Faculty Bibliography

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.

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.

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.

SUMMARY/CONCLUSIONS:A 46-year-old man presents with left knee bucking 3 months after open reduction and internal fixation of a left knee inferior pole patella fracture. Radiograph and magnetic resonance imaging evaluation reveal displacement and comminution of the inferior pole of the patella confirming failure of the repair. The purpose of this video is to demonstrate the surgical management of failed inferior pole patella fractures using suture anchors for repair of the patella tendon and augmentation with ipsilateral autologous hamstring grafts.

Purpose/UNASSIGNED:The purpose of this study was to assess the rate of hospital admissions, inpatient conversions, reoperations, and complications associated with tibial tubercle osteotomies (TTO), high tibial osteotomies (HTO), and distal femoral osteotomies (DFO) performed at our ambulatory surgery center compared with our inpatient hospital facility. Methods/UNASSIGNED:value of <0.05 was considered to be statistically significant. Results/UNASSIGNED: = .698, respectively). Conclusions/UNASSIGNED:Osteotomies about the knee performed in an ambulatory setting were safe, with no difference in readmission, reoperation, or postoperative complications compared to those performed at an inpatient hospital. Additionally, no patient required conversion from an outpatient to an inpatient setting. Level of Evidence/UNASSIGNED:Level III, retrospective comparative study.

PURPOSE/OBJECTIVE:The purpose of this study was to analyze patients that did not return to play (RTP) following arthroscopic Bankart repair (ABR) compared to those who did RTP, and analyze factors associated with not returning to play. METHODS:A retrospective review of patients who underwent ABR, and subsequently did not RTP after a minimum of 24-month follow-up was performed. Additionally, these were pair matched in a 3:1 ratio for age, gender, sport and level of pre-operative play with a control group who RTP. Patients were evaluated for their psychological readiness to return to sport using the SIRSI score. Multivariate regression models were used to evaluate factors affecting RTP. RESULTS:The study included a total of 52 patients who were unable to RTP and 156 who returned to play. Ten patients (19.2 %) who did not RTP passed the SIRSI benchmark of 56 with a mean overall score of 39.8 ± 24.6, in those who returned 73.0 % passed the SIRSI benchmark of 56 with a mean overall score of 68.9 ± 22.0 (p < 0.0001 for both). The most common primary reasons for not returning were 27 felt physically unable to return, whilst 21 felt it was a natural end to their career or their lifestyle had changed. Multi-logistic regression revealed that 4 of the 12 components of the SIRSI score (p < 0.05 for all) and SSV (p = 0.0049), were the factors that were associated with RTP. CONCLUSION/CONCLUSIONS:Following ABR, those that do not return to play exhibit poor psychological readiness to return to play, with multi-linear regression revealing the SIRSI questions associated with fear of re-injury were associated with a lower rate of RTP. Additionally, functional limitations were found to be associated with a lower rate of RTP. LEVEL OF EVIDENCE/METHODS:Level III; Retrospective Comparative Cohort Study.

Purpose/UNASSIGNED:To determine whether an association exists between the presence of cervical spine pathology and postoperative patient-reported outcomes (PROs) in patients undergoing open subpectoral biceps tenodesis (BT). Methods/UNASSIGNED:text, Fisher exact test, or analysis of variance. Results/UNASSIGNED: = .046). There were no significant differences between groups' ASES, baseline VAS, overall satisfaction scores, and willingness to undergo the same operation again. No significant differences were found in postoperative rate of return to sport, time to return, and return to preoperative competitiveness. Conclusions/UNASSIGNED:Patients with SLAP tears undergoing isolated BT in the presence of cervical spinal stenosis may have inferior Subjective Shoulder Value, Shoulder Instability-Return to Sport after Injury, and VAS during sport scores as compared with controls, although many PROs were similar at follow-up. Athletes undergoing BT, particularly with concomitant cervical spine pathology, should be counseled appropriately before surgery. Level of Evidence/UNASSIGNED:Level III, case-control study.

