Faculty Bibliography

PURPOSE/UNASSIGNED:To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction. METHODS/UNASSIGNED:A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups. RESULTS/UNASSIGNED: = .036). CONCLUSIONS/UNASSIGNED:Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.

PURPOSE/UNASSIGNED:To determine the effect of perioperative angiotensin II receptor blocker (ARB) or angiotensin-converting enzyme inhibitors (ACEi) on postoperative arthrofibrosis, as defined by requiring manipulation under anesthesia (MUA) or new diagnosis of adhesive capsulitis (AC) following arthroscopic shoulder procedures. METHODS/UNASSIGNED:Patients were retrospectively identified using Current Procedural Terminology surgical billing codes to identify patients who underwent any shoulder arthroscopic procedure at a single urban academic institution from 2012 to 2020 with a minimum 2-year follow-up. Patients were excluded if <30 years old at time of surgery, as these patients rarely use ARB and ACEi medications, or if they had pre-existing AC. Demographics, active medication prescriptions at the time of surgery, and medical comorbidities were recorded. Multivariable logistic regression was performed to determine the effect of ARB/ACEi on subsequent MUA or AC by 90 days, 1 year, and 2 years. RESULTS/UNASSIGNED:> .05). CONCLUSIONS/UNASSIGNED:ARBs or ACEi did not significantly affect the rate of postoperative arthrofibrosis following shoulder arthroscopy, however female sex, diabetes mellitus, and Black/African American race were associated with an increased rate of necessitating MUA or developing AC within 2 years postoperatively. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.

BACKGROUND:The purpose of this study was to identify socioeconomic predictors of time to initial evaluation, time to surgery, and postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction (MPFLR). METHODS:We conducted a retrospective review of patients at our institution who underwent primary MPFLR with allograft from 2011 to 2019 and had minimum 12-month follow-up. Patients were administered an email survey in January 2022 to assess symptom history, socioeconomic status, and postoperative outcomes including VAS satisfaction and Kujala score. Predictors of time to initial evaluation, time to surgery, and postoperative outcomes were identified using multivariable linear and logistic regression with stepwise selection. RESULTS:Seventy patients were included in the cohort (mean age 24.8 years, 72.9% female, mean follow-up time 45.7 months). Mean time to evaluation was 6.4 months (range 0-221) and mean time to surgery was 73.6 months (range 0-444). Having a general health check-up in the year prior to surgery was predictive of shorter time to initial evaluation (β = - 100.5 [- 174.5, - 26.5], p = 0.008). Home ownership was predictive of shorter time to surgery (β = - 56.5 [- 104.7, 8.3], p = 0.02). Full-time employment was predictive of higher VAS satisfaction (β = 14.1 [4.3, 23.9], p = 0.006) and higher Kujala score (β = 8.7 [0.9, 16.5], p = 0.03). CONCLUSION/CONCLUSIONS:Markers of higher socioeconomic status including having a general check-up in the year prior to surgery, home ownership, and full-time employment were predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes. LEVEL OF EVIDENCE/METHODS: IV, retrospective case series.

PURPOSE/UNASSIGNED:The purposes of this study were to determine why athletes did not return to play (RTP) following operative management of superior-labrum anterior-posterior (SLAP) tears, compare these athletes to those who did RTP, and evaluate the SLAP-Return to Sport after Injury (SLAP-RSI) score to assess the psychological readiness of athletes to RTP after operative management of SLAP tears. METHODS/UNASSIGNED:A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 24-month follow-up was performed. Outcome data, including visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, patient satisfaction, and whether they would undergo the same surgery again was collected. Additionally, the rate and timing of return to work (RTW), the rate and timing of RTP, SLAP-RSI score, and VAS during sport were evaluated, with subgroup analysis among overhead and contact athletes. The SLAP-RSI is a modification of the Shoulder Instability-Return to Sport after Injury (SI-RSI) score, with a score >56 considered to be a passing score for being psychologically ready to RTP. RESULTS/UNASSIGNED: = .001) were all associated with greater likelihood of return to sports at final follow-up. CONCLUSIONS/UNASSIGNED:Following the operative management of SLAP tears, patients who are unable to RTP exhibit poor psychological readiness to return, which may be due to residual pain in overhead athletes or fear of reinjury in contact athletes. Lastly, the SLAP-RSI tool in combination with ASES proved to be useful in identifying patients' psychological and physical readiness to RTP. LEVEL OF EVIDENCE/UNASSIGNED:Level IV, prognostic case series.

