Faculty Bibliography

PURPOSE/OBJECTIVE:To evaluate the variation in tibial tubercle sagittal alignment in patients with and without patellofemoral (PF) cartilage wear. METHODS:This was a single-centre, retrospective review of patients that underwent a cartilage restoration procedure for isolated PF cartilage wear from 2014 to 2020. Patients were matched in a 1:2 ratio for age, sex and BMI to partial meniscectomy patients as controls. The sagittal TT-TG (sTT-TG) distance was measured on preoperative axial T2 magnetic resonance imaging (MRI) and was defined as the distance between a point at the nadir of the trochlear cartilage and the most anterior point of the tibial tubercle. RESULTS:One hundred and forty patients (47 cartilage restoration, 94 meniscectomy) were included. Mean age, BMI, and height for the total cohort were 34.01 ± 8.7, 26.6 ± 6.4, and 173.0 ± 17.7 respectively, with 78 males (55%) and 63 females (45%). There were no significant differences between groups for age, BMI or sex (n.s). The cartilage restoration group (- 2.5 mm ± 5.9) was found to have a significantly more posterior (negative) sTT-TG compared to the meniscectomy group (1.72 mm ± 6.7) (p < 0.001). Interrater reliability was excellent (ICC = 0.931, p < 0.001). Patients with less than - 3.4 mm sTT-TG were 2.74 times more likely to have a cartilage restoration procedure compared to those with greater than - 3.4 mm (OR 2.7, 95% CI 1.3-5.85). Patients with < - 10 mm posterior translation were 13.7× (CI 1.6-111.1) more likely to have a cartilage restoration procedure. CONCLUSION/CONCLUSIONS:Patients that underwent isolated cartilage restoration procedures had a significantly more posterior tibial tubercle than partial meniscectomy controls based on the sagittal TT-TG. The more posterior the tubercle, the more likely the patient had a cartilage restoration procedure. Surgeons should consider the sTT-TG measurement in patients presenting with anterior knee pain, particularly patellofemoral lesions. LEVEL OF EVIDENCE/METHODS:III.

OBJECTIVE/UNASSIGNED:Studies have shown a high prevalence of femoroacetabular impingement (FAI) among elite athletes yet there is a paucity of data on FAI in Nordic skiers. The purpose of this study was to determine the prevalence of radiographic FAI in professional Nordic Combined Skiers and Ski jumpers compared to controls and assess functional outcomes including hip range of motion (ROM) and pain in patients with radiographic evidence of FAI compared to those without it. METHODS/UNASSIGNED:A cohort of elite Nordic Skiers underwent medical history, physical examination, and pelvic radiographs at their visit with a fellowship-trained sports medicine physician. On pelvis radiographs, Alpha angle>55 degrees was deemed cam-positive, and positive crossover signs, Tönnis<0, or LCEA>40 were deemed pincer positive. Further stratification was performed by sex, ski event type, hip pain, presence of cam lesions, and presence of pincer lesions. Spearman correlation matrix was performed to measure the association between radiographic measurements and ROM. RESULTS/UNASSIGNED:Nineteen Nordic skiers and nineteen age, sex, and BMI matched controls were included in the study. There were no significant differences in age, sex, BMI, and hip pain between groups. While Nordic skiers demonstrated decreased ROM bilaterally on external rotation compared to controls, skiers had larger ROM bilaterally on extension, abduction, adduction compared to controls. Skiers were significantly more likely to have bilateral crossover sign and alpha angles>55 compared to controls. Subgroup analysis showed that Cam positive patients had higher flexion and adduction ROM and pincer positive patients had significantly higher flexion and abduction ROM compared to patients without cam and pincer lesions respectively. Patients with hip pain had significantly lower right hip abduction ROM compared to patients without hip pain. No significant correlations were seen between radiographic measurements and ROM. CONCLUSION/UNASSIGNED:Similar to other elite 'hip heavy' sport athletes, Nordic skiers gave a notably higher prevalence of radiographic cam and pincer type morphology and significantly higher ROM compared to nonathletic controls. Clinicians evaluating Nordic skiers should be aware of these baseline findings with respect to a possible elevated long-term risk of symptomatic FAI in these athletes as well as other conditions related to radiographic FAI.

