Faculty Bibliography

OBJECTIVES/OBJECTIVE:An isolated medial patellofemoral ligament (MPFL) reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient-reported outcomes. METHODS:A retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, gender, and follow-up time. Recurrent instability (including redislocation and subluxation), visual analogue scale (VAS) score, Kujala score, and satisfaction were evaluated. RESULTS:There were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow-up time. The mean age was 25.0 years, 76.3% were female, and the mean follow-up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p = 0.311) or revision surgeries (10.2% vs. 10.2%) between groups. CONCLUSION/CONCLUSIONS:Matched patients undergoing MPFLR with TTO compared with isolated MPFLR demonstrate no statistically significant difference in patient-reported outcomes, levels of pain, and satisfaction postoperatively. Furthermore, the addition of a TTO does not increase the risk of further surgery or complications. LEVEL OF EVIDENCE/METHODS:III, retrospective comparative study.

PURPOSE/OBJECTIVE:The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. METHODS:A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS:The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. CONCLUSION/CONCLUSIONS:Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. LEVEL OF EVIDENCE/METHODS:Level V, expert opinion.

PURPOSE/OBJECTIVE:The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability. METHODS:A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS:The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors. CONCLUSION/CONCLUSIONS:Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization. LEVEL OF EVIDENCE/METHODS:Level V, expert opinion.

BACKGROUND/UNASSIGNED:As platelet-rich plasma injection for knee osteoarthritis (OA) has increased in popularity, it has become more important to assess its effectiveness and satisfaction with its use in the context of its high cost. The purpose of this study was to determine satisfaction, commercial appeal, and effectiveness of platelet-rich plasma (PRP) for the treatment of knee OA. METHODS/UNASSIGNED:A retrospective review of patients who underwent PRP injection in the knee from 2016 to 2019 was performed. Satisfaction with the PRP injection (out of 100), whether the patient would want to undergo PRP injection again, whether they would recommend the injection and whether they felt that the injection was worth the cost was collected. VAS pain scores were collected and measured out of 100. RESULTS/UNASSIGNED:Overall, 114 patients were included. The mean pre-injection pain score was 70.4, and the mean pain level decreased after injection to 36.8. Patients rated their satisfaction on average at 49.2, 50.9% stated that they would get the PRP injection again, 60.5% would recommend to a friend, and 50.9% felt the injection was worth the cost. Younger age and improved post-injection pain correlated with increasing likelihood of desiring further PRP injection. CONCLUSIONS/UNASSIGNED:Patients on average rated satisfaction slightly below average, indicating net indifference skewing towards dissatisfaction with their injection, and only half indicated that it was worth the cost and that they would receive it again. Younger age and pain relief increased desire for further injection, but efficacy did not correlate with patients saying that the injection was worth the cost.

»:A high tibial osteotomy (HTO) is a joint-preserving procedure that can be used to treat symptomatic unicompartmental cartilage disorders in the presence of limb malalignment. »:Appropriate patient selection and careful preoperative planning are vital for optimizing outcomes. »:Based on past literature, correction of varus malalignment to 3° to 8° of valgus appears to lead to favorable results. Recently, there has been growing awareness that it is important to consider soft-tissue laxity during preoperative planning. »:Although there has been a recent trend toward performing opening-wedge rather than closing-wedge or dome HTOs for unicompartmental osteoarthritis, current data suggest that all 3 are acceptable techniques with varying complication profiles. »:Based on current evidence, an HTO provides pain relief, functional improvement, and a high rate of return to sport, with reported survivorship ranging from 74.7% to 97.6% and 66.0% to 90.4% at 10 and 15 years, respectively.