BACKGROUND/UNASSIGNED:Despite the widespread use and sales of cannabidiol (CBD) products in the United States, there is a paucity of literature to evaluate its effectiveness, safety, or ideal route of administration for postoperative pain. PURPOSE/UNASSIGNED:To evaluate the potential analgesic effects of buccally absorbed CBD in patients who have undergone arthroscopic rotator cuff repair (ARCR). STUDY DESIGN/UNASSIGNED:Randomized controlled trial; Level of evidence, 1. METHODS/UNASSIGNED:< .05 was considered to be statistically significant. RESULTS/UNASSIGNED:> .05). CONCLUSION/UNASSIGNED:Buccally absorbed CBD demonstrated an acceptable safety profile and showed significant promise in the reduction of pain in the immediate perioperative period after ARCR compared with the control. Further studies are currently ongoing to confirm dosing and effectiveness in other orthopaedic conditions. REGISTRATION/UNASSIGNED:NCT04672252 (ClinicalTrials.gov identifier).

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the mid-term results of posterior medial meniscal root tear (PMMRT) repair through assessment of functional outcome scores and magnetic resonance imaging (MRI). METHODS:This was a single-center, retrospective study evaluating patients that had undergone a PMMRT. This was a follow-up to a previously published 2-year outcome study (all original patients were invited to participate). Clinical outcomes included pre- and postoperative International Knee Documentation Committee (IKDC) and Lysholm scores. Root healing, meniscal extrusion, and cartilage degeneration via International Cartilage Repair Society Scale (ICRS) grades were assessed on MRI by two musculoskeletal fellowship-trained radiologists. RESULTS:10 of the original study's 18 patients were able to participate. Mean age and BMI was 48.4 ± 12.0 years and 29.5 ± 4.5, respectively, with mean follow-up 65.5 ± 8.3 months (range 52.0-75.8) (60% female). The IKDC significantly increased from 43 ± 13 preoperatively to 75 ± 16 at 5-year follow-up (p < 0.001). There was no significant change in IKDC score between 2-year and 5-year follow-up [75 ± 16 vs 73 ± 20, (n.s)]. The Lysholm also significantly increased between preoperative and 5-year follow-up (49 ± 7 vs 84 ± 11, p < 0.001). There was no significant change between Lysholm score at 2-year and 5-year follow-up [84.0 ± 11 vs 82 ± 13, (n.s)]. Mean extrusion did not significantly change from the preoperative state to 5-year follow-up [4.80 mm ± 1.9 vs 5.0 mm ± 2.5, (n.s.)]. Extrusion also did not significantly change between 2-and 5-year follow-up [6.1 ± 3.2 mm vs 5.0 mm ± 2.5, (n.s.)]. No patients with > 3 mm of extrusion on preoperative MRI had < 3 mm of extrusion on postoperative MRI. Both medial femoral condyle and medial tibial plateau ICRS grades significantly increased from preoperative to 2-year follow-up (p = 0.038, p = 0.023, respectively). Medial femoral condyle and medial tibial plateau ICRS grades again significantly increased between 2-year and 5-year follow-up (p = 0.014, p = 0.034). CONCLUSION/CONCLUSIONS:Patients treated with the transtibial suture pullout technique with two locking cinch sutures had maintenance of clinical outcome improvements at 5-year follow-up. However, extrusion was widely prevalent, with worsening progression of femoral and tibial chondral disease. LEVEL OF EVIDENCE/METHODS:Level 4.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the outcomes of patients 5-years post-operatively following arthroscopic superior-labrum anterior-posterior (SLAP) repair, and to evaluate factors associated with satisfaction. METHODS:A retrospective review of patients who underwent SLAP repair with a minimum of 5-year follow-up was performed. Recurrence, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, satisfaction, whether they would undergo the same surgery again, and the rate, level and timing of return to play (RTP) were evaluated. Multi-linear regression models were used to evaluate factors affecting postoperative satisfaction. RESULTS:Overall, 122 patients who underwent SLAP repair were included, with a mean age of 33.4 years. 81% were males, and 58.2% were participating in sport pre-operatively. The mean follow-up was 86.4 ± 14.4 months. At final follow up, the mean satisfaction was 87.7%, and the mean SSV was 82.9. Overall, the rate of RTP was 85.9%, with 64.8% returning at the same level at a mean of 10.5 ± 8 months. Ultimately, 13 (10.7%) patients had a further surgery, including 10 (8.2%) patient that had a biceps tenodesis. VAS during sport (p = 0.025), SSV (p < 0.001), and time to RTP (p = 0.0056), were associated with higher satisfaction. CONCLUSION/CONCLUSIONS:There was a high rate of satisfaction at 5-year follow-up, with excellent patient reported outcomes but with a tenth of patients requiring revision surgeries. Additionally, while there was an overall high rate of RTP, there was only a modest rate of RTP at their pre-injury level and overhead athletes took longer to RTP.