Faculty Bibliography

BACKGROUND:Open subpectoral biceps tenodesis (OSBT) with cortical button fixation can deliver acceptable results for long head of the biceps (LHB) pathology with the benefit of smaller bone tunnel diameter and a potential reduced risk of postoperative humeral shaft fracture. However, functional outcomes and complications of a button-only technique with a small diameter tunnel in the subpectoral region have not been studied sufficiently. PURPOSE/OBJECTIVE:We sought to determine whether OSBT with cortical button fixation results in significant functional improvements from preoperative to final follow-up. The secondary purpose was to determine whether there is a lower risk of major postoperative complications. METHODS:A retrospective review of patients who underwent OSBT with cortical button fixation at one institution was conducted with objective measurements and clinical outcomes collected with a minimum of 2 years of follow-up. Surgical data was collected for analysis. Objective measures obtained at follow-up included physical exam, strength testing using a handheld dynamometer, and Long-Head of the Biceps score. Clinical outcomes were measured using the following validated questionnaires preoperatively and postoperatively: American Shoulder and Elbow Surgeons score (ASES), Disabilities of the Arm, Shoulder and Hand score (DASH), and Oxford Shoulder Score (OSS). RESULTS:Sixty-one patients with mean age of 53.1 ± 10.1 years at the time of surgery were enrolled in the study. Mean follow-up time was 42.4 ± 16.9 months (range: 24 to 64 months). The postoperative LHB score was 95.5 ± 6.1 (range: 77 to 100). All functional outcome measures (ASES, DASH, and OSS) demonstrated statistically significant improvements at final follow-up (p < 0.05 for each). At total of 92.5% of patients stated they would have the procedure again if necessary. Mean elbow flexion strength on the operative side measured 98.7% ± 15.9% (range: 74.1% to 142.3%) of the contralateral arm. The mean LHB tendon diameter was 5.7 ± 0.8 mm and mean tunnel diameter was 5.9 ± 0.7 mm. There were no cases of intraoperative or postoperative fracture, infection, or Popeye deformity noted during the follow-up period. CONCLUSION/CONCLUSIONS:Subpectoral biceps tenodesis with cortical button fixation is a safe and effective surgical treatment option to relieve pain and restore function.

PURPOSE/OBJECTIVE:The purpose of this study is to present one institution's experience managing chronic exertional compartment syndrome (CECS) and to identify patient and surgical characteristics associated with better outcomes following open surgical management of CECS with specific emphasis on return to sports. METHODS:Fifteen patients (10 male, 5 female) who underwent open fasciotomy for CECS with a minimum of 1-year follow-up were included. Chart review was performed to obtain patient demographics, medical and surgical history, presenting symptomatology, and surgical details of fasciotomy. Outcomes were assessed using follow-up questionnaires that consisted of Tegner Activity Scale, EuroQol-5D (EQ5D) index score, EQ-5D rating scale, symptom resolution, patient satisfaction, and return to sports. RESULTS:The mean patient age at the time of surgery was 28.1 years (range: 17 to 49 years). At mean follow-up of 2.7 years (range: 1.0 to 5.1 years), five patients reported complete resolution of symptoms, eight reported improvement (but not resolution) of symptoms, one reported no change in symptoms, and one reported worsening of symptoms. The mean Tegner Activity Score was 6.7 (range: 1 to 9) prior to injury and 4.7 (range: 1 to 9) postoperatively. Patients with any preoperative symptoms at rest had significantly lower Tegner before score (4.0 vs. 7.1, p = 0.036) and EQ5D rating (50.0 vs. 83.5, p = 0.04) compared to those that only experienced symptoms with activity. Patients that had prior surgery, including fasciotomy, had significantly lower EQ-5D rating than patients with no history of prior lower extremity surgery (56.7 vs. 84.6, p = 0.045). Although 10 (66%) patients were able to return to sports, only four (27%) of them were able to return to their prior level of sport. The overall satisfaction rate was 87%. CONCLUSION/CONCLUSIONS:Although open surgical fasciotomy for treatment of chronic exertional compartment syndrome leads to high rates of symptom improvement or resolution, fewer patients are able to return to their prior level of sports. Presence of symptoms at rest, presence of bilateral symptoms, and history of prior lower extremity surgery all portend worse outcomes.

