Faculty Bibliography

INTRODUCTION/BACKGROUND:Peroneal nerve injuries are rare injuries and usually associated with multiligamentous knee injuries (MLKIs) involving one or both cruciate ligaments. The purpose of our study was to perform a multicenter retrospective cohort analysis to examine the rates of peroneal nerve injuries and to see whether a peroneal nerve injury was suggestive of a particular injury pattern. METHODS:A retrospective chart review was conducted in patients who were diagnosed with MLKI at two level I trauma centers from January 2001 to March 2021. MLKIs were defined as complete injuries to two or more knee ligaments that required surgical reconstruction or repair. Peroneal nerve injury was clinically diagnosed in these patients by the attending orthopaedic surgeon. Radiographs, advanced imaging, and surgical characteristics were obtained through a chart review. RESULTS:Overall, 221 patients were included in this study. The mean age was 35.9 years, and 72.9% of the population was male. Overall, the incidence of clinical peroneal nerve injury was 19.5% (43 patients). One hundred percent of the patients with peroneal nerve injury had a posterolateral corner injury. Among patients with peroneal nerve injury, 95.3% had a complete anterior cruciate ligament (ACL) rupture as compared with 4.7% of the patients who presented with an intact ACL. There was 4.4 times of greater relative risk of peroneal nerve injury in the MLKI with ACL tear group compared with the MLKI without an ACL tear group. No statistical difference was observed in age, sex, or body mass index between patients experiencing peroneal nerve injuries and those who did not. CONCLUSION/CONCLUSIONS:The rate of ACL involvement in patients presenting with a traumatic peroneal nerve palsy is exceptionally high, whereas the chance of having a spared ACL is exceptionally low. More than 90% of the patients presenting with a nerve palsy will have sustained, at the least, an ACL and posterolateral corner injury. LEVEL OF EVIDENCE/METHODS:IV, Case Series.

BACKGROUND/UNASSIGNED:Patients undergoing anterior cruciate ligament (ACL) reconstruction have been shown to be at risk for postoperative arthrofibrosis. Diagnostic biomarkers associated with the development of postoperative stiffness are unknown. HYPOTHESIS/UNASSIGNED:Biomarkers found in the synovial fluid at the time of surgery are associated with the development of postoperative arthrofibrosis in a cohort of patients undergoing ACL reconstruction. STUDY DESIGN/UNASSIGNED:Case-control study; Level of evidence, 3. METHODS/UNASSIGNED:Patients undergoing ACL reconstruction were prospectively enrolled. Synovial fluid was collected before surgical incision. A cohort of patients with postoperative stiffness requiring manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) was retrospectively identified. Matching of cases to controls was performed using a 1:2 pair matching algorithm. Risk factor-adjusted single-biomarker and multivariable models were used to assess the association of synovial fluid biomarkers with postoperative stiffness requiring MUA/LOA. Stepwise logistic regression controlling for clinical risk factors was used to identify biomarkers that are possible predictors of postoperative stiffness. RESULTS/UNASSIGNED:= .046). CONCLUSION/UNASSIGNED:Higher concentrations of synovial fluid biomarkers bFGF and RANTES were associated with increased risk for stiffness requiring intervention after ACL reconstruction. Interleukin 6 (IL-6), vascular endothelial growth factor A (VEGF-A), tissue inhibitor of metalloproteinases 1 (TIMP-1), interleukin 1 receptor antagonist (IL-1RA), matrix metalloproteinase 3 (MMP-3), monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein 1B (MIP-1B) were not associated with the development of postoperative arthrofibrosis.

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.

PURPOSE OF REVIEW/OBJECTIVE:Given the continued controversy among orthopedic surgeons regarding the indications and benefits of arthroscopic partial meniscectomy (APM), this review summarizes the current literature, indications, and outcomes of partial meniscectomy to treat symptomatic meniscal tears. RECENT FINDINGS/RESULTS:In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for APM or non-surgical intervention depending on the tear pattern and symptoms. Non-surgical management for meniscal pathology includes non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), and intraarticular injections to reduce inflammation and relieve symptoms. There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of APM compared to PT or sham surgery in symptomatic degenerative meniscal tears. These most notably include the 2013 Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial, the 2018 ESCAPE trial, and the sham surgery-controlled Finnish Degenerative Meniscal Lesion Study (FIDELITY), which failed to identify substantial benefits of APM over nonoperative treatment or even placebo surgery. Despite an abundance of literature exploring outcomes of APM for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following APM. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant OA. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most RCTs show that exercise therapy may be non-inferior to APM in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of APM before proceeding to surgical management.

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.