PURPOSE/OBJECTIVE:The purpose of this study was to perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature in order to assess the evidence defining the optimal combination of surgical technique single row repair (SRR), double-row repair (DRR), or transosseous-equivalent/suture-bridge (TOE/SB) arthroscopic rotator cuff repair (ARCR) and postoperative rehabilitation (early or late) protocol for ARCR. METHODS:The literature search was performed based on the PRISMA guidelines. Randomized SSR-Early trials (RCT) comparing SRR vs DRR vs TOE/SB ARCR techniques were included, as well as early versus late postoperative ROM. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score. RESULTS:28 studies comprising 2,181 total shoulders met the inclusion criteria. TOE/SB-late (OR 0.19 [0.08;0.46) and DRR-late (OR 0.25 [0.12;0.52) were found to significantly reduce the rate of re-tear, with TOE/SB-late resulting in the highest P-score for the American Shoulder & Elbow Surgeons (ASES) (P Score: 0.7911) score and re-tear rate (P Score: 0.8725). DRR-early did not result in any significant improvements over the SRR-early group, except in internal rotation. There was no significant difference in forward flexion between groups, with almost equivalent P-Scores. Furthermore, TOE/SB-early and TOE/SB-late trended toward worsening external rotation compared to the control. CONCLUSION/CONCLUSIONS:The current study suggests that rotator cuff repair using the transosseous-equivalent/suture-bridge technique and late postoperative mobilization yields the highest functional outcomes and lowest re-tear rate in the arthroscopic management of symptomatic rotator cuff tears.

Identifying the specific source of gluteal pain can elude the most seasoned orthopaedic diagnosticians. Patients will often present with a protracted course of symptoms, and failure to successfully identify and treat the underlying etiology leads to frustration for both patient and clinician. Pain deep in the buttocks can arise from compression, inflammation, or injury of one or more of the structures in this anatomically dense area. Although sacroiliitis, hip arthritis, and trochanteric bursitis may also masquerade as gluteal pain, sciatic nerve irritation in its various presentations causes a substantial percentage of cases. Deep gluteal syndrome, hamstring syndrome, and ischiofemoral impingement can have overlapping presentations but can be differentiated by clinical examination and judiciously placed diagnostic corticosteroid injections. Although nonsurgical management, including physical therapy, relative rest, and injections represent the mainstay of treatment, open and endoscopic surgical approaches have yielded encouraging success rates in refractory cases.

»:Biceps tendon pathologies include a spectrum of injuries that range from mild tendinosis to complete tendon rupture. »:Tendinosis, the most common pathology, occurs more frequently with age and is likely related to chronic degeneration. On the other side of the spectrum of severity lies a rupture of the long head of the biceps tendon (LHBT), which may be accompanied by injury to the glenoid labrum. »:Superior labral anterior-posterior (SLAP) tears are frequently associated with biceps pathology. Surgical management for injuries of the bicipital-labral complex includes biceps tenodesis or tenotomy and SLAP repair. A consensus as to which of these procedures is the optimal choice has not been reached, and management may ultimately depend on patient-specific characteristics. »:Due to the relatively low incidence of distal biceps tendon rupture, agreement on the optimal management strategy has not been reached. Surgical repair, or reconstruction in the case of a chronic rupture, is often chosen. However, nonoperative management has also been utilized in older, less-active patients.

Objectives: Socioeconomic factors have been shown to impact patient care in many surgical fields; however, their effects have not been thoroughly evaluated in the context of anterior cruciate ligament reconstruction (ACLR) outcomes. The purpose of this study is to investigate the effects of socioeconomic factors on time to surgery, knee function, and subjective outcomes measures following ACLR.
Method(s): A retrospective query of primary ACLR surgeries at a single institution performed from 2011 to 2015 with minimum twoyear follow-up was conducted. Patient demographics, insurance type, worker's compensation status, surgical variables, IKDC 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.
Result(s): 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group). The Medicaid group demonstrated lower annual income (p<0.01) and a lower level of completed education compared to the non- Medicaid group (p<0.01). Medicaid patients had a greater duration between time of initial knee injury and surgery compared to the non-Medicaid group (11.8 +/- 16.3 months versus 6.1 +/- 16.5 months, p = 0.04). At the time of follow-up, patients in the non- Medicaid group had a significantly greater IKDC score compared to Medicaid patients (82.5 +/- 13.8 versus 75.3 +/- 20.8, p = 0.03).
Conclusion(s): Socioeconomic factors impacted care in the setting of ACL injury. Medicaid insurance patients were seen significantly later after initial injury when compared to non-Medicaid carriers, and had worse outcomes compared to their non-Medicaid peers. Higher annual income brackets had significantly higher clinical outcomes scores at a minimum of two years postoperatively. Education level did not affect outcomes

BACKGROUND/UNASSIGNED:During the COVID impacted 2020-2021 season of the English soccer league, there was an appreciable number of injuries experienced by players. These injuries, however, have not been quantified against previous seasons to highlight the altered season as a causative factor. METHODS/UNASSIGNED:, with the provided information allowing for the sorting of the data into muscular and ligamentous injuries and skeletal injuries. RESULTS/UNASSIGNED:Overall 226, 260, and 289 muscular and ligamentous injuries were observed across the 2018/2019, 2019/2020, and 2020/2021 seasons, respectively. There were 495 minutes on average played leading up to first injury in the 2020/2021 season, compared with 521 minutes in the 2019/2020 season and 536 minutes in the 2018/2019. There was an average of games played to injury of 5.6 games in the 2020/2021 year, with 6.0 in the 2019/2020 year and 6.1 in the 2018/2019 year. Additionally, there was a significantly shorter time in between games was noted during the COVID-affected season with a mean time of 6.8 days in-between games played during the 2020-2021 season as compared to the previous years of 9.12 and 7.12 days. CONCLUSION/UNASSIGNED:Our study found that there were more injuries and a decreased time to first injury observed during the COVID-impacted 2020-2021 season than the two preceding seasons, perhaps demonstrating a link between fixture congestion and athlete injuries as evidenced by the significantly shorter time between games. It is therefore prudent to retain fixture spacing for athlete recovery even against the backdrop of an overall shortened season.