PURPOSE/OBJECTIVE:High tibial osteotomy (HTO) is an invaluable tool in the treatment of a variety of conditions in active patients with varus malalignment of the knee. The polyetheretherketone (PEEK) iBalance HTO system has been designed to make the osteotomy safer, more reproducible, and avoid metal hardware related complications. The purpose of this study was to evaluate short-term outcomes in patients who underwent an open wedge high tibial osteotomy with the iBalance HTO system. METHODS:We identified patientswho underwent HTO using iBalance with a minimum of 2-year follow-up. Medical records were reviewed for demographics, Workers Compensation and no-fault insurance claims, history of smoking, concomitant procedures, degree of correction, and complications. Patient outcomes using Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS) were recorded before undergoing HTO and compared with those recorded after a 2-year follow-up. Statistical analysis was performed using paired sample t-tests with p < 0.05 considered significant. RESULTS:Twenty-three patients with mean age of 44.9 (± 8.48) were identified. The mean correction angle was 9.9° (range: 5° to 15°). Sixteen patients underwent a concomitant procedure. The average follow-up was 2 years (range: 2 to 3.5 years). Six patients reported a positive history of smoking. The mean preoperative KOOS scores of symptoms, pain, activities of daily living (ADL), sport, and quality of life were 14 (± 18.5), 53.1 (± 14.8), 69.1 (± 21.7), 29.2 (± 22.0), and 30.0 (± 20.0), respectively. The mean preoperative VAS score was 5.5 (± 2.5). At follow-up, the mean scores of symptoms, pain, ADL, sport, and quality of life all improved to 67.53 (± 24.9), 68.06 (± 23.4), 75.74 (± 25.3), 45.91 (± 36.1), and 43.47 (± 33.4), respectively. The mean VAS at follow-up was 1.9 (± 2.1). There was a significant increase (p < 0.05) in all KOOS categories, except ADL. Additionally, there was a statistical difference between smoking and change in ADL score. Former smokers demonstrated an average decrease of 10.3 points, increasing their disability, and nonsmokers increased 15.3 points on the KOOS ADL scale, decreasing their disability. There were three complications (DVT, cellulitis, and serosanguinous drainage) within a month after the procedure. There were three complications, including a revision HTO, pes anserine bursitis, and lateral hamstring tendinitis, within the 2-year follow up including one revision after 1 year. Five patients went on to total knee arthroplasty at an average of 3 years (range: 1 to 5 years). CONCLUSION/CONCLUSIONS:This study suggests that the iBalance medial opening wedge HTO system implant can be used with comparable outcomes to traditional methods, however the conversion rate to total knee arthroplasty may be higher than previously reported. This appears to be unrelated to implant choice and likely related to extended indications for the procedure in younger patients refusing knee arthroplasty. The iBalance medial opening wedge HTO system has shown to be safe, removing many of the complications existing with other osteotomy implant options. Our findings highlight the importance of additional studies in order to investigate the risk factors causing progression from HTO to TKA.

PURPOSE/OBJECTIVE:The purpose of the study was to investigate clinical outcomes following a mini-open posterior technique. METHODS:Patients who received mini-open popliteal cyst excisions between April 1999 and April 2010 were identified. Charts were retrospectively reviewed for postoperative complications, cyst recurrence, previous aspiration, re-operation, intraoperative findings, cyst size, comorbidities, and co-surgeries. Visual Analogue Pain Scale and Rauschning's symptomatic knee criteria were collected prospectively to assess functional outcomes. RESULTS:Twenty-two legs in 21 patients were included in the study [males: 12 (57%); females: 9 (43%); age: 48.23 ± 11.74 years; BMI: 26.7 ± 4.54 kg/m2; follow-up: 4.55 ± 3.01 years]. Average cyst size was 4.16 ± 1.64 cm and were all located in the posteromedial aspect of the leg. All 22 cases had associated intra-articular pathology based on MRI, physical examination, and arthroscopy. Complications after cyst excision included: paresthesia in the distribution of the saphenous nerve (3/22, 14%), keloid formation (1/22, 4%), joint effusion requiring aspiration (1/22, 4%), and one recurrence requiring cystectomy 10 years later (4%). All incidences of paresthesia resolved. Mean visual analog pain score decreased by 6 points (p < 0.001) and Rauschning and Lindgren score decreased by two categories, from a 2.6 (category 2-3) preoperatively to 0.6 (category 0-1) postoperatively (p < 0.001). CONCLUSION/CONCLUSIONS:Mini-open popliteal cyst excision is a safe and effective technique for refractory popliteal cysts in patients who desire a decrease in pain, an increase range of motion, and improved function in knee flexion and extension. Further studies are needed to evaluate the clinical outcomes of patients over a longer duration as our one patient with a 10-year follow-up required a repeat procedure.