PURPOSE/UNASSIGNED:To evaluate functional outcomes and satisfaction in patients who underwent telerehabilitation (telerehab) compared with in-person rehabilitation after arthroscopic meniscectomy. METHODS/UNASSIGNED:A randomized-controlled trial was conducted including patients scheduled to undergo arthroscopic meniscectomy for meniscal injury by 1 of 5 fellowship-trained sports medicine surgeons between September 2020 and October 2021. Patients were randomized to receive telerehab, defined as exercises and stretches provided by trained physical therapists over a synchronous face-to-face video visit or in-person rehabilitation for their postoperative course. International Knee Documentation Committee Subjective Knee Form (IKDC) score and satisfaction metrics were collected at baseline and 3 months postoperatively. RESULTS/UNASSIGNED: = .044) if there were in the in-person group. Satisfaction differed significantly between the 2 groups at the end of their rehabilitation course, and only 64% of those in the telerehab group would elect to undergo telerehab again for future indications. Furthermore, they believed that future rehabilitation would benefit from a hybrid model. CONCLUSIONS/UNASSIGNED:Telerehab showed no difference versus traditional in-person rehabilitation in terms of functional outcomes up to 3 months after arthroscopic meniscectomy. However, patients were less satisfied with telerehab. LEVEL OF EVIDENCE/UNASSIGNED:I, randomized controlled trial.

