Faculty Bibliography

BACKGROUND:Given the relatively low incidence of infection, the role of prophylactic antibiotics for infection prevention in arthroscopic surgery is unclear. Without established evidence-based guidelines, it becomes important to understand the trends and common practices in the field. HYPOTHESIS/OBJECTIVE:We hypothesized that a majority of surgeons would use preoperative intravenous antibiotics and that postoperative antibiotics would be rarely used. METHODS:A web-based link containing a questionnaire on perioperative antibiotic use for arthroscopic surgery of the knee and shoulder was sent to sports medicine surgeons at several institutions in the New York tri-state region. The questionnaire addressed antibiotic use both preoperatively and postoperatively and the type of medication used. RESULTS:During the study period, 86 surgeons responded to the knee portion of the survey and 139 surgeons responded to the shoulder portion of the survey. A significant majority (94.24% for knee and 93.02% for shoulder) of the respondents routinely preferred to use preoperative intravenous antibiotics for both shoulder and knee surgery. The antibiotic of choice for a majority of the respondents was cefazolin (98.1% respondents). In patients with penicillin allergies, most preferred to use clindamycin. Most respondents (84.5%) did not routinely use postoperative oral antibiotics. CONCLUSION/CONCLUSIONS:There is significant consensus among orthopedic surgeons performing knee and shoulder arthroscopic surgery regarding use of preoperative antibiotics, with the majority routinely prescribing preoperative intravenous antibiotics for prophylaxis and cefazolin being the most commonly used antibiotic. The majority of surgeons prefer not to use postoperative oral antibiotics. CLINICAL RELEVANCE/CONCLUSIONS:This study describes the current trends in the use of perioperative antibiotics among orthopedic surgeons for routine arthroscopic procedures in the shoulder and knee.

Introduction/UNASSIGNED:The traditional nociceptive approach to pain identifies the mind and body as functionally separate. However, the biopsychosocial model accounts for the impact of social, psychological and physical factors on the patient experience. The purpose of this study was to determine the relationship between diagnosis, physical disability, and psychological distress among patients with anterior knee pain-one of the most common complaints in an orthopedic clinic. Methods/UNASSIGNED:This was a single-center, cross-sectional study. Patients presenting for initial evaluation of knee pain completed the Pain Catastrophizing Scale, Kujala Anterior Knee Pain Scale, and SF-12 questionnaires. Statistical analysis was performed using SPSS Version 24. Results/UNASSIGNED:207 patients, 108 (52.2%) females and 99 (47.8%) males, with a mean age 44.5 ± 15.4 years were enrolled. The osteoarthritis cohort had the highest pain catastrophizing score (17 ± 14.5), lowest Kujala score (48.3 ± 18.1), lowest SF-12 PCS (37.5 ± 8.3), and lowest SF-12 MCS (50.8 ± 11.0). Across all diagnoses, there was a statistically significant negative correlation between the total Pain Catastrophizing Score (PCS) and the Kujala, SF-12 Physical, and SF-12 Mental Component Scores. Bivariate and multivariate analysis demonstrated a correlation between PCS and duration of symptoms and African-Americans. The Kujala and SF-12 PCS demonstrated a statistically significant correlation with age, smoking, and the Asian Indian ethnicity. The SF-12 MCS showed a significant relationship with the Asian Indian ethnicity. Bivariate analysis also showed a statistically significant relationship between the SF-12 PCS and the SF-12 MCS. Conclusion/UNASSIGNED:Knee pain patients presenting to an orthopedic sports medicine clinic demonstrate diminished physical quality of life and psychological reserves. This study determined an association between catastrophizing behavior and other patient reported outcomes measuring pain, physical distress, quality of life and mental/emotional well-being. To optimize patient outcomes, psychological domain should be managed contemporaneously to orthopedic pathology.

PURPOSE/OBJECTIVE:The purpose of the current study is to meta-analyze the current evidence in the literature to compare arthroscopic Bankart repair versus conservative management for first-time anterior shoulder dislocation. METHODS:A literature search of MEDLINE, EMBASE and The Cochrane Library, was performed based on the PRISMA guidelines. Prospective studies comparing arthroscopic Bankart repair versus conservative management as treatment for first-time anterior shoulder dislocation were included. Recurrence, further treatment, and return to play were compared, with all statistical analysis performed using Review Manager Version 5.3. A p-value of < 0.05 was considered statistically significant. RESULTS:= 0, p = 0.002). CONCLUSION/CONCLUSIONS:Arthroscopic Bankart repair resulted in a 7-fold lower recurrence rate and a higher rate of return to play compared to conservative management. Thus, arthroscopic Bankart repair may be advisable to perform routinely for first-time dislocators who participate in sports.