Background: Pectoralis major ruptures are increasing in incidence primarily due to an increase in awareness, activity level among young males between 20 - 40 years of age, and use of anabolic steroids. Although the majority of pectoralis major ruptures are acute injuries, many chronic ruptures are unrecognized and it is imperative to understand proper evaluation of these injuries, as well as the appropriate treatment for acute and chronic ruptures. Purpose: Pectoralis major ruptures can lead to deformity and physical disability if left untreated. This review paper discusses the both acute and chronic ruptures as well as indications for nonoperative treatment and operative treatment to give the reader the best understanding of this diagnosis and proper management. Methods: A systematic review of the literature was performed using a search of electronic databases. Search terms such as pectoralis major rupture, pectoralis major repair, pectoralis major tendon transfer and pectoralis major nonoperative treatment were used. Case reports, systematic reviews, prospective and retrospective studies were included to provide a comprehensive review. The only exclusion criteria consisted of studies not published in English. This review article includes the anatomy and biomechanics of the pectoralis major muscle, proper evaluation of the patient, operative and nonoperative treatment of acute and chronic pectoralis major ruptures, and outcomes of the recommended treatment. Conclusion: Nonoperative treatment is indicated for patients with medical comorbidities, older age, incomplete tears, or irreparable damage. Patients treated non-operatively have been shown to lose strength, but regain full range of motion. Patients with surgery before 6 weeks reported better outcomes than patients with surgery between 6-8 weeks. The chronicity of the rupture (>8 weeks) increases likelihood of reconstruction, involving the use of autografts or allografts. Patients treated with delayed repair had significantly better strength, satisfaction and outcomes than patients with nonoperative treatment. The pectoralis tendon can also be transferred in patients with rotators cuff tears, atrophy, or significant functional limitation. Tendon transfers have been shown to have unpredictable outcomes, but overall satisfactory results.

Objectives: Bone Marrow Lesions (BML) are a common finding on knee MRI. In the knee, BML have a strong correlation to patient-reported pain, function, joint deterioration and rapid progression to TKR. Histologic analyses of BML have demonstrated findings consistent with fracture and bony remodeling of the trabeculae. The Subchondroplasty (SCP) Procedure aims to treat the bone defects present in the BML by percutaneously filling them with a bone substitute material, designed to flow through intact bone, harden at body temperature and then heal through natural bone turnover. Previous retrospective, single-center case series have demonstrated improvements in patient-reported outcomes. The purpose of this prospective, multi-center study is to evaluate the 2- year clinical and radiographic outcomes of patients with BML of the knee treated with the Subchondroplasty Procedure.
Method(s): Seventy patients were treated between 2012 and 2017 for BML of the tibial plateau and/or femoral condyle. Self-drilling cannulas were inserted into the BML using arthroscopic and fluoroscopic guidance, then injected with AccuFill Bone Substitute Material. All patients also underwent arthroscopy to aid in targeting the underlying bony lesion and address intra-articular pathology. MRIs and radiographs were obtained pre-operatively, at 6, 12 and 24 months, with additional radiographs collected at 6 weeks and 3 months. Patient-reported outcomes, including VAS pain, IKDC and KOOS were collected pre-operatively, 2 and 6 weeks, and 3, 6, 12 and 24 months post-operatively.
Result(s): Seventy patients (36 males and 34 females), average age 57 were consented and enrolled in the study. Preoperative K-L grade included 1.4% Grade 0, 2.9% Grade 1, 27.1% Grade 2, 55.7% Grade 3 and 7.1% Grade 4. Fifty eight tibial plateaus and 41 femoral condyles were treated (29 bipolar lesions treated). VAS Pain scores improved from a mean of 6.2/10 pre-op to 2.9/10 at 1 year. IKDC scores improved from mean 33.9 pre-op to 61.3 at 1 year. KOOS scores improved from baseline to 1 year (Fig. 1) with mean KOOS Pain from 45.8 to 73.9, ADL 52.9 to 79.2, Symptoms 49.7 to 71.9, Sports 21.2 to 49.9 and Quality of Life 18.1 to 52.3. All patient-reported outcomes showed statistically significant improvement at one year. Two year outcomes collected to date appear to follow the same trend. The last study subject is due to return in January 2019 at which point the final 2 year analysis will be completed. Six patients (8.6%) converted to arthroplasty (1 UKA and 5 TKA) at one year. To date, the 24 month conversion rate is 16.1% out of 62 subjects. The final conversion rate for 24 months will be calculated after the final subject returns. Radiographs and MRIs demonstrated good incorporation of the AccuFill material through 12 months with evidence of early remodeling and a lack of OA progression in the majority of subjects. Twenty-four month MRIs demonstrate continued remodeling of the AccuFill material.
Conclusion(s): This study presents statistically and clinically-meaningful evidence of improvements in clinical outcomes following Subchondroplasty procedure for BML of the knee. The low conversion rate suggests this lessinvasive procedure may delay the need for knee arthroplasty. MR imaging demonstrates good incorporation of the BSM and evidence of remodeling and reduction in material volume over time

