displaced PCL avulsion fractures should undergo operative fixation and current data suggests excellent outcomes when treating these patients with either open or arthroscopic fixation, with a low complication rate. PCL avulsion fractures, although rare, should undergo fixation when displacement is present. Current studies report successful outcomes and a low complication rate.

Objectives: The purpose of this study was to determine if patellar tendon (PT) thickness measured on pre-operative magnetic resonance imaging (MRI) is a risk factor for failure after anterior cruciate ligament reconstruction (ACLR) using bone-patella tendon-bone (BTB) autograft.
Method(s): 18 patients [age (mean 96 Normal 0 false false false EN-US X-NONE X-NONE /*Style Definitions*/ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent: mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; mso-bidi-font-size:12.0pt; font-family:Helvetica;} +/- standard deviation) 21.5 +/- 4.99years] that underwent an ACLR with BTB autograft and returned for revision ACLR between July 2005-January 2017 at our institution were included in the study. Failures were age-, sex-, height-, and weight-matched to 36 control (age 21.5 +/- 4.99years) BTB-ACLR patients that have not required revision at a minimum of 2-years follow-up. Demographic data and mechanism of injury were recorded from patients' medical records. PT thickness was measured at 3 points (5mm lateral to the center, center, and 5mm medial to the center) each at the level of the inferior pole of the patella (IPP), midpoint (MP), and insertion to tibial tubercle (ITT) on pre-operative axial-cut MRI.
Result(s): All ACLR failures occurred after a non-contact pivot-shift type injury. Mean time between primary ACLR and revision was 2.4 +/- 2.4 years and mean follow-up time was 3.1 +/- 0.9 years in the control group. Patients with a failed ACLR had significantly thicker PTs at the IPP (lateral: 4.66 +/- 1.47 vs 3.96 +/- 0.66mm; central: 5.39 +/- 1.49 vs 4.51 +/- 1.04mm; medial: 5.51 +/- 1.52 vs 4.59 +/- 1.05mm) and MP (lateral: 4.50 +/- 0.83 vs 4.12 +/- 0.54mm; central: 4.83 +/- 0.80 vs 4.43 +/- 0.59mm; medial: 4.57 +/- 0.88 vs 4.13 +/- 0.59mm). There were no significant differences in PT thickness at the ITT. PT width tended to be larger in the failure cohort but this was not statistically significant (IPP: 32.2 +/- 4.6 vs 29.8 +/- 4.3mm; MP: 31.3 +/- 4.9 vs 29.5 +/- 3.8mm; ITT: 27.7 +/- 3.7 vs 26.2 +/- 2.9mm).
Conclusion(s): Contrary to conventional wisdom, we found that BTB autograft ACLR failures had significantly thicker patellar tendons at the inferior pole of the patella and midpoint. Further studies are need to investigate possible causes for this inverse correlation, such as poor histological tendon quality or mechanical impingement due to increased tendon size

Little research has been conducted evaluating surgical trends during the past 10 years and subsequent procedure risk factors for patients undergoing bone-blocking procedures for the treatment of anterior shoulder instability. The Statewide Planning and Research Cooperative System database was queried between 2003 and 2014 to identify patients undergoing soft tissue or bone-blocking procedures for anterior shoulder instability in New York. Patient demographics and 1-year subsequent procedures were analyzed. Multivariate logistic regression analyses were conducted to identify 1-year subsequent procedure risk factors. From 2003 through 2014, a total of 540 patients had Latarjet procedures performed. During this period, the volume of Latarjet procedures increased by 950%, from 12 procedures in 2003 to 126 procedures in 2014. The volume of open Bankart repairs declined by 77%; arthroscopic Bankart repairs fluctuated, being up (328%) between 2003 and 2012 and then down (6%) between 2012 and 2014. Of the 540 patients, 2.4% (13 of 540) required intervention for recurrent shoulder instability events. Age older than 20 years and workers' compensation were identified as independent risk factors for reoperation. The number of bone-blocking procedures, such as the Latarjet, has increased by nearly 1000% during the past decade in New York. Only 2.4% (13 of 540) of the patients had subsequent shoulder instability interventions. [Orthopedics. 201x; xx(x):xx-xx.].