Faculty Bibliography

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.

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.

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.

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.

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.

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 purpose of this study was to establish consensus statements on the treatment of UCL injuries and to investigate whether consensus on these distinct topics could be reached. METHODS:A modified consensus technique was conducted among twenty-six elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90-99% agreement. RESULTS:Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus. CONCLUSION/CONCLUSIONS:There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and prior injury. There was unanimous agreement that advanced imaging in the form of either an MRI or MRA should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of non-operative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for RTS were regarding: portions of the physical exam should be considered when determining whether to allow a player to RTS, unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS. LEVEL OF EVIDENCE/METHODS:Expert opinion (Level V).

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.