STUDY DESIGN/METHODS:Retrospective analysis of outcomes in cervical spine and shoulder arthroscopy patients. OBJECTIVE:The objective of this study is to assess differential improvements in health-related quality of life for cervical spine surgery compared with shoulder surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:An understanding of outcome differences between different types of orthopedic surgeries is helpful in counseling patients about expected postoperative recovery. This study compares outcomes in patients undergoing cervical spine surgery with arthroscopic shoulder surgery using computer-adaptive Patient-reported Outcome Information System scores. MATERIALS AND METHODS/METHODS:Patients undergoing cervical spine surgery (1-level or 2-level anterior cervical discectomy and fusion, cervical disc replacement) or arthroscopic shoulder surgery (rotator cuff repair±biceps tenodesis) were grouped. Patient-reported Outcome Information System scores of physical function, pain interference, and pain intensity at baseline and at 3, 6, and 12 months were compared using paired t tests. RESULTS:Cervical spine (n=127) and shoulder (n=91) groups were similar in sex (25.8% vs. 41.8% female, P=0.731) but differed in age (51.6±11.6 vs. 58.60±11.2, P<0.05), operative time (148.3±68.6 vs. 75.9±26.9 min, P<0.05), American Society of Anesthesiologists (ASAs) (2.3±0.6 vs. 2.0±0.5, P=0.001), smoking status (15.7% vs. 4.4%, P=0.008), and length of stay (1.1±1.0 vs. 0.3±0.1, P=0.000). Spine patients had worse physical function (36.9 ±12.6 vs. 49.4±8.6, P<0.05) and greater pain interference (67.0±13.6 vs. 61.7±4.8, P=0.001) at baseline. Significant improvements were seen in all domains by 3 months for both groups, except for physical function after shoulder surgery. Spine patients had greater physical function improvements at all timepoints (3.33 vs. -0.43, P=0.003; 4.81 vs. 0.08, P=0.001; 6.5 vs. -5.24, P=<0.05). Conversely, shoulder surgery patients showed better 6-month improvement in pain intensity over spine patients (-8.86 vs. -4.46, P=0.001), but this difference resolved by 12 months. CONCLUSIONS:Cervical spine patients had greater relative early improvement in physical function compared with shoulder patients, whereas pain interference and intensity did not significantly differ between the 2 groups after surgery. This will help in counseling patients about relative difference in recovery and improvement between the 2 surgery types. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Magnetic resonance imaging (MRI) is an integral component of the treatment algorithm for proximal hamstring avulsion injuries. OBJECTIVE:The purpose of this study was to survey orthopedic surgeons and musculoskeletal radiologists on the reporting and analysis of proximal hamstring avulsions on MRI. METHODS:Two online surveys were developed to evaluate musculoskeletal radiologists' and orthopedic surgeons' perceptions of MRI-reporting for proximal hamstring avulsion injuries. Each survey was designed to provide information on physicians' best practices with respect to four primary questions (1) ischial tuberosity landmark determination (2) difficulties associated with measuring tendon retraction, (3) important ancillary findings, and (4) perceived clinical impact of measured retraction. Descriptive statistics were calculated for all categorical variables, which were reported as frequencies with percentages. Chi-squared test was utilized to compare rates of responses between surgeons and radiologists. Statistically significant differences were analyzed with post-hoc Fisher's exact tests; p < 0.05 considered statistically significant. RESULTS:218-Musculoskeletal radiologists and 33-orthopedic surgeons responded to their respective surveys. There were statistically significant differences with responses to two of the questions asked in both surveys; (1) in cases of complete hamstring avulsion (avulsion of both the semimembranosus and conjoint tendon), which arrow represents the tendon gap measurement used for planning surgery? p = 0.028; (2) in cases of avulsion of only the conjoint tendon, which arrow represents the tendon gap measurement used for planning surgery? p = 0.013. Post-hoc testing demonstrated that for either partial or complete hamstring avulsions, more surgeons use the conjoint tendon origin to measure tendon retraction than radiologists (p < 0.05 for both). Significantly more radiologists use the semimembranosus origin to measure hamstring retraction for partial or complete hamstring tears (p < 0.05 for both). However, for each of these questions, both radiologists and surgeons most frequently stated that the conjoint tendon landmark should be used for surgical planning. CONCLUSION/CONCLUSIONS:Musculoskeletal radiologists and orthopedists frequently utilize the conjoint tendon origin as an anatomic landmark for measuring complete and partial proximal hamstring avulsion injuries; though, orthopedists are more likely to utilize this landmark. Additionally, the broad surface area of the ischial tuberosity may lead to variability in measurement. CLINICAL IMPACT/CONCLUSIONS:Standard landmarks at the ischial tuberosity and/or detailed descriptions of tendon retractions would improve communication between radiologists and surgeons for proximal hamstring avulsions.

PURPOSE/UNASSIGNED:To compare satisfaction and return to play (RTP) rates between patients undergoing primary biceps tenodesis for a symptomatic SLAP tear and patients undergoing secondary biceps tenodesis following a failed SLAP repair. METHODS/UNASSIGNED:value of <.05 was considered to be statistically significant. RESULTS/UNASSIGNED: = .9529) between patient groups. Patients reported playing tennis, swimming, golf, rock climbing, and basketball. No patients required a further shoulder surgery after undergoing biceps tenodesis. CONCLUSIONS/UNASSIGNED:In this study, patients undergoing primary biceps tenodesis had significantly better functional outcomes compared with secondary biceps tenodesis following a failed SLAP repair. LEVEL OF EVIDENCE/UNASSIGNED:III, retrospective comparative study.

