Faculty Bibliography

OBJECTIVE:The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return-to-play guidelines, and subsequent rates of return to play following cartilage restoration procedures in the knee. DESIGN/METHODS:MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA guidelines to find studies on cartilage restoration procedures in the knee, including (1) microfracture (Mfx), (2) osteochondral autograft transfer (AOT), (3) osteochondral allograft implantation (OCA), and (4) autologous chondrocyte implantation (ACI). Studies were included if they reported return-to-play data or rehabilitation protocols. RESULTS:Overall, 179 studies fit our inclusion criteria, with 48 on Mfx, 34 on AOT, 54 on OCA, and 51 on ACI. The rate of return to play was reported as high as 88.2% with AOT, and as low as 77.2% following OCA, with rates of return to play at the same/higher level as high as 79.3% with AOT, and as low as 57.3% following ACI. The average reported time of return to play was as low as 4.9 months with AOT, and as high as 11.6 months following ACI. CONCLUSIONS:The majority of patients are able to return to play following cartilage restoration procedures in the knee, regardless of surgical procedure utilized. However, while the rate of return to play at the same level was similar to the overall rate of return following AOT, there was a large number of patients unable to return to the same level following Mfx, OCA, and ACI. Additionally, there is wide variety in the rehabilitation protocols, and scant literature on return-to-play protocols.

PURPOSE/OBJECTIVE:High tibial osteotomy (HTO) is an invaluable tool in the treatment of a variety of conditions in active patients with varus malalignment of the knee. The polyetheretherketone (PEEK) iBalance HTO system has been designed to make the osteotomy safer, more reproducible, and avoid metal hardware related complications. The purpose of this study was to evaluate short-term outcomes in patients who underwent an open wedge high tibial osteotomy with the iBalance HTO system. METHODS:We identified patientswho underwent HTO using iBalance with a minimum of 2-year follow-up. Medical records were reviewed for demographics, Workers Compensation and no-fault insurance claims, history of smoking, concomitant procedures, degree of correction, and complications. Patient outcomes using Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS) were recorded before undergoing HTO and compared with those recorded after a 2-year follow-up. Statistical analysis was performed using paired sample t-tests with p < 0.05 considered significant. RESULTS:Twenty-three patients with mean age of 44.9 (± 8.48) were identified. The mean correction angle was 9.9° (range: 5° to 15°). Sixteen patients underwent a concomitant procedure. The average follow-up was 2 years (range: 2 to 3.5 years). Six patients reported a positive history of smoking. The mean preoperative KOOS scores of symptoms, pain, activities of daily living (ADL), sport, and quality of life were 14 (± 18.5), 53.1 (± 14.8), 69.1 (± 21.7), 29.2 (± 22.0), and 30.0 (± 20.0), respectively. The mean preoperative VAS score was 5.5 (± 2.5). At follow-up, the mean scores of symptoms, pain, ADL, sport, and quality of life all improved to 67.53 (± 24.9), 68.06 (± 23.4), 75.74 (± 25.3), 45.91 (± 36.1), and 43.47 (± 33.4), respectively. The mean VAS at follow-up was 1.9 (± 2.1). There was a significant increase (p < 0.05) in all KOOS categories, except ADL. Additionally, there was a statistical difference between smoking and change in ADL score. Former smokers demonstrated an average decrease of 10.3 points, increasing their disability, and nonsmokers increased 15.3 points on the KOOS ADL scale, decreasing their disability. There were three complications (DVT, cellulitis, and serosanguinous drainage) within a month after the procedure. There were three complications, including a revision HTO, pes anserine bursitis, and lateral hamstring tendinitis, within the 2-year follow up including one revision after 1 year. Five patients went on to total knee arthroplasty at an average of 3 years (range: 1 to 5 years). CONCLUSION/CONCLUSIONS:This study suggests that the iBalance medial opening wedge HTO system implant can be used with comparable outcomes to traditional methods, however the conversion rate to total knee arthroplasty may be higher than previously reported. This appears to be unrelated to implant choice and likely related to extended indications for the procedure in younger patients refusing knee arthroplasty. The iBalance medial opening wedge HTO system has shown to be safe, removing many of the complications existing with other osteotomy implant options. Our findings highlight the importance of additional studies in order to investigate the risk factors causing progression from HTO to TKA.

PURPOSE/OBJECTIVE:The purpose of this study is to present one institution's experience managing chronic exertional compartment syndrome (CECS) and to identify patient and surgical characteristics associated with better outcomes following open surgical management of CECS with specific emphasis on return to sports. METHODS:Fifteen patients (10 male, 5 female) who underwent open fasciotomy for CECS with a minimum of 1-year follow-up were included. Chart review was performed to obtain patient demographics, medical and surgical history, presenting symptomatology, and surgical details of fasciotomy. Outcomes were assessed using follow-up questionnaires that consisted of Tegner Activity Scale, EuroQol-5D (EQ5D) index score, EQ-5D rating scale, symptom resolution, patient satisfaction, and return to sports. RESULTS:The mean patient age at the time of surgery was 28.1 years (range: 17 to 49 years). At mean follow-up of 2.7 years (range: 1.0 to 5.1 years), five patients reported complete resolution of symptoms, eight reported improvement (but not resolution) of symptoms, one reported no change in symptoms, and one reported worsening of symptoms. The mean Tegner Activity Score was 6.7 (range: 1 to 9) prior to injury and 4.7 (range: 1 to 9) postoperatively. Patients with any preoperative symptoms at rest had significantly lower Tegner before score (4.0 vs. 7.1, p = 0.036) and EQ5D rating (50.0 vs. 83.5, p = 0.04) compared to those that only experienced symptoms with activity. Patients that had prior surgery, including fasciotomy, had significantly lower EQ-5D rating than patients with no history of prior lower extremity surgery (56.7 vs. 84.6, p = 0.045). Although 10 (66%) patients were able to return to sports, only four (27%) of them were able to return to their prior level of sport. The overall satisfaction rate was 87%. CONCLUSION/CONCLUSIONS:Although open surgical fasciotomy for treatment of chronic exertional compartment syndrome leads to high rates of symptom improvement or resolution, fewer patients are able to return to their prior level of sports. Presence of symptoms at rest, presence of bilateral symptoms, and history of prior lower extremity surgery all portend worse outcomes.

