Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose of the current study is to perform a systematic review of the literature and evaluate maximum medical improvement and minimal clinically important difference (MCID) of different injectables in the treatment of symptomatic knee osteoarthritis. METHODS:A systematic review was performed to evaluate maximum medical improvement and MCID in patients undergoing injections of different modalities for knee osteoarthritis. Demographic factors of the patients being reviewed were analyzed, with patient-reported outcomes as reported by visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) being used to evaluate the clinical trajectory of patients receiving intra-articular injections. RESULTS:Overall, 79 (level of evidence I: 79) studies met inclusion criteria, with 8761 patients. Corticosteroid (CS) injections, middle molecular weight hyaluronic acid (MMW-HA), and leukocyte-rich platelet rich plasma (LR-PRP) injections reached their maximum pain control at 4 to 6 weeks after injection, as measured by VAS. The lowest VAS scores were reached for low molecular weight hyaluronic acid (LMW-HA), high molecular weight hyaluronic acid (HMW-HA), and leukocyte-poor platelet rich plasma (LP-PRP) by 3 months after injection. Similarly, the WOMAC scores were lowest at 4 to 6 weeks after CS and MMW-HA injections, and at 3 months after HMW-HA and LP-PRP injections. LR-PRP demonstrated the most prolonged pain relief relative to the other injection types, with the lowest VAS score of all groups measured at final follow-up. LP-PRP showed the lowest WOMAC scores at final follow-up, one year post-injection. CONCLUSION/CONCLUSIONS:PRP injections provide continued pain relief at up to 1 year after injection. Corticosteroids and hyaluronic acid have good efficacy and are suitable for many patients but lack this longevity. LEVEL OF EVIDENCE/METHODS:Level I, a systematic review of Level I studies.

BACKGROUND:The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair. METHODS:Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability. RESULTS:Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%). CONCLUSIONS:Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

PURPOSE/OBJECTIVE:The purpose of the current study is to compare the outcomes of open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under the age of 30 years. METHODS:A retrospective review of patients under the age of 30 years who underwent either isolated BT or AR for a diagnosis of a SLAP tear between 2011 and 2019 was performed. Patients were included if they were >16 years old at the time of surgery, had an isolated SLAP tear involving instability of the biceps-labral anchor (types II-IV), were skeletally mature, and had a minimum follow-up of 12 months. The American Shoulder & Elbow Surgeons score, visual analog scale, Subjective Shoulder Value, patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A P value of <.05 was considered statistically significant. RESULTS:Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, and the mean follow-up duration was 60 months. At final follow-up, there was no difference between treatment groups in any of the functional outcome measures assessed (P > .05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; P = .53), timing of RTP (BT: 8.8 months, AR: 9.4 months; P = .61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; P > .99). Among those undergoing AR, 9 required a revision procedure (11.5%) compared to none treated with BT (P = .11). CONCLUSIONS:In patients under the age of 30 years with a symptomatic isolated SLAP tear, BT may be a reliable alternative to AR. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

PURPOSE/OBJECTIVE:The purpose of this study was to identify if the location of posterolateral corner (PLC) injury was predictive of clinical common peroneal nerve (CPN) palsy. METHODS:A retrospective chart review was conducted of patients presenting to our institution with operative PLC injuries. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. A fellowship-trained musculoskeletal radiologist reviewed the PLC injury and categorized it into distal, middle and proximal injuries with or without a biceps femoral avulsion. The CPN was evaluated for signs of displacement or neuritis. RESULTS:Forty-seven operatively managed patients between 2014 and 2019 (mean age-at-injury 29.5 ± 10.7 years) were included in this study. Eleven (23.4%) total patients presented with a clinical CPN palsy. Distal PLC injuries were significantly associated with CPN palsy [9 (81.8%) patients, (P = 0.041)]. Nine of 11 (81.8%) patients with CPN palsy had biceps femoral avulsion (P = 0.041). Of the patients presenting with CPN palsy, only four (36.4%) patients experienced complete neurologic recovery. Three of 7 patients (43%) with an intact CPN had full resolution of their clinically complete CPN palsy at the time of follow-up (482 ± 357 days). All patients presenting with a CPN palsy also had a complete anterior cruciate ligament (ACL) rupture in addition to a PLC injury (P = 0.009), with or without a posterior cruciate ligament (PCL) injury. No patient presenting with an isolated pattern of PCL-PLC injury (those without ACL tears) had a clinical CPN palsy. CONCLUSION/CONCLUSIONS:Distal PLC injuries have a strong association with clinical CPN palsy, with suboptimal resolution in the initial post-operative period. Specifically, the presence of a biceps femoris avulsion injury was highly associated with a clinical CPN palsy. Additionally, CPN palsy in the context of PLC injury has a strong association with concomitant ACL injury. Furthermore, the relative rates of involvement of the ACL vs. PCL suggest that specific injury mechanism may have an important role in CPN palsy. LEVEL OF EVIDENCE/METHODS:IV.