Suprascapular neuropathy is a potential source of shoulder pain and functional limitation that can present secondary to various etiologies including entrapment or compression. Cystic lesions arising from a labral or capsular tear can compress the nerve along its course over the scapula. Nerve traction is theorized to arise from chronic overhead athletics or due to a retracted rotator cuff tear. The diagnosis of suprascapular neuropathy is based on a combination of a detailed history, a comprehensive physical examination, imaging, and electrodiagnostic studies. Although the anatomic course and variations in bony constraint are well understood, the role of surgical treatment in cases of suprascapular neuropathy is less clear. Recent reviews on the topic have shed light on the outcomes after the treatment of suprascapular neuropathy because of compression, showing that surgical release can improve return to play in well-indicated patients. The incidence of compressive neuropathy is quite high in the overhead athletic cohort, but most patients do not show clinically relevant deficiencies in function. Surgical release is therefore not routinely recommended unless patients with pain or deficits in strength fail appropriate nonsurgical treatment.

As the world grapples with the COVID-19 pandemic, we as health care professionals thrive to continue to help our patients, and as orthopedic surgeons, this goal is ever more challenging. As part of a major academic tertiary medical center in New York City, the orthopedic department at New York University (NYU) Langone Health has evolved and adapted to meet the challenges of the COVID pandemic. In our report, we will detail the different aspects and actions taken by NYU Langone Health as well as NYU Langone Orthopedic Hospital and the orthopedic department in particular. Among the steps taken, the department has reconfigured its staff's assignments to help both with the institution's efforts and our patients' needs from reassigning operating room nurses to medical COVID floors to having attending surgeons cover urgent care locations. We have reorganized our residency and fellowship rotations and assignments as well as adapting our educational programs to online learning. While constantly evolving to meet the institution's and our patient demands, our leadership starts planning for the return to a new "normal".

PURPOSE/OBJECTIVE:In recent years, meniscal allograft transplantation (MAT) has been established as an effective option for young patients with symptomatic meniscus insufficiency with goals of functional improvement and joint preservation. Currently, there is little available information on return-to-play among patients in this cohort. 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 MAT. METHODS:MEDLINE, EMBASE and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on MAT. Studies were included if they reported return-to-play data or rehabilitation protocols. The rate and timing of return-to-play was assessed. The rehabilitation protocols were recorded, including time to start range of motion (ROM), full ROM, partial weight bearing (WB), and full WB. RESULTS:Overall, 67 studies met the inclusion criteria. Eleven studies, including 624 patients, reported 483 out of 624 patients (77.4%) returning to play, with 326 out of a reported 475 patients (68.6%) returning to the same/higher level, at a mean time to return of 9.0 months. There was significant variability in the reported rehabilitation protocols, but the most commonly reported time to begin ROM exercises was within the first week by 42 out of 60 studies (70.0%) and full ROM at 8 weeks by 18 out of 46 studies (39.1%). Partial weight bearing was most commonly begun in the fourth week by 20 out of 46 studies (43.5%), and for full WB the sixth week by 43 out of 65 studies (66.1%). Time elapsed following surgery was the most commonly reported criteria for return-to-play by 44 out of 48 studies (91.6%), with 6 months being the most common time point utilized by 17 out of 45 studies (37.8%). A small proportion of studies, 16 out of 48 (33.3%), advised against returning to competitive/collision sports altogether following MAT. CONCLUSIONS:In conclusion, there is a high rate of return-to-play following MAT, with the majority of patients returning to the same level of play. However, there is significant variability in reported rehabilitation protocols, and poor-quality reporting in return-to-play criteria in the literature indicates a need for further study and the development of an evidence-based consensus statement for this patient population. The results from this study can be used to better inform patients on their expected outcomes and provide a more informed consent process. LEVEL OF EVIDENCE/METHODS:IV.

Meniscus surgery has dramatically changed over the last 20 years. This article reviews the advances and current evidence in meniscus repair.

