Faculty Bibliography

PURPOSE/OBJECTIVE:Lateral patellar instability is a debilitating condition not only to athletes, but also to a wide range of highly active individuals. Many of these patients experience symptoms bilaterally, though it is unknown how these patients fair with return to sports following a second medial patellofemoral ligament reconstruction (MPFLR). The purpose of this study is to evaluate the rate of return to sport following bilateral MPFLR compared to a unilateral comparison group. METHODS:Patients who underwent primary MPFLR with minimum 2-year follow-up were identified from 2014 to 2020 at an academic center. Those who underwent primary MPFLR of bilateral knees were identified. Pre-injury sport participation and Tegner score, Kujala score, Visual Analog Score (VAS) for pain, satisfaction, and MPFL-Return to Sport after Injury (MPFL-RSI) scale were collected. Bilateral and unilateral MPFLRs were matched in a 1:2 ratio based on age, sex, body mass index, and concomitant tibial tubercle osteotomy (TTO). A sub-analysis was performed regarding concomitant TTO. RESULTS:The final cohort consisted of 63 patients, including 21 patients who underwent bilateral MPFLR, matched to 42 unilateral patients at mean follow-up of 47 ± 27 months. Patients who underwent bilateral MPFLR returned to sport at a rate of 62% at a mean of 6.0 ± 2.3 months, compared to a unilateral rate of 72% at 8.1 ± 4.2 months (n.s.). The rate of return to pre-injury level was 43% among bilateral patients and 38% in the unilateral cohort. There were no significant differences in VAS pain, Kujala, current Tegner, satisfaction, and MPFL-RSI scores between cohorts. Approximately half of those (47%) who failed to return to sport cited psychological factors and had significantly lower MPFL-RSI scores (36.6 vs 74.2, p = 0.001). CONCLUSION/CONCLUSIONS:Patients who underwent bilateral MPFLR returned to sports at a similar rate and level compared to a unilateral comparison group. MPFL-RSI was found to be significantly associated with return to sport. LEVEL OF EVIDENCE/METHODS:III.

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.

BACKGROUND/UNASSIGNED:The purpose of this study was to compare opioid analgesic use and patient-reported outcomes (PROs) after anterior cruciate ligament reconstruction (ACLR) between patients with and without cannabis use disorder (CUD). HYPOTHESIS/UNASSIGNED:We hypothesized that patients with CUD would have greater postoperative opioid usage with comparable improvement in PROs. STUDY DESIGN/UNASSIGNED:Retrospective matched-cohort study. LEVEL OF EVIDENCE/UNASSIGNED:Level 3. METHODS/UNASSIGNED:values <0.05 were considered significant. RESULTS/UNASSIGNED:= 0.94). CONCLUSION/UNASSIGNED:There were no significant differences detected in opioid usage or PRO improvement after ACLR between patients with CUD and those without. However, because a sample size was not determined a priori, a larger sample may show a difference. CLINICAL RELEVANCE/UNASSIGNED:CUD does not appear to correlate with inferior outcomes after ACLR.

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.

BACKGROUND/UNASSIGNED:An increased posterior tibial slope (PTS) is a risk factor for primary anterior cruciate ligament (ACL) tears and graft failure, but the PTS has not been well-defined in those who have experienced bilateral ACL injuries. PURPOSE/UNASSIGNED:The primary aim was to compare the PTS, as well as the rate of an elevated PTS (>12° on lateral radiography; >7° on magnetic resonance imaging [MRI]), between patients who have undergone bilateral ACL reconstruction (ACLR) versus unilateral ACLR. A secondary purpose was to examine whether these associations remained consistent on both plain radiography and MRI. STUDY DESIGN/UNASSIGNED:Cross-sectional study; Level of evidence, 3. METHODS/UNASSIGNED:We retrospectively identified patients who underwent primary ACLR at our institution from the years 2012 to 2020. Patients who underwent nonsimultaneous bilateral ACLR (n = 53) were matched to those who underwent unilateral ACLR (n = 53) by age, sex, and body mass index. Exclusion criteria were rotated lateral radiographs, MRI scans of inadequate quality, and concomitant ligament injuries or fractures. Those who had undergone unilateral ACLR with <5-year follow-up were further excluded. There were 3 blinded readers who measured the PTS on lateral radiographs, while the medial PTS (MPTS) and lateral PTS (LPTS) were measured on MRI scans. Bivariate regression was performed to determine the correlation between radiographic and MRI measurements. RESULTS/UNASSIGNED:= .810). CONCLUSION/UNASSIGNED:Patients who underwent bilateral ACLR had a significantly greater PTS on radiography and a significantly greater LPTS on MRI compared with those who underwent unilateral ACLR. The rate of a radiographic PTS >12° was 2.4 times greater among patients undergoing bilateral ACLR compared with those undergoing unilateral ACLR. PTS measurements on radiography demonstrated a weak to negligible correlation with PTS measurements on MRI, suggesting that future normative PTS values should be reported specific to the imaging modality.

