Faculty Bibliography

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.

The anterior cruciate ligament (ACL) is the primary restraint to tibial internal rotation and is supported by secondary stabilizers, including the iliotibial band (ITB), anterolateral ligament (ALL), anterolateral capsule, and lateral meniscus, which provide additional rotational control. Combined injury to primary and secondary rotational stabilizers can lead to anterolateral rotatory instability. This can best be demonstrated in patients with large pivot-shifts. Biomechanical studies have demonstrated that ACL reconstruction (ACLR) alone does not restore native kinematics in the setting of a combined injury. Concomitant anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET) techniques have been evaluated as a possible solution. Both the LET and ALLR may help restore rotational control, with the LET being slightly more powerful due to its more horizontal force vector based on biomechanical studies. However, there may be a slight risk of overconstraint with both techniques, more pronounced with the LET. Clinical studies evaluating the techniques for both primary and revision ACLR have generally found both to be safe and effective, leading to decreased rates of re-rupture and improved outcome scores. Either technique is a reasonable addition to ACLR when additional rotational control is indicated, though the LET may be more reproducible.

Anterior cruciate ligament (ACL) repair is a procedure that has been used to treat torn ACLs dating back to the early 1900s. With unpredictable outcomes of repair, a paradigm shift led to surgeons to opt for ACL reconstruction as a new gold standard, as the evidence showed a more reliable outcome. However, there has been a recent resurgence in ACL repair worthy of review, particularly in proximal avulsions. Suture anchor repair is one repair technique in which recent studies show low failure rates, low reoperation rates, and favorable clinical outcomes. More recent data supports augmenting this strategy with suture tape. An innovation in ACL repair techniques is the Bridge-Enhanced ACL Repair (BEAR) technique, which combines a patient's whole blood with a collagen-based scaffold to augment the repair. While promising results have been shown with these techniques, narrow indications are necessary for a successful ACL repair.

OBJECTIVE:To determine whether concomitant psychiatric diagnoses and medication use were associated with postfasciotomy outcomes in patients with chronic exertional compartment syndrome (CECS). DESIGN/METHODS:Retrospective comparative cohort study. SETTING/METHODS:Single academic medical center from 2010 to 2020. PATIENTS/METHODS:All patients above 18 years old who underwent fasciotomy for CECS. ASSESSMENT OF RISK FACTORS/INDEPENDENT VARIABLES/UNASSIGNED:Psychiatric history was recorded from electronic health records including disease diagnosis and medications. MAIN OUTCOME MEASURES/METHODS:The 3 main outcome measures were postoperative pain using the Visual Analog Scale, functional outcomes using the Tegner Activity Scale, and return to sport. RESULTS:Eighty one subjects (legs), 54% male, with an average age of 30 years and follow-up of 52 months were included. 24 subjects (30%) had at least one psychiatric diagnosis at the time of surgery. Regression analysis found psychiatric history to be an independent predictor of worse postoperative pain severity and postoperative Tegner scores (P < 0.05). Furthermore, subjects with psychiatric disorders not on medication had worse pain severity (P < 0.001) and Tegner scores (P < 0.01) versus controls, whereas subjects with a psychiatric disorder on medication had better pain severity (P < 0.05) versus controls. CONCLUSIONS:History of psychiatric disorder was predictive of worse postoperative pain and activity outcomes after fasciotomy for CECS. Use of psychiatric medication was associated with improvement in pain severity in some domains.

INTRODUCTION/BACKGROUND:Prior studies of hamstring tendon tears have reported varied findings on whether increased delay from injury to surgery is associated with worse outcomes. The purpose of this study was to determine whether increased time from injury to surgical repair is associated with worse clinical outcomes in patients with proximal hamstring ruptures. MATERIALS AND METHODS/METHODS:Patients who underwent surgical repair of a proximal hamstring rupture from 2010 to 2019 were followed for a minimum of 24 months from surgery. A cutoff of 6 weeks from injury to the time of surgery was used to distinguish between acute and chronic ruptures. All patients completed patient-reported outcome measures (PROs) at the final follow-up. Multiple factors were analyzed for their effects on PROs including time to surgery, amount of tendon retraction, and demographics such as sex and age. RESULTS:Complete data sets were obtained for 38 patients at a mean follow-up of 4.9 years. All data is reported as a mean ± standard deviation. Patients who underwent acute repair of proximal hamstring ruptures had significantly greater Perth Hamstring Assessment Tool (PHAT) scores than those who underwent chronic repair (76.9 ± 18.8 vs 60.6 ± 18.2, p = 0.01). Increased time to surgery was significantly correlated with worse PHAT scores (ρ = - 0.47, p = 0.003). There was no difference in PROs based on the amount of tendon retraction, number of tendons torn, sex, smoking status, or BMI. CONCLUSIONS:This study found that acute repair performed within 6 weeks of injury appears to yield improved PROs compared to chronic repair. These data highlight the importance of timely and accurate diagnosis of proximal hamstring ruptures and early operative intervention for surgical candidates.