PURPOSE/OBJECTIVE:Extensor mechanism ruptures (EMR) of the knee are rare but debilitating injuries that always require surgery to restore knee function. The purpose of this study was to systematically review the literature to ascertain the rate of return to play following patellar or quadriceps tendon ruptures. METHODS:A systematic literature search was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using the EMBASE, MEDLINE, and Cochrane Library databases. Inclusion criteria consisted of clinical studies reporting on return to play after patellar or quadriceps tendon repair. Statistical analysis was performed with the use of SPSS. RESULTS:Our review found 48 studies including 1135 cases meeting our inclusion criteria. There were 33 studies including 757 patellar tendon (PT) repairs, and 18 studies including 378 quadriceps tendon (QT) repairs. The overall rate of return to play for PT repairs was 88.9%, with 80.8% returning to the same level of play. The overall rate of return to play for QT repairs was 89.8%, with 70.0% returning to the same level of play. Among professional athletes, the overall rate of return to play after PT repair and QT repair was 76.9% and 70.9%, respectively. Following PT repair, 95.8% were able to return to work, and following QT repair, 95.9% were able to return to work. CONCLUSION/CONCLUSIONS:The overall rate of return to play was high following both PT and QT repairs. Moreover, a high percentage of those patients were able to return to their pre-operative level of sport with a low risk for re-rupture. LEVEL OF EVIDENCE/METHODS:Level IV.

Objectives: Tranexamic acid (TXA) is a commonly used medication in orthopaedic procedures, reducing perioperative bleeding and need for transfusion. The purpose of this double-blind randomized controlled study was to evaluate if IV TXA for primary anterior cruciate ligament (ACL) reconstruction with bone-patella tendon-bone (BTB) could reduce perioperative blood loss or postoperative intra-articular hemarthrosis without postoperative drains.
Method(s): A controlled, randomized, double-blinded trial was conducted in 110 patients who underwent ACLR with BTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-gram boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated, and the volume of blood (ml) was recorded. Additionally, perioperative blood loss (ml); Visual Analog Scale (VAS) on postoperative days (POD) 1-7 and post-operative weeks (POW) 1, 6 and 12; postoperative opioid consumption POD 1-7; range of motion (ROM) and ability to straight leg raise (SLR) at POW 1, 6, 12; and pre and postoperative thigh circumference ratio (TCR).
Result(s): There was no significant difference in perioperative blood loss between the experimental and control groups (32.5ml v. 35.6ml, p=0.47). The experimental group had 23 knees aspirated; control group had 26 knees aspirated (p=0.56). No significant difference seen in postoperative hemarthrosis volume with IV TXA (26.7ml v. 37.3ml, p=0.12). There was no significant difference in VAS score between the two groups (p=0.15), additionally, there was no difference in postoperative opioid consumption (p=0.33). There was no significant difference in ROM or ability to SLR, or pre- nor post-operative TCR (p > 0.05 for all).
Conclusion(s): IV TXA in patients who undergo ACLR with BTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early post-operative recovery regarding ROM or quadriceps reactivation

Objectives: Medial patellofemoral ligament reconstruction (MPFLR) using allograft tissue has several potential benefits including the absence of donor site morbidity, ability to predict graft parameters, and decreased operative time. The purpose of this study was to evaluate the outcomes of patients following MPFLR with allograft. Our hypothesis was that there would be a low rate of recurrent instability, and excellent clinical outcomes reported.
Method(s): A retrospective review of athletes who underwent MPFL Reconstruction, with a minimum of 12-month follow-up was performed. Recurrent instability (including re-dislocation and subluxation), Visual Analogue Scale (VAS) score, Kujala score, satisfaction, and whether they would undergo the same surgery again, were evaluated.
Result(s): Overall, follow up was attained for 131 patients with 141 knees (73.4%). The mean patient age of 25.0 years, 67.4% females, and mean time to follow-up was 46.8 months (12-111). At final follow up, the mean VAS score was 1.4 +/- 2.0, the mean Kujala score was 84.8 +/- 15.6, the mean satisfaction score was 84% +/- 26.0, and 117 (83.0%) would undergo the same procedure again if required. There was 17 (12.0%) patients that had recurrent instability, with 2 being re-dislocations (1.4%). A further procedure was performed in 14 patients (9.9%). There were no intra-operative complications in our series.
Conclusion(s): There was a low rate of recurrent instability following MPFLR with allograft, with excellent patient reported outcomes, and a low complication rate

Objectives: The purpose of this study is to compare the outcomes of mini-open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under 30.
Method(s): A retrospective review of patients who underwent either isolated BT or AR for the diagnosis of a SLAP tear was performed. Patients with a follow-up duration of <24 months were excluded. The American Shoulder & Elbow Surgeons (ASES) score, Visual Analogue Scale (VAS), Subjective Shoulder Value (SSV), patient satisfaction, willingness to undergo surgery again, revisions, and return to work/sport were evaluated. A p value of <0.05 was considered to be statistically significant.
Result(s): Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, 79.4% were male, and the mean follow-up duration was 60 months. At final follow up, there was no difference between treatment groups in any of the functional outcome measures assessed (p > 0.05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; p = 0.53), timing of RTP (BT: 8.8 months, AR: 9.4 months; p = 0.61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; p = 1). However, there was a significantly lower rate of revision surgery with BT (0%) as compared to AR (14.1%; p = 0.03).
Conclusion(s): In patients under the age of 30 with isolated SLAP tear pathology, BT is a reliable alternative to AR, with a low rate of revision surgery, and excellent patient reported outcomes