PURPOSE/OBJECTIVE:Given the wide variation that exists in the amount and duration of postoperative opioid medication prescribed by orthopedic surgeons, the purpose of the current study was to analyze the opioid prescribing patterns at our institution for adolescent patients undergoing outpatient sports medicine procedures Methods: A total of 468 adolescent patients (between the ages of 13 and 18 years old) who underwent outpatient shoulder, hip, or knee arthroscopy (including ACL reconstruction) between 2016 and 2018 were retrospectively identified, and demographic data were collected. Opioid prescriptions following surgery were converted to morphine milligram equivalents (MME) for direct comparison. Prescribing patterns of the 44 surgeons included in our cohort were evaluated with respect to procedures performed and overall surgical volume. High-dose prescriptions were defined as ≥ 300 MME (equivalent to 40 tabs of oxycodone/ acetaminophen [Percocet] 5/325 mg) and low-dose prescriptions were defined as < 300 MME. RESULTS:The mean discharge prescription following outpatient arthroscopy in this patient population was 299.8 ± 271 MME. When each individual case-type was analyzed, there were significant positive correlations between surgeonvolume and MME prescribed following shoulder arthroscopy (r = 0.387, p < 0.001) and knee arthroscopy, (r = 0.350, p < 0.001). Results of logistic regression demonstrated that for every 10 additional cases performed, the odds that a given surgeon would prescribe ≥ 300 MME postoperatively increased by a factor of 1.14 (p < 0.001). There were no significant correlations observed following hip arthroscopy, anterior cruciate ligament reconstruction, or meniscus repair. Over the course of the observation period, a significant reduction in opioid prescribing was seen among the participating surgeons. CONCLUSION/CONCLUSIONS:Surgeons who perform a greater volume of outpatient shoulder and knee arthroscopy on adolescent patients were more likely to prescribe high opioid dosages postoperatively. Awareness of existing variation in narcotic prescribing patterns for patients in this age group is important for quality of care and safety improvement amidst the opioid epidemic.

PURPOSE/OBJECTIVE:Over 200,000 anterior cruciate ligament (ACL) reconstructions are performed in the US each year. The recovery process following surgery can be slow and difficult with patients suffering persistent strength and endurance deficits. Testosterone is an important anabolic hormone responsible for maintenance and development of muscle mass. While the response of the hypothalamic-pituitary axis (HPA) to surgery has been investigated, no studies exist tracking the HPA response, specifically that involved in testosterone homeostasis, to ACL reconstructions. The purpose of this study was to explore the response of endogenous testosterone production after ACL reconstruction and determine a possible correlation between perioperative testosterone levels in males and postoperative strength and clinical outcomes. METHODS:This was a single-center, prospective observational study measuring preoperative and postoperative testosterone levels. Plasma testosterone, follicle stimulating hormone (FSH), and lutenizing hormone (LH) were measured before 10:30 am on the day of surgery. These were then checked at the same time of day at 1 week, 6 weeks, and 12 weeks postoperatively. Patients were also evaluated with the visual analog scale for pain (VAS), Tegner, and Lysholm scales preoperatively and at postoperative visits. Statistical analysis was performed using ANOVA and were considered significant at p < 0.05. RESULTS:Twenty male patients with a mean age of 34.0 ± 9.2 years undergoing ACL reconstruction were enrolled between October 2017 and April 2018. Results showed a decrease in testosterone (3.7 ng/mL vs. 2.9 ng/mL, p = 0.05), free testosterone (8.2 pg/mL vs. 6.8 pg/mL, p = 0.05), and follicle stimulated hormone (1.8 mIU/mL vs. 1.7 mIU/ mL, p = 0.83) between the preoperative plasma draw and 1-week postoperative follow-up visit. Luteinizing hormone (1.1 mIU/mL vs. 1.5 mIU/mL, p = 0.11) increased postoperatively. By week 6, testosterone returned to baseline (3.7 ng/mL vs. 3.9 ng/mL), while free testosterone continued to increase through week 12. Lutenizing hormone peaked at the 1-week postoperative visit and trended downward until week 6 (1.5 mIU/mL vs. 1.4 mIU/mL, p = 0.79). Follicle stimulating hormone continued to increase after the week-1 visit through week 12. Patient reported outcomes exhibited a trend similar to hormone levels, with the lowest patient reported outcome (PRO) scores reported at week 1 and a constant trend upward. Although there were similar trends, there were no significant correlations between change in hormone levels and change in PRO scores. CONCLUSION/CONCLUSIONS:Our study emphasizes the crucial period of hormonal decrease and their return to baseline. This knowledge will contribute to the understanding and timing of hormone therapy supplementation. Short-term testosterone replacement may be beneficial to return patients to work and physical activity at a faster rate.