Faculty Bibliography

PURPOSE/OBJECTIVE:To establish consensus statements on the diagnosis, nonoperative management, and labral repair for posterior shoulder instability. METHODS:A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS:Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization. CONCLUSIONS:The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required. LEVEL OF EVIDENCE/METHODS:Level V, expert opinion.

BACKGROUND/UNASSIGNED:Patellofemoral instability is a relatively common condition and is multifactorial in its cause, with both soft tissue and bony components. Trochleoplasty is a newly described surgical procedure to help improve outcomes following patellar restabilization. INDICATIONS/UNASSIGNED:Trochleoplasty is an emerging surgical technique during patellar stabilization surgery in those patients with underlying trochlear dysplasia. TECHNIQUE DESCRIPTION/UNASSIGNED:Trochleoplasty was performed via an open medial parapatellar arthrotomy. Using a combination of osteotome and guided bur, the subchondral surface was undermined to produce a deeper sulcus. The cartilage surface was then plastically deformed into the newly developed trochlea. Trochleoplasty was then secured with a central triple-loaded interference screw and 3 peripheral interference screws. Medial patellofemoral ligament reconstruction was then performed in standard fashion. RESULTS/UNASSIGNED:Postoperative course was complicated by arthrofibrosis, which required manipulation at 4 weeks. Following manipulation, the patient recovered uneventfully and had returned to full activities at 6 months with full strength, range of motion, and minimal pain. DISCUSSION/CONCLUSION/UNASSIGNED:Trochleoplasty with combined soft tissue reconstruction is a viable treatment option in those patients with recurrent patellar instability and underlying trochlear dysplasia. While not without complications, this surgical technique remains a powerful tool in the correctly indicated patient. Appropriate patient selection and adherence to postoperative rehabilitation are crucial for optimal outcomes. PATIENT CONSENT DISCLOSURE STATEMENT/UNASSIGNED:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

BACKGROUND/UNASSIGNED:Isolated medial compartment knee osteoarthritis (OA) presents a challenging problem to treat for knee surgeons, with a multitude of options from conservative management, including injections and unloader braces, meniscal procedures, osteotomies, and unicompartmental knee arthroplasty (UKA). A new medial implantable shock absorber (MISHA) allows for offloading 142 N of the medial compartment during stance phase of gait. INDICATIONS/UNASSIGNED:US Food and Drug Administration approval was obtained on April 10, 2023, with the following indications: isolated medial knee OA (Kellgren-Lawrence grades I-IV) that failed 6 months of conservative management, ages 25 to 65 years, body mass index <35 or body weight <300 lbs, <15° of varus, no flexion contracture >10°, and no significant medial osteophytes or medial meniscal extrusion. TECHNIQUE DESCRIPTION/UNASSIGNED:A longitudinal medial knee incision is made 1 cm proximal to the medial epicondyle to the pes insertion, around 3 cm medial to the tibial tubercle, exposing the superficial medial collateral ligament, and medial joint line. The establishment of the femoral anisometric point is critical to provide a 4-mm posterior condylar offset in 90° of flexion compared to full extension. A trial implant can be placed to confirm appropriate anisometry, implant loading in extension, and relaxation in flexion. The final implant is placed and the titanium femoral and tibial baseplates are fixed with 3 unicortical titanium locking screws each. RESULTS/UNASSIGNED:Expected results per recommended postoperative protocol are immediate weightbearing without range of motion restrictions. From author experience, patients typically feel improvement and return to sport more rapidly than with anterior cruciate ligament reconstructions. Recovery and return to work are faster than osteotomies or UKAs based on comparative short-term studies. While long-term results are lacking given the novelty of the procedure, prospective studies have demonstrated 100% arthroplasty-free survival at 2 years and 85% survival at 5 years. DISCUSSION/CONCLUSION/UNASSIGNED:The MISHA is a viable option for isolated medial compartment knee OA that provides a joint-preserving alternative to arthroplasty and a less morbid alternative to osteotomy. This treatment can be technically difficult to perform, but several pearls and techniques can offer a reproducible, minimally invasive surgery and good functional results. PATIENT CONSENT DISCLOSURE STATEMENT/UNASSIGNED:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

