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.

OBJECTIVE: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 cartilage restoration procedures in the knee. DESIGN/METHODS:MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA guidelines to find studies on cartilage restoration procedures in the knee, including (1) microfracture (Mfx), (2) osteochondral autograft transfer (AOT), (3) osteochondral allograft implantation (OCA), and (4) autologous chondrocyte implantation (ACI). Studies were included if they reported return-to-play data or rehabilitation protocols. RESULTS:Overall, 179 studies fit our inclusion criteria, with 48 on Mfx, 34 on AOT, 54 on OCA, and 51 on ACI. The rate of return to play was reported as high as 88.2% with AOT, and as low as 77.2% following OCA, with rates of return to play at the same/higher level as high as 79.3% with AOT, and as low as 57.3% following ACI. The average reported time of return to play was as low as 4.9 months with AOT, and as high as 11.6 months following ACI. CONCLUSIONS:The majority of patients are able to return to play following cartilage restoration procedures in the knee, regardless of surgical procedure utilized. However, while the rate of return to play at the same level was similar to the overall rate of return following AOT, there was a large number of patients unable to return to the same level following Mfx, OCA, and ACI. Additionally, there is wide variety in the rehabilitation protocols, and scant literature on return-to-play protocols.

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: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.

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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Objectives: There has been continued controversy regarding whether or not headgear use in women's lacrosse will increase or decrease the rate of head injuries. In 2017, the Public Schools Athletic of New York City became the first high school organization in the country to mandate ASTM standard F3137 headgear for all women's lacrosse players. The purpose of this study is to investigate the effect of mandated headgear use on the rate of head and face injuries in high school women's lacrosse.
Method(s): This was a prospective cohort study. The study group included eight varsity and junior varsity women's lacrosse teams, as well as their game opponents, who were mandated to wear F3137 headgear for all practice and game events over the course of the 2017 and 2018 seasons. Certified athletic trainers assessed and documented all injuries that occurred as a result of participation on the lacrosse teams and athlete exposures were estimated based on the number of team practice and game events. Injury rates were compared with those from the High School RIO (Reporting Information Online) injury data reports from the 2009 to 2016 seasons.
Result(s): Over the study period, 17 total injuries were reported during 22,397 exposures for an injury rate of 0.76 injuries per 1,000 athlete-exposures. Two head/face injuries, both of which were classified as concussions, were reported during the study for a head/face injury rate and concussion rate of 0.09 per 1,000 athlete-exposures. The headgear cohort demonstrated significant decreases in rates of in-game head/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 non-head/face injury (RR 0.239, 95% CI [0.049, 0.703]) when compared to the control cohort.
Conclusion(s): Mandated use of F3137 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

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

OBJECTIVE. The purpose of this article is to describe Stener-like lesions of the superficial medial collateral ligament (sMCL) of the knee, which, to our knowledge, have not yet been reported in the radiologic literature. This lesion, defined as a distal tear with interposition of osseous or soft-tissue structures between the ligament and its tibial attachment, often requires surgical intervention. MATERIALS AND METHODS. Knee MRI examinations of grade 3 sMCL tears were identified via a search of department imaging and orthopedic case files of medial collateral ligament (MCL) tears for the period of January 2010-April 2017 using the keywords "complete MCL tear" or "near complete MCL tear." Two musculoskeletal radiologists reviewed the MRI examinations. The location of the sMCL tear, presence of a Stener-like lesion, associated ligamentous injuries, and surgical findings were recorded. RESULTS. Review of 65 knee MRI examinations identified 20 cases of distal tibial grade 3 sMCL tear. Of the distal tears, 12 (60%) were Stener-like lesions and six (30%) were borderline lesions. Of these 18 cases, 14 (78%) were associated with multiligament knee injury and nine (50%) underwent MCL repair or reconstruction. Ten of the 12 (83%) Stener-like lesions were displaced superficial to the pes anserinus and two (17%) were entrapped, one in a reverse Segond fracture and one in the femorotibial compartment. CONCLUSION. Stener-like lesions represent a high percentage of tibia-sided sMCL avulsions, are found most often with pes anserinus interposition, and are frequently associated with multiligamentous injury, suggesting high-energy trauma. MRI diagnosis is important because interposition preventing anatomic healing and potential secondary valgus instability often prompt surgical intervention.

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.

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.