PURPOSE/OBJECTIVE:To determine the rate and characteristics of postoperative flares in rheumatic disease patients undergoing arthroscopic surgery, and the role of perioperative immunosuppression (IS) management in preventing or provoking these exacerbations. METHODS:We conducted a retrospective review of arthroscopic surgeries in patients with rheumatologic disease over 11 years. Patients taking IS at baseline and those without were matched 1:1 using propensity scores on age, sex, rheumatic disease type, and procedure complexity. Patients taking IS at baseline were sub-divided into those remaining on IS perioperatively versus those who held IS before surgery. Multivariable logistic regression identified risk factors for postoperative flares for the three IS groups, and survival analysis was used to compare the probability of remaining flare-free up to 12 weeks postoperatively. RESULTS:After matching, 428 patients (214 on various types of baseline IS, 214 not on baseline IS) were included, with 110 on baseline IS remaining on it perioperatively. Rates of postoperative flares were similar for those staying on vs holding their baseline IS (9.1% vs 9.6%) but flares were less frequent in patients not on baseline IS (1.9%). Patients who remained on perioperative IS did not have significantly less flares compared to patients taken off perioperative IS (OR 0.764 [0.267, 2.181]; p = 0.61). Patients not on baseline IS had a significantly higher probability ofremaining flare-free up to 12 weeks (p = 0.004). CONCLUSION/CONCLUSIONS:Rheumatic disease patients who hold IS medication before undergoing arthroscopy, out of concern for potential infection or complications, do not significantly increase their risk of flaring their autoimmune disease whether they had been taking csDMARDs or biologic agents. Those not taking any IS at baseline have a much lower risk of post-arthroscopic flaring, though as a group they likely harbor less of an autoimmune burden.

Introduction: While OCA has been shown to result in good long-term outcomes, there is still a considerable failure rate present with room for improvement. Objectives: The purpose of this study is to evaluate the impact that osteochondral allograft cartilage thickness has on contact pressures, and to simulate whether a mismatch of the subchondral bony interface relative to the host-recipient site results in altered biomechanics. Methods: Properties of articular cartilage and bone were incorporated into a finite element model to create a simulated osteochondral lesion (diameter: 10 mm, height: 10 mm, cartilage thickness: 2 mm, subchondral bone thickness: 8 mm). Five osteochondral plugs were constructed to fill the defect, with cartilage-to-bone ratios between 1:9 and 1:1. The plugs were inserted and given a static downward force of 5000 N. Resultant stresses and displacements were measured. Results: The 2:8 cartilage-to-bone ratio plug, matched with the recipient site, was deemed optimal based on its resultant stress and displacement. The 1:9 plug displaced less than the 2:8 match and endured greater stress per unit of cartilage volume, whereas the 3:7 plug also displayed similar displacement to the 1:9 plug but had greater cartilage volume and was able to distribute less stress per unit of cartilage volume. The 4:6 plug displaced to a similar extent as the 3:7 plug but displayed a unique pattern of strain. The 5:5 plug was considered nonfunctional, as the majority of displacement was seen in the cartilage of the recipient site rather than in the plug itself. Conclusions: The relationship between the cartilage-to-bone ratio in osteochondral allografts and that of their surroundings significantly impacts the distribution of stresses and predilection for micromotion at the repair site.