PURPOSE/OBJECTIVE:The purpose of the current study was to define the incidence of minor and major complications following TTO at a tertiary-care institution, with determination of predictive factors related to the occurrence of a major complication. STUDY DESIGN/METHODS:Retrospective case series. METHODS:Patients who underwent TTO from 2011 to 2023 were retrospectively identified. Patients who did not have at least 30 days of follow-up and revision cases were excluded. Complications classified as "major" included intraoperative fracture, postoperative fracture, loss of fixation, delayed union, non-union, pulmonary embolism (PE), patella tendon rupture, deep infection, painful hardware requiring removal, arthrofibrosis requiring reoperation, recurrent patellar instability, reoperation for other indications, readmission, and revision. Complications classified as minor included superficial infection, deep venous thrombosis, wound dehiscence, and postoperative neuropraxia. Chi-square tests were used for categorical variables, t-tests for continuous variables. RESULTS:Four hundred and seventy-six TTOs in 436 patients were included in the final cohort with a mean follow-up of 1.9 years (range 1 month-10 years). Patients were 68.5% female with average age 28.3 years (range 13-57 years). The overall complication rate was 27.5 percent. Major complications were recorded in 23.7% of TTOs, and minor complications in 8.4% of TTOs. Reoperation was required in 16.6% of TTOs at a mean of 14 months following the index procedure. The most common complications were painful hardware requiring removal (6.5%), superficial infection (5.7%), and arthrofibrosis requiring return to the operating room (OR) (5.0%). Prior ipsilateral surgery was identified as a significant independent predictor of major complication by regression analysis. Hardware removal was more common with headed screws. Arthrofibrosis requiring reoperation was more common in patients who underwent a concomitant cartilage restoration/repair procedure. CONCLUSION/CONCLUSIONS:The overall complication rate following tibial tubercle osteotomy was 27.5%, with painful hardware requiring removal (6.5%) as the most common complication, and an overall reoperation rate of 16.6%. TTOs with major complications were performed at earlier years, in patients who were older, had a previous ipsilateral arthroscopic knee surgery, had an indication of cartilage lesion/arthritis, and had a steeper osteotomy cut angle. Hardware removal was found to be more common in patients with headed as compared to headless screws. Complications also varied based on timing after surgery.

BACKGROUND:Increased Posterior Tibial Slope (PTS) angle has been reported to be a risk factor for primary anterior cruciate ligament (ACL) tears. However, it is unknown whether increased PTS has an associated increased risk for non-contact versus contact ACL injury. PURPOSE/OBJECTIVE:The purpose of this study is to determine whether patients with non-contact ACL injury have a higher PTS angle than those with contact ACL injury. METHODS:A total of 1700 patients who underwent primary ACL reconstruction between January 2011 and June 2023 at a single academic institution were initially included. Electronic medical records were reviewed for demographic information as well as evidence that the patient sustained a contact or non-contact ACL injury. Patients in the contact cohort were propensity score matched to patients in the non-contact cohort by age, sex and BMI. Additionally, patients in the contact cohort were then propensity score matched to a control group of patients with intact ACLs also by age, sex and BMI. RESULTS:One hundred and two patients with contact injury were initially identified and 1598 patients with non-contact injuries were identified. Of the 102, 67 had knee X-rays that were suitable for measurement. These 67 contact injury patients were propensity score matched to 67 noncontact patient and 67 patients with intact ACLs based on age, sex and BMI. There were no significant differences between contact and non-contact cohorts in age (28.7±6.3 vs. 27.1±6.5, p = 0.147), sex (Female: 36.0% vs. 34.3%, p = 0.858), or BMI (26.7±5.6 vs 26.1±3.4, p = 0.475). There was no significant difference in PTS angle between contact versus non-contact ACL injury patients (11.6±3.0 vs.11.6±2.8, p = 0.894). There was a significant difference in PTS between the contact ACL injury and the intact cohort (11.6±3.0 vs. 10.0±3.9, p = 0.010) and the non-contact ACL injury and the intact cohort (11.6±2.8 vs. 10.0±3.9, p = 0.010). CONCLUSION/CONCLUSIONS:There was no significant difference in the degree of PTS between patients who sustained contact versus non-contact ACL injuries. Additionally, there was a significantly increased PTS in both the contact and non-contact ACL injury cohorts compared to patients with intact ACLs.