INTRODUCTION/BACKGROUND:Burnout is an occupational hazard for physicians at all stages of training and medical practice. The purpose of the current study was to determine whether residency factors, with the use of an activity monitor, including the amount of exercise, have any impact on burnout among orthopaedic surgery residents in varying years of training. METHODS:Orthopaedic residents at a single institution were recruited immediately before beginning a new clinical rotation and followed for four weeks. On enrollment, the participants were given a wrist-worn activity monitor (Fitbit Flex) and instructed on its use for tracking physical activity. REDCap was used to collect burnout levels (as assessed by using the Maslach Burnout Inventory and the Patient Health Questionnaire-9), which were completed a total of five times, once at enrollment and weekly during the study period. RESULTS:Twenty-seven residents were enrolled, including 13 junior residents (interns and second years) and 14 senior residents (third, fourth, and fifth years). Seven residents were on fracture rotations, whereas 20 were not. As measured by using the Maslach Burnout Inventory, juniors were more emotionally exhausted (P = 0.01) and depersonalized (P = 0.027). No difference in the objective physical activity data as measured by using the Fitbit Flex and no difference in the self-reported hours of sleep were observed. Residents on orthopaedic trauma rotations also reported significantly higher rates of emotional exhaustion and depersonalization (P < 0.001) than other residents and were more physically active on average (P < 0.030). DISCUSSION/CONCLUSIONS:Although depersonalization and depression are common symptoms seen among orthopaedic surgery residents, this study demonstrated that quality of life improves markedly as they progress through their residency training. Residents on orthopedic trauma rotations have greater levels of emotional exhaustion and depersonalization. This pilot study suggests that burnout prevention programs should begin at the start of training to provide residents with strategies to combat and then reinforced while on orthopaedic trauma rotations. LEVEL OF EVIDENCE/METHODS:Level III Diagnostic Study.

BACKGROUND:Surgical options for pathology affecting the long head of the biceps tendon (LHBT) include tenotomy and tenodesis, both of which can be performed with a variety of fixation methods. This study aimed to compare surgical treatment options for LHBT lesions using a network meta-analysis of published clinical studies. METHODS:A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Clinical studies comparing surgical treatment options for LHBT lesions were included. Postoperative outcomes were compared between surgical treatment options using a frequentist approach to network meta-analysis. RESULTS:There were 22 studies comparing surgical treatment options for LHBT pathology including arthroscopic tenotomy, arthroscopic suprapectoral tenodesis, arthroscopic intracuff tenodesis, and open subpectoral tenodesis, consisting of 1804 patients. Compared with arthroscopic tenotomy, open subpectoral tenodesis resulted in a significantly greater American Shoulder and Elbow Surgeons score (mean difference, 4.58; P = .014). On the basis of the P-score, all 3 tenodesis techniques ranked above tenotomy with respect to the Constant score. Compared with arthroscopic tenotomy, the incidence of Popeye deformity was reduced with arthroscopic suprapectoral tenodesis (odds ratio [OR], 0.23; P < .001) and open subpectoral tenodesis (OR, 0.25; P = .022). The incidence of bicipital groove pain was increased after arthroscopic intracuff tenodesis (OR, 2.89; P = .021) compared with arthroscopic tenotomy. CONCLUSION/CONCLUSIONS:Lesions of the LHBT treated with open or arthroscopic tenodesis resulted in comparatively superior functional outcomes and a lower incidence of Popeye deformity, whereas arthroscopic intracuff tenodesis resulted in a higher incidence of bicipital groove pain.

BACKGROUND:There has been a recent surge in health-care providers offering stem cell therapy (SCT) to patients with musculoskeletal disease. The purpose of this study was to identify and quantify the misinformation present in online direct-to-consumer (DTC) advertising of SCT targeting patients with musculoskeletal disease in the U.S. It was hypothesized that DTC advertising of SCT contains substantial misinformation. METHODS:A list of keywords was used to identify web sites of practices advertising SCT directly to patients with musculoskeletal disease. Web sites were evaluated to determine the specialties of providers offering SCT, types of SCT being advertised, and misinformation presented. Categories of misinformation included false general claims, inaccurate statements regarding mechanism of action, unfounded results, and scare tactics. RESULTS:Of the 896 practice web sites included in the analysis, 95.9% contained at least 1 statement of misinformation, with a mean of 4.65 ± 3.66 statements of misinformation among the sites. Practices associated with an orthopaedic surgeon provided 22% fewer statements of misinformation than practices without an orthopaedic surgeon when we controlled for the effects of other specialties. Practices associated with a podiatrist also provided 22% fewer statements of misinformation. CONCLUSIONS:Nearly all practices failed to accurately represent the clinical efficacy of SCT in DTC advertising. While practices associated with an orthopaedic surgeon were less likely to provide misinformation, the majority of all web sites contained some type of misinformation, ranging from errors in the basic science of stem cells to outright false and misleading claims of their clinical effectiveness.