PURPOSE/OBJECTIVE:Multi-ligamentous knee injuries (MLKIs) are high-energy injuries that may infrequently present with concomitant patellar tendon rupture. There is limited information in the literature regarding these rare presentations, with even less information regarding clinical outcomes. Using propensity-score matching, the purpose of this study was to compare the outcomes of MLKIs with and without patellar tendon ruptures and to investigate the overall predictors of these outcomes. METHODS:Twelve patients who underwent surgical repair for combined MLKI and patellar tendon rupture from 2011 to 2020 with minimum 1-year follow-up data were identified from two separate institutions. Patients were propensity-score matched with a 1:1 ratio with controls based on age, body mass index (BMI), gender, and time from surgery. Patient-reported outcomes included International Knee Documentation Committee (IKDC) Subjective Knee Form, Lysholm and Tegner scores. RESULTS:Twelve MLKIs with concomitant patellar tendon injuries were identified out of a multicenter cohort of 237 (5%) patients sustaining MLKI and were case matched 1:1 with 12 MLKIs without extensor mechanism injuries. The average follow-up was 5.5 ± 2.6 years. There were no differences in Schenck Classification injury patterns. There were significant differences found across IKDC (Patellar Tendon mean: 53.1 ± 24.3, MLKI mean 79.3 ± 19.6, P < 0.001) and Lysholm scores (Patellar Tendon mean: 63.6 ± 22.3, MLKI mean 86.3 ± 10.7, P < 0.001) between the two, illustrating poorer outcomes for patients with concomitant patellar tendon ruptures. CONCLUSION/CONCLUSIONS:In the setting of MLKI, patients who have a concomitant patellar tendon rupture have worse functional outcomes compared to those without. This information will be important for patient counseling and might be considered to be added to Schenck classification, reflecting its prognostic value. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND:Recent interest has surged in the anterolateral ligament (ALL) and complex (ALC) of the knee. Its existence and role in rotary stability of the knee, particularly in the setting of anterior cruciate ligament (ACL) reconstruction, remains a contentious and controversial topic. UNDERSTANDING THE ALC/UNASSIGNED:We must review our history and recognize the pioneers who pushed our understanding of the ALL forward before it was popularly recognized as a discrete structure. Additionally, given that many eponyms remain in common use related to the ALC, we must standardize our nomenclature to prevent misuse or misunderstanding of terms in the literature. In this review, modern understanding of the anterolateral ligament complex (ALC) is traced to 1829 by exploring eponymous terms first in anatomy and then in surgical technique. Understanding our history and terminology will allow us to better understand the ALC itself. CONCLUSION/CONCLUSIONS:This review aims to provide historical context, define terminology, and provide insight into the clinical relevance of the ALC.

BACKGROUND:Tibial tubercle anteromedialization (AMZ) is a commonly performed procedure for patients with patellofemoral instability or patellofemoral osteochondral disease. While prior studies have demonstrated that this form of osteotomy produces generally good outcomes, the time needed for return to work and return to sport remains unclear. This study aimed to determine the mean length of time before return to work and the rate of return to sport following AMZ. PATIENTS AND METHODS/METHODS:Patients who had undergone AMZ for either patellofemoral instability or isolated osteochon- dral defect with a minimum follow-up time of 1 year were identified. Patients less than 18 years of age were excluded. Patients were asked to complete a series of patient reported outcomes surveys including specific queries regarding their return to work and return to athletic activity. RESULTS:A total of 109 patients were included in this study. The majority were female (79 patients, 72.3%). The mean age was 30.74 ± 9.90 years at the time of surgery. The mean follow-up duration was 3.40 ± 1.97 years. Of the 109 patients, 104 (95.4%) had returned to work at the time of follow-up. Mean time to return to work was 2.96 ± 3.33 months (range: 0.25 to 24 months). Of the 90 patients who were involved in a sport or physical activity prior to injury, 64 patients (71.1%) had returned to sport at some level at the time of most recent follow-up. Of those who had returned to sport, mean time to return to sport was 9.21 ± 5.46 months (range: 1 to 24 months). CONCLUSIONS:At a minimum follow-up time of 1 year, patients who underwent AMZ were found to have a return to sport rate of 71% with a mean time of 9.21 months to return to athletic activity. Over 95% of AMZ patients had returned to work by 1 year after the procedure. Patients required an average of 3 months to return to work, although those with physically demanding jobs required slightly more time. Data from the current study is useful in setting expectations for patients undergoing tibial tubercle anteromedialization for patellofemoral instability or patellofemoral osteochondral disease.