Faculty Bibliography

Purpose: The aim of this study is to identify markers of early failure of anterior cruciate ligament graft reconstruction (ACLR) based on preoperative MR imaging.
Material(s) and Method(s): We identified 26 patients with early ACLR graft failure (<2 years) who underwent revision between 2011-2015 in a retrospective review of our database. Exclusion criteria included graft choice other than autografts (n=4) and non available preoperative MRI (n=3). Nineteen patients with early ACLR failure were included in the study group. The control group consisted of 38 subjects who underwent ACLR with a minimum of 2 years of clinical follow up and no evidence of graft failure matched by age, sex, BMI and graft type. Preoperative MRI obtained within 8 weeks (range 1-8) following initial trauma were reviewed blinded to the ACLR failure by an experienced (20 years) musculoskeletal radiologist for intra and periarticular lesions including: anterolateral ligament (ALL) injuries (stretch, partial, complete), medial meniscus tear (MM), lateral meniscus tear (LM) tear, posteromedial corner injury (PMC), posterolateral corner injury (PLC) injury, medial collateral ligament tear (MCL), and lateral collateral ligament tear (LCL). Logistic regression analysis was performed.
Result(s): Mean time to ACLR failure was 14 months (range, 1-24 months). Mean follow up of those in the control group was 38 months (range, 2561). Medial meniscus (MM) tear was the best predictor of early ACLR failure (Accuracy=66.7%, p=0.08) followed by the lateral meniscus (p=0.13). MM was a significant predictor of ACLR failure (p=0.02) with odds ratio (OR) 4.2 and 95% confidence interval (CI) [1.19 14.9]. All other variables were not associated with ACLR failure (p>0.20).
Conclusion(s): MM tears were the best predictor of early failure of ACLR. Thus, preserving the integrity of theMMduringACLR procedure may be crucial in minimizing the risk for early ACLR failure

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

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:To correlate the histopathologic appearances of resected long head of the biceps tendon (LHBT) specimens following biceps tenodesis, with pre-operative MRI and arthroscopic findings, with attention to the radiologically normal biceps. MATERIAL AND METHODS/METHODS:Retrospective analysis of patients who had undergone preoperative MRI, subsequent arthroscopic subpectoral tenodesis for SLAP tears and histopathologic inspection of the excised sample between 2013 and 16. Those with a normal MRI appearance or mildly increased intrasubstance signal were independently analyzed by 2 blinded radiologists. A blinded orthopedic surgeon and pathologist reviewed all operative imaging and pathologic slides, respectively. RESULTS:Twenty-three LHBT resected samples were identified on MRI as either normal (Reader 1 n = 15; Reader 2 n = 14) or demonstrating low-grade increased signal (Reader 1 n = 8; Reader 2 n = 9). Of these, 86.9% demonstrated a histopathological abnormality. 50% of samples with histopathological abnormality demonstrated normal appearance on MRI. The most common reported histopathology finding was myxoid degeneration (73.9%) and fibrosis (52.2%). The most common arthroscopic abnormality was fraying (18.2%) and erythema (13.6%). Utilizing histopathology as the gold standard, the two radiologists demonstrated a sensitivity of 35.0% v 42.9%, specificity of 66.7% v 100%, PPV of 87.5% v 100%, and NPV of 13.3% v 14.3%. Corresponding arthroscopic inspection demonstrated a sensitivity of 31.6%, specificity of 66.6%, PPV 85.7% and NPV of 13.3%. There was moderate agreement between the two radiologists, κ = 0.534 (95% CI, 0.177 to 0.891), p = 0.01. CONCLUSION/CONCLUSIONS:Histopathological features of low grade tendinosis including mainly myxoid degeneration and fibrosis are frequently occult on MR imaging.

While yoga has been widely studied for its benefits to many health conditions, little research has been performed on the nature of musculoskeletal injuries occurring during yoga practice. Yoga is considered to be generally safe, however, injury can occur in nearly any part of the body-especially the neck, shoulders, lumbar spine, hamstrings, and knees. As broad interest in yoga grows, so will the number of patients presenting with yoga-related injuries. In this literature review, the prevalence, types of injuries, forms of yoga related with injury, specific poses (asanas) associated with injury, and preventive measures are discussed in order to familiarize practitioners with yoga-related injuries.

Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.

Meniscal tears are common injuries that may result in functionally limiting pain, swelling, and mechanical symptoms. The management of meniscal pathology has evolved as surgeons' understanding of the important role the menisci play in normal knee kinematics increases. Recent emphasis on partial meniscectomy, expanding indications for meniscal repair, and the increased use of meniscal allograft transplantation have helped improve the outcomes of patients with a meniscal tear who undergo treatment. Orthopaedic surgeons should understand meniscal function, pathology, and treatment approaches.

Management of proximal and distal biceps tendon pathology is evolving. The long head of the biceps tendon, if inflamed, may be a pain-producing structure. In appropriately indicated patients, a symptomatic long head of the biceps tendon can be surgically managed via tenotomy, tenodesis, and/or superior labrum anterior to posterior repair. In some patients, primary superior labrum anterior to posterior pathology can be managed via biceps tenodesis. Determining which procedure is most appropriate for and which technique and implant are preferred in a given patient with biceps tendon pathology is controversial. Less debate exists with regard to the timing of distal biceps tendon repair; however, considerable controversy exists with regard to selection of an appropriate surgical technique and implant. In addition, the treatment of patients with a chronic and/or retracted distal biceps tendon tear and patients in whom distal biceps tendon repair fails is extremely challenging. Orthopaedic surgeons should understand the anatomy of, nonsurgical and surgical treatment options for, and outcomes of patients with proximal or distal biceps tendon pathology.

Introduction/UNASSIGNED:Rupture of the distal biceps brachii results in significant weakness and limitation of function in those affected. Acute ruptures of the biceps tendon are generally best treated with early repair, ideally within 3weeks of injury. The preferred treatment of chronic ruptures is still uncertain. Case Report/UNASSIGNED:We present a case of a chronic distal biceps tendon rupture repaired with a novel, two-incision, minimally invasive anterior approach utilizing an Achilles tendon allograft and cortical button fixation, in a patient with a high demand occupation as a cabinet maker. Conclusion/UNASSIGNED:Numerous surgical techniques have been described for the repair or reconstruction of chronic distal biceps ruptures. Most described techniques have utilized an extensile anterior approach or an extensile anterior approach combined with another posterolateral incision. We believe that this minimally invasive approach allows for better cosmesis and quicker recovery and return to work in patients with high demand occupations.