PURPOSE OF REVIEW/OBJECTIVE:The purpose of the current article is to review the available literature related to bone marrow-derived mesenchymal stem cell therapy in the management of musculoskeletal pathologies and demonstrate the critical need for additional well-designed clinical studies. RECENT FINDINGS/RESULTS:In recent years, there has been a rapid increase in interest regarding the use of bone marrow-derived mesenchymal stem cells in the treatment of musculoskeletal injury and disease. The clinical use of BM-MSCs and other forms of stem cell therapy has far outpaced the basic and translational science evidence required to elucidate the potential efficacy of this orthobiologic treatment approach. Early studies have demonstrated potential clinical benefit of utilizing bone marrow-derived mesenchymal stem cell therapy in the management of knee osteoarthritis, focal chondral lesions, shoulder pathology including rotator cuff tears and glenohumeral arthritis, and degenerative disk disease in the spine. To date, most published studies are small case series often lacking a control group or a standardized method of treatment. Bone marrow-derived mesenchymal stem cell therapy is becoming an increasingly common treatment for musculoskeletal injuries and disease. Although early clinical studies have shown promising outcomes, methodological flaws and lack of standardization among trials have limited the conclusions that can be drawn from the existing literature. A better understanding of the underlying mechanism of action and more carefully designed clinical trials will help reveal the efficacy and utility of BM-MSCs as a treatment modality for various orthopedic pathologies.

Placental-derived tissues are a known source of anti-inflammatory and immune modulating factors. Published pilot data on amniotic suspension allograft (ASA) for the treatment of osteoarthritis (OA) demonstrated safety and trends for improved pain and function. A multicenter randomized controlled trial was designed to evaluate the efficacy of symptom modulation with ASA compared with saline and hyaluronic acid (HA) in subjects with knee OA. A total of 200 subjects were randomized 1:1:1 to ASA, HA, or saline, with subjects blinded to their allocation. Changes from baseline of patient-reported outcomes (PROs)-EQ-5D-5L, Knee Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS), Tegner, and Single Assessment Numerical Evaluation (SANE)-were compared between groups. Patients reporting unacceptable pain at 3 months were considered treatment failures and withdrawn from the study. Statistical analysis was completed by comparing changes in PROs from baseline to 3 and 6 months for all groups. Comparison of demographics between treatment groups showed no significant differences between groups. Patients reporting unacceptable pain at 3 months in each group were ASA (13.2%), HA (68.8%), and saline (75%). Patients receiving ASA demonstrated significantly greater improvements from baseline for overall pain (VAS), KOOS pain, and KOOS-activities of daily living scores compared with those in the HA group (3 months) and both groups (6 months). ASA patients had significantly greater improvements in KOOS symptom scores compared with HA and saline at 3 and 6 months, respectively. OMERACT-OARSI responder rates for ASA, HA, and saline groups were 69.1, 39.1, and 42.6%, respectively (p = 0.0007). Subjects receiving ASA treatment showed greater improvements in PROs and fewer patients reported unacceptable pain compared with HA and saline. The evidence presented in this Level I Randomized Controlled Trial suggests that ASA injection is an effective treatment for the nonoperative management of symptomatic knee OA.

Objective: Poor sleep quality due to nocturnal pain is increasingly reported as a major symptom in advanced glenohumeral arthritis. The current study aimed to evaluate preoperative and postoperative sleep quality, shoulder pain, and function in patients who underwent total shoulder arthroplasty (TSA). Preoperative factors contributing to delayed improvements in sleep quality were examined. Methods: Patients scheduled for anatomic or reverse TSA due to glenohumeral arthritis were included. Patients completed the Pittsburgh Sleep Quality Index (PSQI) and American Shoulder and Elbow Surgeons (ASES) survey preoperatively, and at 6 weeks, 3 months, 6 months, and 1 year following surgery. A higher PSQI score (maximum 21) indicated greater sleep disturbance. Results: Seventy-four patients (34 males, 40 females), with a mean age of 65.8 years were prospectively enrolled. Eighty-four percent of patients reported preoperative PSQI scores indicative of sleep disturbance (6 or greater), with a mean of 10.1 ± 4.3. The PSQI score significantly improved to 7.7 at 6 weeks (P = .003), and to 6.1 at 3 months (P = .08). At 12 months, the PSQI was within normal limits (less than or equal to 5) with a mean score of 4.3. A normal PSQI score was achieved by 40.8%, at 6 weeks, 50% at 3 months, 53.7% at 6 months, and 73.9% at 1 year. The ASES score significantly improved from 32.6 ± 17.2 at baseline to 58.4 at 6 weeks (p < .001), 76.1 at 3 months (p < .001), and 85.3 at 12 months. Linear regression demonstrated that the ASES and PSQI scores were negatively associated with each other at each time point. Body mass index and female gender were associated with a delayed return to baseline sleep quality. Conclusion: Shoulder-related sleep disturbance significantly improved at 6 weeks following TSA, and normalized for most patients by 1 year post-operatively. Enhanced sleep quality after TSA was directly related to improved functional outcomes.