Faculty Bibliography

Background/UNASSIGNED:Double-row transosseous-equivalent (TOE) rotator cuff repair techniques have been widely accepted because of their superior biomechanical properties when compared with arthroscopic single-row repair. Concerns regarding repair overtensioning with medial-row knot tying have led to increased interest in knotless repair techniques; however, there is a paucity of clinical data to guide the choice of technique. Hypothesis/UNASSIGNED:Arthroscopic TOE repair techniques using knotless medial-row fixation will demonstrate lower retear rates and greater improvements in the Constant score relative to conventional knot-tying TOE techniques. Study Design/UNASSIGNED:Systematic review; Level of evidence, 4. Methods/UNASSIGNED:A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Inclusion criteria were English-language studies that examined repair integrity or Constant scores after arthroscopic rotator cuff repair with TOE techniques. Two investigators independently screened results for relevant articles. Data regarding the study design, surgical technique, retear rate, and Constant shoulder score were extracted from eligible studies. A quality assessment of all articles was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results/UNASSIGNED:The systematic review identified a total of 32 studies (level of evidence, 1-4) that met inclusion and exclusion criteria. Of the 32 studies, 5 reported on knotless TOE techniques, 25 reported on knot-tying TOE techniques, and 2 reported on both. In the knotless group, retear rates ranged from 6% to 36%, and Constant scores ranged from 38-65 (preoperative) to 73-83 (postoperative). In the knot-tying group, retear rates ranged from 0% to 48%, and Constant scores ranged from 42-64 (preoperative) to 55-96 (postoperative). Conclusion/UNASSIGNED:Despite several theoretical advantages of knotless TOE repair, both knotless and knot-tying techniques reported considerable improvement in functional outcomes after rotator cuff repair. Although tendon failure rates showed a downward trend in knotless studies, additional prospective studies are warranted to better understand the role of medial-row fixation on tendon repair integrity and postoperative clinical outcomes.

Purpose: Soft tissue reconstruction of the coracoclavicular ligament is an increasingly common treatment approach for significant acromioclavicular joint separation injury. We have anecdotally noted loss of acromioclavicular joint reduction, coracoclavicular interval widening, distal clavicular osteolysis, and widening of osseous tunnels on follow-up radiographic exams. Our purpose is to report radiographic features and complications following coracoclavicular soft tissue reconstruction.
Material(s) and Method(s): Retrospective query of our imaging database identified 55 cases of coracoclavicular ligament reconstruction. Cases with at least one month of follow-up and available operative report were reviewed with attention to : 1. alignment of the acromioclavicualar joint, 2. coracoclavicular interval widening, 3. radiographic features of distal clavicular osteolysis, and 4. widening of the reconstruction tunnel.
Result(s): 32 patients with post-operative imaging following coracoclavicular ligament reconstruction (23 male, 9 females; average age 43, age range 24-64, imaged 1 to 34 months following surgery, average 9.5 months) were included. Loss of acromioclavicular joint reduction was the most common imaging finding at follow-up (n = 25, 78%), with 88% of cases seen within 6 months of surgery. 19 (76%) patients with loss of acromioclavicular reduction progressed to coracoclavicular interval widening. Distal clavicular osteolysis was seen in 21 patients (66%), with 90% of cases seen within 6 months of surgery. Reconstruction tunnels widened on average 2 mm (range 0 - 4 mm). Revision surgery was required in 5 patients (16%), with 80% of revisions occurring more than a year following surgery.
Conclusion(s): Loss of acromioclavicular joint reduction, distal clavicular osteolysis, and tunnel widening are frequently demonstrated after coracoclavicular ligament reconstruction. Radiologists should be aware of the frequently observed imaging findings following coracoclavicular reconstruction. Attention to early loss of reduction or distal clavicular may guide treatment approach and impact patient outcomes