Background/Purpose: 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. 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.
Method(s): 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.
Result(s): After matching,428 patients (214 on 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 of remaining flare-free up to 12 weeks (p = 0.004).
Conclusion(s): Rheumatic disease patients who hold IS medication before undergoing arthroscopy do not increase their risk of flaring their autoimmune disease. Those not taking any IS at baseline have amuch lower risk of post-arthroscopic flaring, though as a group they might harbor less of an autoimmune burden. Given the overall low observed rates of postoperative infection and complications among our cohort, the feared trade-off between infection risk and flare risk may not hold true in arthroscopy

Background/Purpose: Recent literature suggests that rheumatic disease patients hold most immunosuppressive (IS) medications before and after joint replacement surgery, to prevent infections and other complications. But there are currently no guidelines on peri-arthroscopic management of IS treatment in this population. The purpose of this study is to characterize the rheumatic disease patient population undergoing arthroscopy, compare the incidence of postoperative complications among patients who either remained on IS perioperatively, held IS perioperatively or were not on IS at baseline, and compare the incidence of postoperative complication by rheumatic disease type, medication type, and procedure.
Method(s): We conducted a retrospective review of all arthroscopic sports medicine surgeries in patients with a rheumatic disease diagnosis at our institution over an 11-year period. Patients on IS at baseline were grouped into those who remained on IS perioperatively or held all IS before the date of their surgery. These two groups were compared to rheumatic disease patients who were not on IS at baseline. Incidence of postoperative complications was calculated for the three cohorts and by medication class, rheumatic disease type, and procedure risk. Analysis of variance (ANOVA), Chi-squared, and Fisher's exact tests were used to determine the statistical significance of between-group differences in postoperative complication incidence.
Result(s): We identified 1,316 rheumatic disease patients undergoing arthroscopy, with 214 of them taking IS medications at baseline. Overall, 8.4% (n=110) remained on IS perioperatively, 7.9% (n=104) held IS perioperatively, and 83.7% (n=1102) were not on IS at baseline. In all cohorts, 7 patients experienced postoperative complications, with 6 of the 7 due to infections. There were two cases (1.82%) of infections among patients remaining on IS perioperatively, zero cases (0%) of infection in patients who held all IS, and four cases (0.36%) of postoperative infection in patients who were not on any IS at baseline. There was no statistically significant difference in postoperative infections or complication rates among the three cohorts or further subgroups.
Conclusion(s): Physicians and surgeons will increasingly be faced with challenging perioperative management decisions regarding IS in their rheumatic disease patients undergoing arthroscopic surgery. The present study is the first to suggest a low and acceptable risk of postoperative infections and other complications in these patients on IS at the time of arthroscopy

BACKGROUND:The purpose of this study was to evaluate for changes in the incidence of arthroscopic meniscal procedures, especially meniscal allograft transplantation (MAT) in New York State (NYS) between 2005 to 2014. METHODS:The New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2005 through 2014 to identify patients undergoing meniscetomies, meniscal repairs, and MAT. Patients were followed longitudinally to determine the incidence of subsequent ipsilateral knee procedures. The impact of patient demographics and surgeon volume on reoperation was explored. RESULTS:From 2005 through 2014, there were 524,737 arthroscopic meniscal procedures. Of these, there were 510,406 meniscectomies, 14,214 meniscal repairs, and 117 MATs. The number of MATs increased 15.5% per year, with the largest increase being between 2013 to 2014 (an increase of 86.5%). Average MAT patient age was 29.8 ± 11.1 years; 65.0% of patients were male; 66% were Caucasian; 84% were privately-insured; and 23% of surgeons met the criteria for high-volume (five or more MATs in a year). A total of 25.6% (30/117) patients underwent subsequent surgery; 26 patients underwent knee procedures at mean of 18.9 ± 18.3 months after initial MAT, the most common of which were ipsilateral meniscectomies (19/26). Four patients underwent total knee arthroplasty (TKA) at a mean of 21.0 ± 9.2 months after initial MAT. Patients undergoing TKA after MAT were significantly older (42.0 ± 15.0 years vs, 29.3 ± 10.7 years; p = 0.0242) than patients who did not. Neither demographics nor surgeon volume were statistically significant factors for undergoing subsequent surgery (p > 0.05). CONCLUSION/CONCLUSIONS:Meniscal allograft transplantation, though relatively uncommon, is being performed with greater frequency in NYS. Surgeons should counsel patients regarding the likelihood of requiring subsequent knee surgery after MAT, with repeat arthroscopic partial meniscectomy being the most commonly performed procedure.

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.

SUMMARY/CONCLUSIONS:This case presentation described a technique for repairing an acute quadriceps tendon rupture with suture anchors. The patient was a 51-year-old man who sustained an acute quadriceps tendon rupture after a fall. We used a midline incision over the quadriceps tendon and muscle. The tendon was found to be completely avulsed from the superior border of the patella. Three suture anchors were used to re-approximate the quadriceps tendon to the patella and additional sutures were used to repair the medial and lateral patellar retinacula. The patient had excellent range of motion at his 6-week follow-up appointment after the procedure.