PURPOSE/OBJECTIVE:There is limited clinical outcome data comparing fixation methods for tenodesis of the long head of the biceps tendon (LHBT), particularly button fixation. The purpose of this study was to compare clinical outcomes, patient-reported outcomes, and return to sport (RTS) between patients undergoing LHBT with bicortical versus unicortical button technique. The authors hypothesized these fixation methods would be similar for all outcomes. METHODS:Patients who underwent LHBT using unicortical or bicortical button fixation with minimum 2-year follow-up were identified. Postoperative outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) questionnaire and visual analogue scale (VAS) pain score. A sports activity survey was collected to assess baseline sport participation and ability to return to pre-injury activities. Continuous variables were analyzed using the Mann-Whitney-U test. Categorical variables were analyzed using Chi-squared tests. Multivariable logistic and linear regression were performed to determine predictors of RTS and time to RTS. RESULTS:Sixty-four subjects (19 unicortical and 45 bicortical button fixation) were included (average follow-up 3.5 (range: 2.0-7.8) years). There were no significant differences found between button groups for VAS pain score (1.5 vs. 1.2; p = 0.876), VAS pain during sport score (1.6 vs. 1.1, p = 0.398), and ASES score (66 vs. 71; p = 0.294). There were no significant differences in rate of RTS (75.0 vs. 77.4%; p = 0.885) or average time to return to sport (11.7 ± 7.3 vs. 7.0 ± 4.0 months; p = 0.081) between groups. CONCLUSION/CONCLUSIONS:There were no significant differences in clinical outcomes, pain, or return to sport between patients who underwent LHBT with unicortical or bicortical button fixation.

BACKGROUND/UNASSIGNED:As machine learning becomes increasingly utilized in orthopaedic clinical research, the application of machine learning methodology to cohort data from the Multicenter ACL Revision Study (MARS) presents a valuable opportunity to translate data into patient-specific insights. PURPOSE/UNASSIGNED:To apply novel machine learning methodology to MARS cohort data to determine a predictive model of revision anterior cruciate ligament reconstruction (rACLR) graft failure and features most predictive of failure. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:The authors prospectively recruited patients undergoing rACLR from the MARS cohort and obtained preoperative radiographs, surgeon-reported intraoperative findings, and 2- and 6-year follow-up data on patient-reported outcomes, additional surgeries, and graft failure. Machine learning models including logistic regression (LR), XGBoost, gradient boosting (GB), random forest (RF), and a validated ensemble algorithm (AutoPrognosis) were built to predict graft failure by 6 years postoperatively. Validated performance metrics and feature importance measures were used to evaluate model performance. RESULTS/UNASSIGNED:The cohort included 960 patients who completed 6-year follow-up, with 5.7% (n = 55) experiencing graft failure. AutoPrognosis demonstrated the highest discriminative power (model area under the receiver operating characteristic curve: AutoPrognosis, 0.703; RF, 0.618; GB, 0.660; XGBoost, 0.680; LR, 0.592), with well-calibrated scores (model Brier score: AutoPrognosis, 0.053; RF, 0.054; GB, 0.057; XGBoost, 0.058; LR, 0.111). The most important features for AutoPrognosis model performance were prior compromised femoral and tibial tunnels (placement and size) and allograft graft type used in current rACLR. CONCLUSION/UNASSIGNED:The present study demonstrated the ability of the novel AutoPrognosis machine learning model to best predict the risk of graft failure in patients undergoing rACLR at 6 years postoperatively with moderate predictive ability. Femoral and tibial tunnel size and position in prior ACLR and allograft use in current rACLR were all risk factors for rACLR failure in the context of the AutoPrognosis model. This study describes a unique model that can be externally validated with larger data sets and contribute toward the creation of a robust rACLR bedside risk calculator in future studies. REGISTRATION/UNASSIGNED:NCT00625885 (ClinicalTrials.gov identifier).

