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.

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.

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.

Background/UNASSIGNED:Peroneal nerve (PN) palsy is one of the most debilitating sequelae of multiligamentous knee injuries (MLKIs). There is limited research on recovery from complete PN palsy. Purpose/Hypothesis/UNASSIGNED:The purpose of this study was to characterize PN injuries and develop a predictive model of complete PN recovery after MLKI using machine learning. It was hypothesized that elevated body mass index (BMI) would be predictive of lower likelihood of recovery. Study Design/UNASSIGNED:Case-control study; Level of evidence, 3. Methods/UNASSIGNED:The authors conducted a retrospective review of patients seen at 2 urban hospital systems for treatment of MLKI with associated complete PN palsy, defined as the presence of complete foot drop with or without sensory deficits on physical examination. Recovery was defined as the complete resolution of foot drop. A random forest (RF) classifier algorithm was used to identify demographic, injury, treatment, and postoperative variables that were significant predictors of recovery from complete PN palsy. Validity of the RF model was assessed using overall accuracy, F1 score, and area under the receiver operating characteristic curve (AUC). Results/UNASSIGNED:Overall, 16 patients with MLKI with associated complete PN palsy were included in the cohort. Among them, 75% (12/16) had documented knee dislocation requiring reduction. Complete recovery occurred in 4 patients (25%). Nerve contusions on magnetic resonance imaging were more common among patients without PN recovery, but there were no other significant differences between recovery and nonrecovery groups. The RF model found that older age, increasing BMI, and male sex were predictive of worse likelihood of PN recovery. The model was found to have good validity, with a classification accuracy of 75%, F1 score of 0.86, and AUC of 0.64. Conclusion/UNASSIGNED:The RF model in this study found that increasing age, BMI, and male sex were predictive of decreased likelihood of nerve recovery. While further study of machine learning models with larger patient data sets is required to identify the most superior model, these findings present an opportunity for orthopaedic surgeons to better identify, counsel, and treat patients with MLKIs and concomitant complete PN palsy.

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.

Objectives: The purpose of the current study was to investigate clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex.
Method(s): A retrospective review of overhead athletes who underwent biceps tenodesis for a SLAP tear was performed. 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 play (RTP) were evaluated. Psychological readiness to return to sport was evaluated using the SLAP-Return to Sport after Injury (SLAP-RSI) score. A p value of <0.05 was considered to be statistically significant.
Result(s): The current study included 44 overhead athletes. The mean age was 34.9 (16-46), 79.5% were males, and the mean follow-up was 49 months (18-107). Overall, we found that 81.8% of patients returned to play their overhead sport following biceps tenodesis, and 59.1% of patients returned to the same or higher level of play. It took patients on average 8.7 months to return to play following biceps tenodesis. The mean SLAP-RSI score was 69.3, and 70.5 % of patients passed the SLAP-RSI threshold of 56. The mean scores for ASES, VAS, SSV, and satisfaction were 92, 0.8, 80.5, and 87.9%, respectively. No patients in our cohort required a revision surgery.
Conclusion(s): This study found that athletes undergoing biceps tenodesis as the treatment for a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery

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 examine the relationship between obesity and post-operative stiffness following surgical management of MLKIs using a large two-center cohort, by both (1) using binary cutoffs at various body mass indexes (BMI) and (2) a linear regression model. METHODS:190 consecutive patients who underwent surgical management of MLKIs between January 2001 and March 2020 were reviewed at two level 1 academic trauma centers. Patient demographics, surgical characteristics, and MUA/lysis of adhesions (LOA) were reviewed. Patients were stratified by obesity grades: grade 1 (BMI 30 to < 35) grade 2 (BMI 35 to < 40); grade 3 (BMI > 40), and compared with a non-obese comparison group with BMI < 30. Multivariate logistic regressions were performed including the covariates of age, gender, BMI, acute versus chronic injury, external fixator, vascular injury, knee dislocation, and Schenck Classification. Fisher's Exact Test was used to compare rate of MUA between grades of obesity. Analyses were performed with R. Statistical significance was set at p < 0.05. RESULTS:. The mean overall follow up was 27.2 ± 7.2 months (range 14 - 142 months). There were 55 (29.1%) MUA procedures observed at a mean 3.77 ± 2.18 months (range 1.8 - 9.7 months) after final MLKI surgery. No significant difference was found in BMI of patients who underwent a MUA compared to patients who did not (30.2 vs. 28.8; p = 0.67). There was no significant difference in rate or time to MUA following MLKI surgery between groups, with logistic regression demonstrating no significance (p=0.144). Use of external fixation at the index surgery (OR = 3.3 (95% CI: 2.2, 4.7, p < 0.0001)) and vascular injury (OR = 6.2 ((95% CI: 1.8, 24.5, p = 0.005)) were found to be independent predictors for need for MUA. CONCLUSION/CONCLUSIONS:No difference in risk for post-operative stiffness requiring MUA following surgery for MLKI was found based on BMI. At all BMI levels, there were no significant increase in need for post-operative MUA, suggesting at minimum a neutralizing effect of obesity on post-operative stiffness. In addition, patients with external fixator use and vascular injury at index surgery were found to be at significantly higher risk for post-operative stiffness requiring MUA following surgery for MLKI. Surgeons should be aware of the risk factors for arthrofibrosis when proceeding with surgical repair or reconstruction of two or more ligaments of the knee.

BACKGROUND/UNASSIGNED:Multiple surgical options exist for the treatment of patellar instability; however, the most common procedures involve either a reconstruction of the medial patellofemoral ligament (MPFL) or a repair/plication of the MPFL and medial soft tissues. PURPOSE/UNASSIGNED:To perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature to compare MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability. STUDY DESIGN/UNASSIGNED:Systematic review and network meta-analysis; Level of evidence, 1. METHODS/UNASSIGNED:scores. RESULTS/UNASSIGNED:score for all outcomes in those with first-time dislocation. CONCLUSION/UNASSIGNED:The current study demonstrated that MPFL reconstruction results in the lowest rate of recurrent patellar instability and best functional outcomes as measured using the Kujala score.

Entrapment neuropathies of the shoulder most commonly involve the suprascapular or axillary nerves, and they primarily affect the younger, athletic patient population. The extremes of shoulder mobility required for competitive overhead athletes, particularly in the position of abduction and external rotation, place this cohort at particular risk. Anatomically, the suprascapular nerve is most prone to entrapment at the level of the suprascapular or spinoglenoid notch; the axillary nerve is most prone to entrapment as it traverses the confines of the quadrilateral space.Radiographs should be ordered as a primary imaging study to evaluate for obvious pathology occurring along the course of the nerves or for pathology predisposing the patient to nerve injury. Magnetic resonance imaging plays a role in not only identifying any mass-compressing lesion along the course of the nerve, but also in identifying muscle signal changes typical for denervation and/or fatty atrophy in the distribution of the involved nerve.