BACKGROUND/UNASSIGNED:The minimal clinically important difference (MCID) is a term synonymous with orthopaedic clinical research over the past decade. The term represents the smallest change in a patient-reported outcome measure that is of genuine clinical value to patients. It has been derived in a myriad of ways in existing orthopaedic literature. PURPOSE/UNASSIGNED:To describe the various modalities for deriving the MCID. STUDY DESIGN/UNASSIGNED:Narrative review; Level of evidence, 4. METHODS/UNASSIGNED:The definitions of common MCID determinations were first identified. These were then evaluated by their clinical and statistical merits and limitations. RESULTS/UNASSIGNED:There are 3 primary ways for determining the MCID: anchor-based analysis, distribution-based analysis, and sensitivity- and specificity-based analysis. Each has unique strengths and weaknesses with respect to its ability to evaluate the patient's clinical status change from baseline to posttreatment. Anchor-based analyses are inherently tied to clinical status yet lack standardization. Distribution-based analyses are the opposite, with strong foundations in statistics, yet they fail to adequately address the clinical status change. Sensitivity and specificity analyses offer a compromise of the other methodologies but still rely on a somewhat arbitrarily defined global transition question. CONCLUSION/UNASSIGNED:This current concepts review demonstrates the need for (1) better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and (2) better study design-namely, until a universally accepted MCID derivation exists, studies attempting to derive the MCID should utilize the anchor-based within-cohort design based on Food and Drug Administration recommendations. Ideally, large studies reporting the MCID as an outcome will also derive the value for their populations. It is important to consider that there may be reasonable replacements for current derivations of the MCID. As such, future research should consider an alternative threshold score with a more universal method of derivation.

BACKGROUND:Female ice hockey players have rates of sports-related concussion that are similar to male participants at various levels of play, despite differences in the rules that do not allow for body checking in the women's game. At the elite level, there are limited data regarding concussion rates and concussion symptom reporting. Therefore, it was hypothesized that there would be a high incidence of concussion and concussion symptom-reporting in professional women's ice hockey players. METHODS:A survey was given to 54 players in the National Women's Hockey League at the end of the 2018-2019 season. Players reported on the number of concussions diagnosed by a physician throughout their careers, the number of times they have had concussion symptoms, if they had ever continued playing after experiencing concussion symptoms, and if they had ever failed to report concussion symptoms to a medical professional or coach. RESULTS:Fifty-four players completed the survey. Thirtyone (57%) respondents reported at least one concussion diagnosed during their playing career, with 16 (30%) reporting two or more diagnosed concussions. Thirty-six (67%) players reported experiencing concussion symptoms at least once, with 26 (48%) reporting two or more occurrences of such symptoms. Of the 36 players who had experienced symptoms of concussion, 25 (69%) reported that they continued playing at least once after experiencing concussion symptoms. Seventeen players (36%) reported that they did not initially tell anyone about their concussion symptoms on at least one occasion, while seven players (19%) never disclosed their symptoms. CONCLUSION/CONCLUSIONS:There is a high incidence of sport-related concussions reported in women's professional ice hockey players as well as an alarming rate of symptom nonreporting. CLINICAL RELEVANCE/CONCLUSIONS:This study provides new data on rates of concussion and symptom non-reporting among female professional ice hockey players and will aid clinicians in decision making when caring for these athletes.

OBJECTIVE/UNASSIGNED:The purpose of this study was to evaluate the efficacy of osteochondral allograft (OCA) in patients older than 45 years of age, particularly with respect to return to sport. DESIGN/UNASSIGNED:A retrospective review was performed to evaluate patients greater than 45 who underwent an OCA for a symptomatic osteochondral defect of the knee between June 2011 and January 2019. RESULTS/UNASSIGNED:< 0.01). Furthermore, the mean Visual Analogue Scale while playing sport was 3.4 ± 3.2, and the mean Knee Injury and Osteoarthritis Outcome Score was 77.5 ± 12.7 at final follow-up. Overall, 11 patients (78.6%) were able to return to their desired sport. No clinical failures were identified during the follow-up period. CONCLUSION/UNASSIGNED:In our series of patients 45 years and older who were treated with OCA for focal osteochondral injuries of the knee, we found a significant improvement in clinical outcome scores at a midterm follow-up of 37 months with no revision OCA procedures or conversion to any form of knee arthroplasty. In addition, a high percentage of patients were able to return to their preferred level of athletic activity.