PURPOSE/OBJECTIVE:To evaluate long-term outcomes of patients treated with posterior medial meniscal root tear (PMMRT) repair through assessment of functional outcome scores and to identify patient surgical and magnetic resonance imaging (MRI) characteristics associated with improved outcomes. METHODS:This was a single-centre, retrospective study evaluating patients who had undergone a PMMR repair using a transtibial suture pullout technique with two locking cinch sutures. This was performed as a follow-up to previously published 2-year and 5-year outcome studies, using the same cohort. All patients from the prior short-term and midterm studies were invited to participate. Patient-reported outcome (PROs) scores, including the International Knee Documentation Committee (IKDC) and Lysholm scores, were collected. Previously collected demographic data were updated based on review of the electronic medical record. Patient outcomes were assessed preoperatively, as well as at 2-year, 5-year and 8-year postoperatively. MRI outcome measurements were assessed at 2-year and 5-year follow-ups. All statistical analysis was performed using SPSS version 26. RESULTS:Seventeen patients of the original 18 patients (94.4%) were included in the final analysis. Additionally, three patients who had additional ipsilateral surgery were excluded from the analysis of PROs. The IKDC score significantly increased from 44.7 ± 11.6 at preoperative baseline to 71.2 ± 21.3 at 8-year post-operation (p = 0.001). There were no significant differences in IKDC score between 2-year and 8-year follow-ups (p = n.s.) or 5-year and 8-year follow-ups (p = n.s.). The Lysholm score significantly increased from 49.6 ± 7.3 at preoperative baseline to 76.4 ± 17.2 at 8-year follow-up (p < 0.001). There was no significant difference in Lysholm scores between 2-year and 8-year follow-ups (p = n.s.) or 5-year and 8-year follow-ups (p = n.s.). A linear regression analysis found that 5-year IKDC scores were significantly correlated with 8-year IKDC scores (β = 0.681, p = 0.038). At 8-year follow-up, four (23.5%) patients required additional procedures on their operative knee (one total knee arthroplasty conversion). CONCLUSION/CONCLUSIONS:Patients treated with repair of PMMRT had maintenance of clinical outcome improvements at long-term follow-up despite worsening MRI outcomes at short-term and medium-term follow-ups. While a high proportion of patients required additional procedures on their operative knee at 8-year follow-up, few of these patient's additional procedures were related to failure of their primary surgery. Providers and patients may expect durable clinical outcomes following the repair of PMMRT, irrespective of radiographic appearance. LEVEL OF EVIDENCE/METHODS:Level IV.

BACKGROUND/UNASSIGNED:Operative treatment of chronic exertional compartment syndrome (CECS) with fasciotomy is effective for symptomatic resolution, but outcomes at medium- to long-term follow-up are unclear. HYPOTHESIS/UNASSIGNED:Patients will have favorable satisfaction at medium- to long-term follow-up and a high return to sport (RTS) rate after fasciotomy for treatment of CECS. STUDY DESIGN/UNASSIGNED:Cross-sectional. LEVEL OF EVIDENCE/UNASSIGNED:Level 3. METHODS/UNASSIGNED:Retrospective review of patients who underwent fasciotomy for treatment of CECS from 2010 to 2021. Outcomes were assessed using Tegner Activity Scale, symptom resolution, patient satisfaction, return to activities, and EQ-5D-5L survey. RESULTS/UNASSIGNED:= 0.02) than those who had fasciotomy of >3 compartments; 19 (38.0%) patients reported experiencing paresthesia after their operation. No patients experienced major complications. CONCLUSION/UNASSIGNED:Medium- to long-term outcomes of patients with CECS treated with fasciotomy demonstrated high satisfaction levels and high RTS rate. However, rate of minor complications including paresthesia, swelling, and cramping was high.

BACKGROUND/UNASSIGNED:There are currently no guidelines on peri-arthroscopic management of immunosuppressive (IS) treatment in rheumatic disease patients. PURPOSE/UNASSIGNED: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 complications by rheumatic disease type, medication type, and procedure. METHODS/UNASSIGNED: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 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. RESULTS/UNASSIGNED: = 1102) were not on IS at baseline. In all cohorts, seven patients experienced postoperative complications; six of whom experienced infections. Two (1.82%) occurred in patients remaining on IS perioperatively, zero infections occured in patients who held all IS, and four (0.36%) occured 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/UNASSIGNED:The risk of postoperative complications including infectious, major, and minor complications in patients on IS at the time of arthroscopy is low and acceptable.