Objectives: The current opioid epidemic necessitates physicians to seek ways to decrease patients' requirements of narcotic medications without sacrificing their postoperative comfort level. This study evaluated patients' pain following arthroscopic shoulder instability repair and compared the use of narcotic medications between patients prescribed NSAIDs with rescue opioid prescription to those prescribed opioids alone. We hypothesized there would not be a significant difference in postoperative pain and addition of NSAIDs would result in decreased opioid use.
Method(s): Forty patients scheduled to undergo an arthroscopic shoulder instability repair were randomized to receive Ibuprofen 600mg and a 10-pill rescue prescription of Percocet 5/325mg (n=20) or Percocet 5/325mg (n=20). Primary outcomes were the amount of Percocet tablets used in the first week and VAS on postoperative day (POD) 1, 4, and 7. Statistical analysis was done using independent t-tests and bivariate analysis for correlation. Findings were considered significant at p<0.05.
Result(s): Forty patients with a mean age of 35.08 (+/- 8.48)were enrolled between December 2017 and May 2018. The total amount of opioid consumption was statistically significantly lower in the multimodal group compared to the opioid group (p <0.04) as well as Percocet consumption between POD 0-4 (p <0.04). There were no significant differences in VAS at any point between the two groups. One patient in the Ibuprofen cohort experienced dizziness on POD 1. Two patients in the Percocet cohort experienced nausea and vomiting on POD 1 and POD 4.
Conclusion(s): Multimodal analgesia using NSAIDs with an opioid rescue prescription has resulted in significant reduction in postoperative narcotic consumption. As both cohorts showed similar pain levels, it is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed. The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution

Platelet-rich plasma is used for the treatment of musculoskeletal ailments including rotator cuff pathology with mixed outcomes. Varied cytology and leukocyte counts within platelet-rich plasma may influence the results. The impact of this biological therapy on rotator cuff disease management is poorly understood.

Purpose: To evaluate the prevalence and association of anterolateral ligament (ALL) rupture with other meniscal and ligamentous injuries of the knee in patients with complete acute traumatic anterior cruciate ligament (ACL) tear.
Material(s) and Method(s): Based on retrospective review of our orthopedic surgery database, 57 patients M45:F12, mean age 21 (range:13-34) with acute post traumatic ACL rupture who underwent ACLR seen between 2011 and 2015 were enrolled in this cohort. Preoperative MR examinations was performed by an experienced (20 years) MSK radiologist assessing these variables: anterolateral ligament (ALL) rupture, MM tear, LM tear tear, posteromedial corner injury (PMC), posterolateral corner injury (PLC) injury, MCL tear, and lateral collateral ligament tear (LCL). Odds ratios and their 95% confidence interval were used to assess the associations of ALL with other injuries in the knee. To rule out confounding factors we used the Cochran Mantel Haenszel method in an analysis stratified by gender and BMI (normal, overweight).
Result(s): Most commonly reported lesions were of the MM 63%, and PLC 64%. ALL partial or complete tears and Segond avulsion fracture were reported in 28 patients (49%). Anterolateral lesions were associated with a 10 fold decreased risk of MM tear (odds ratio [OR] = 0.10, 95% [CI]=[0.028, 0.38]) and a 4.6 fold increased risk of LCL tear (OR=4.68, 95% CI=[1.28 17.1]). Neither gender nor BMI were confounding for the associations of ALL with MM and LCL tears. No other statistically significant associations betweenALL rupture and LM, PMC, PLC and MCL injury were found.
Conclusion(s): Failure of the ALL during acute traumatic ACL rupture is often associated with tear of the LCL. This may have a protective effect over theMMdue to potential 'capsular release' ewith increased mobility of the MM and decreased risk of clipping/tearing between the approximating medial compartment surfaces during pivot shift trauma