PURPOSE/OBJECTIVE:To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids following arthroscopic partial meniscectomy. METHODS:This was a single-center, prospective, nonrandomized, comparative observational study. Patients ages 18 to 65 years who were indicated for arthroscopic meniscectomy were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) ibuprofen (600 mg every 6-8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg as needed for breakthrough pain) or (2) 30 to 40 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 8 hours, 24 hours, 48 hours, and 1 week after surgery, which included medication usage, visual analog scale pain score, incidence of adverse events, and patient satisfaction. RESULTS:Sixty-eight patients with mean age 51.2 years (±10.4 years) were enrolled between October 2016 and February 2017. Enrollment in the opioid group continued until 30 patients were enrolled in the NSAID group, and at final analysis there were 28 patients in the NSAID group and 40 in the opioid group. There were no significant differences in sex, visual analog scale pain score, or patient satisfaction between the 2 groups at any time point. Patients in the opioid group had a significantly higher mean opioid consumption on postoperative day 1 (1.1 vs 0.5 tablets, P < .03) and postoperative days 3 to 7 (2.6 vs 0.5 tablets, P < .02) compared with NSAID group patients. There was a trend toward greater total (1 week) opioid usage (4.7 vs 2.0 tablets) in the opioid group; however, this was not statistically significant (P < .08). Fifty-three percent of opioid group patients independently chose to forego their opioid medication for an over-the-counter NSAID and/or acetaminophen instead. No patients requested a medication refill. CONCLUSIONS:We found no significant difference in pain control, satisfaction, and total 1-week opioid use between patients prescribed NSAIDs with opioids and those prescribed opioids alone. All patients used only limited amounts of opioids to control postoperative pain, suggesting we are currently overprescribing opioids after arthroscopic partial meniscectomy. LEVEL OF EVIDENCE/METHODS:Level II, prospective comparative study.

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.

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

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.

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.

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.

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.].

PURPOSE/OBJECTIVE:To compare patellar instability with magnetic resonance imaging analysis using continuous real-time radial gradient-echo (GRE) imaging in the assessment of symptomatic patients and asymptomatic subjects. METHODS:Symptomatic patients with suspected patellofemoral maltracking and asymptomatic volunteers were scanned in real time by a radial 2-dimensional GRE sequence at 3 T in axial orientation at the patella level through a range of flexion-extension. The degree of lateral maltracking, as well as the associated tibial tubercle-trochlear groove distance and trochlea depth, was measured. Patellar lateralization was categorized as normal (≤2 mm), mild (>2 to ≤5 mm), moderate (>5 to ≤10 mm), or severe (>10 mm). The patellofemoral cartilage was also assessed according to the modified Outerbridge grading system. RESULTS:The study included 20 symptomatic patients (13 women and 7 men; mean age, 36 ± 12.8 years) and 10 asymptomatic subjects (3 women and 7 men; mean age, 33.1 years). The mean time to perform the dynamic component ranged from 3 to 7 minutes. Lateralization in the symptomatic group was normal in 10 patients, mild in 1, moderate in 8, and severe in 1. There was no lateral tracking greater than 3 mm in the volunteer group. Lateral maltracking was significantly higher in symptomatic patients than in asymptomatic subjects (4.4 ± 3.7 mm vs 1.5 ± 0.71 mm, P = .007). Lateral tracking significantly correlated with tibial tubercle-trochlear groove distance (r = 0.48, P = .006). There was excellent agreement on lateral tracking between the 2 reviewers (intraclass correlation coefficient, 0.979; 95% confidence interval, 0.956-0.990). CONCLUSIONS:The inclusion of a dynamic radial 2-dimensional GRE sequence is a rapid and easily performed addition to the standard magnetic resonance imaging protocol and allows dynamic quantitative assessment of patellar instability and lateral maltracking in symptomatic patients. With a paucity of reported data using this technique confirming that these results reach clinical significance, future work is required to determine how much lateral tracking is clinically significant. LEVEL OF EVIDENCE/METHODS:Level III, case control.