STUDYDESIGN/UNASSIGNED:Retrospective-comparative; LOE-3. OBJECTIVE:The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following 1-or-2-level lumbar fusion has on Hospital-Consumer-Assessment-of-Healthcare-Providers-and-Systems-(HCAHPS)-survey results. SUMMARY OF BACKGROUND DATA/BACKGROUND:Prior research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction. METHODS:A retrospective review of prospectively-collected data was conducted on patients who underwent 1-or-2-level lumbar fusions L3-S1 between October 2014-October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions > 2 levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram-morphine-equivalents (MME). RESULTS:330 patients met inclusion criteria, 259 pre-protocol, 71 post-protocol. There were 256 1-level fusions and 74 2-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (p > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7%(95) pre-protocol, to 59.2%(42) post-protocol; p < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL; p = 0.003. Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3%; p < 0.001. Average opioids prescribed on discharge in the pre-protocol period was was 534 ± 425 MME, compared to after initiation of the protocol it was 320 ± 174 MME; P < 0.001. There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol vs 4.51 ± 0.82 post-protocol; p = 0.986. CONCLUSION/CONCLUSIONS:A reduction in opioids prescribed at discharge after 1-or-2-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

BACKGROUND:The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair. METHODS:Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability. RESULTS:Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%). CONCLUSIONS:Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

PURPOSE/OBJECTIVE:The purpose of this study was to perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature in order to assess the evidence defining the optimal combination of surgical technique single row repair (SRR), double-row repair (DRR), or transosseous-equivalent/suture-bridge (TOE/SB) arthroscopic rotator cuff repair (ARCR) and postoperative rehabilitation (early or late) protocol for ARCR. METHODS:The literature search was performed based on the PRISMA guidelines. Randomized SSR-Early trials (RCT) comparing SRR vs DRR vs TOE/SB ARCR techniques were included, as well as early versus late postoperative ROM. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score. RESULTS:28 studies comprising 2,181 total shoulders met the inclusion criteria. TOE/SB-late (OR 0.19 [0.08;0.46) and DRR-late (OR 0.25 [0.12;0.52) were found to significantly reduce the rate of re-tear, with TOE/SB-late resulting in the highest P-score for the American Shoulder & Elbow Surgeons (ASES) (P Score: 0.7911) score and re-tear rate (P Score: 0.8725). DRR-early did not result in any significant improvements over the SRR-early group, except in internal rotation. There was no significant difference in forward flexion between groups, with almost equivalent P-Scores. Furthermore, TOE/SB-early and TOE/SB-late trended toward worsening external rotation compared to the control. CONCLUSION/CONCLUSIONS:The current study suggests that rotator cuff repair using the transosseous-equivalent/suture-bridge technique and late postoperative mobilization yields the highest functional outcomes and lowest re-tear rate in the arthroscopic management of symptomatic rotator cuff tears.

PURPOSE/OBJECTIVE:The purpose of this study was to identify if the location of posterolateral corner (PLC) injury was predictive of clinical common peroneal nerve (CPN) palsy. METHODS:A retrospective chart review was conducted of patients presenting to our institution with operative PLC injuries. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. A fellowship-trained musculoskeletal radiologist reviewed the PLC injury and categorized it into distal, middle and proximal injuries with or without a biceps femoral avulsion. The CPN was evaluated for signs of displacement or neuritis. RESULTS:Forty-seven operatively managed patients between 2014 and 2019 (mean age-at-injury 29.5 ± 10.7 years) were included in this study. Eleven (23.4%) total patients presented with a clinical CPN palsy. Distal PLC injuries were significantly associated with CPN palsy [9 (81.8%) patients, (P = 0.041)]. Nine of 11 (81.8%) patients with CPN palsy had biceps femoral avulsion (P = 0.041). Of the patients presenting with CPN palsy, only four (36.4%) patients experienced complete neurologic recovery. Three of 7 patients (43%) with an intact CPN had full resolution of their clinically complete CPN palsy at the time of follow-up (482 ± 357 days). All patients presenting with a CPN palsy also had a complete anterior cruciate ligament (ACL) rupture in addition to a PLC injury (P = 0.009), with or without a posterior cruciate ligament (PCL) injury. No patient presenting with an isolated pattern of PCL-PLC injury (those without ACL tears) had a clinical CPN palsy. CONCLUSION/CONCLUSIONS:Distal PLC injuries have a strong association with clinical CPN palsy, with suboptimal resolution in the initial post-operative period. Specifically, the presence of a biceps femoris avulsion injury was highly associated with a clinical CPN palsy. Additionally, CPN palsy in the context of PLC injury has a strong association with concomitant ACL injury. Furthermore, the relative rates of involvement of the ACL vs. PCL suggest that specific injury mechanism may have an important role in CPN palsy. LEVEL OF EVIDENCE/METHODS:IV.