PURPOSE/OBJECTIVE:The indications for surgical treatment of proximal hamstring ruptures are continuing to be refined. The purpose of this study was to compare patient-reported outcomes (PROs) between patients who underwent operative or nonoperative management of proximal hamstring ruptures. METHODS:A retrospective review of the electronic medical record identified all patients who were treated for a proximal hamstring rupture at our institution from 2013 to 2020. Patients were stratified into two groups, nonoperative or operative management, which were matched in a 2:1 ratio based on demographics (age, gender, and body mass index), chronicity of the injury, tendon retraction, and number of tendons torn. All patients completed a series of PROs including the Perth Hamstring Assessment Tool (PHAT), Visual Analogue Scale for pain (VAS), and the Tegner Activity Scale. Statistical analysis was performed using multi-variable linear regression and Mann-Whitney testing to compare nonparametric groups. RESULTS:Fifty-four patients (mean age = 49.6 ± 12.9 years; median: 49.1; range: 19-73) with proximal hamstring ruptures treated nonoperatively were successfully matched 2:1 to 27 patients who had underwent primary surgical repair. There were no differences in PROs between the nonoperative and operative cohorts (n.s.). Chronicity of the injury and older age correlated with significantly worse PROs across the entire cohort (p < 0.05). CONCLUSIONS:In this cohort of primarily middle-aged patients with proximal hamstring ruptures with less than three centimeters of tendon retraction, there was no difference in patient-reported outcome scores between matched cohorts of operatively and nonoperatively managed injuries. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:Acute Rockwood type III-V acromioclavicular (AC) dislocations have been treated with numerous surgical techniques over the years. The purpose of this study was to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) to quantitatively define the optimal treatment for operative AC dislocations. METHODS:A literature search of three databases was performed on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing one of ten treatments for acute Rockwood type III-V AC dislocations (Nonoperative [NO]; Kirschner wire fixation [KW]; Coracoclavicular screw fixation [Scr]; Hook plate [HP]; Open coracoclavicular cortical button [CBO]; Arthroscopic coracoclavicular cortical button [CBA]; Two or more coracoclavicular cortical buttons [CB2]; Isolated graft reconstruction [GR]; cortical button with graft augmentation [CB+GR]; coracoclavicular and acromioclavicular fixation [AC]) were included. Clinical outcomes were compared using a frequentist approach to NMA, with statistical analysis performed using R. Treatment options were ranked using the P-score, which estimates the likelihood that the investigated treatment is the ideal method for an optimal result in each outcome measure on a scale from 0 - 1. RESULTS:From 5362 reviewed studies, 26 studies met the inclusion criteria, with a total of 1581 patients included in the NMA. AC, CB+GR, GR, CB2, CBA, and CBO demonstrated superiority over HP, Scr, KW, and NO treatments at final follow up for Constant-Murley and DASH scores, with AC and CB+GR demonstrating the highest P-scores for Constant (P-score = 0.957 and 0.781, respectively) and GR and CBO with the highest P-scores for DASH (P-score = 0.896 and 0.750, respectively). GR had the highest P-score for VAS (P-score = 0.986). HP, CB2, CB+GR, AC, CBA, and CBO demonstrated superiority with final follow up coracoclavicular distance (CCD) and recurrence, with HP and CB2 having the highest P-score for CCD (P-score = 0.798 and 0.757, respectively) and GR and CB+GR having the highest P-score for recurrence (P-score = 0.880 and 0.855, respectively). KW and Scr had the shortest operative times (P-score = 0.917 and 0.810, respectively), with GR and CBA demonstrating longest operative times (P-score = 0.120 and 0.097, respectively). CONCLUSIONS:While there are multiple fixation options for acute surgical AC dislocations, adding AC fixation or graft augmentation likely improves functional outcomes and decreases CCD and recurrence at final follow up, at the expense of longer operative times.

PURPOSE/OBJECTIVE:The current investigation evaluated the relationship between the synovial fluid cytokine microenvironment at the time of isolated anterior cruciate ligament (ACL) reconstruction and the presence of subsequent chondral wear and radiologic evidence of osteoarthritis (OA) on cartilage-specific MRI sequences at a minimum of 5-year follow-up. METHODS:Patients who underwent primary ACL reconstruction with no baseline concomitant cartilage or meniscal defects and had synovial fluid samples obtained at the time of surgery were retrospectively identified. Patients with a minimum of 5 years of postoperative follow-up were contacted and asked to complete patient-reported outcome (PRO) measures including Visual Analog Scale (VAS) for pain, Lysholm Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Tegner Activity Scale, along with postoperative magnetic resonance imaging (MRI). The concentration of ten biomarkers that have previously been suggested to play a role in cartilage degradation and inflammation in the joint space was measured. Linear regression controlling for age, sex, and body mass index (BMI) was performed to create a model using the synovial fluid concentrations at the time of surgery to predict postoperative semiquantitative cartilage lesion size and depth on MRI at a minimum of 5 years follow up. RESULTS:The patients were comprised of eight males (44.4%) and ten females (55.6%) with a mean age at the time of surgery of 30.8 ± 8.7 years (range 18.2-44.5 years). The mean follow-up time was 7.8 ± 1.5 years post-operatively (range 5.7-9.7 years). MCP-1, VEGF, and IL-1Ra were found to have significant associations with the presence of postoperative cartilage wear (p < 0.05). No correlations were demonstrated among the biomarker concentrations at the time of injury with PRO scores at final follow-up (NS). CONCLUSION/CONCLUSIONS:Synovial fluid inflammatory biomarker concentrations at the time of injury can predict progression of early-stage post-traumatic osteoarthritis at a mean of almost 8 years post-operatively. Findings from this study may help identify treatment targets to alter the natural history of cartilage loss following anterior cruciate ligament injury. LEVEL OF EVIDENCE/METHODS:Level III, retrospective cohort study.

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.

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.