Faculty Bibliography

Objectives: The current opioid epidemic necessitates physicians to seek ways to decrease patients' requirements of narcotic medications without sacrificing their postoperative comfort level. This study evaluated patients' pain following arthroscopic shoulder instability repair and compared the use of narcotic medications between patients prescribed NSAIDs with rescue opioid prescription to those prescribed opioids alone. We hypothesized there would not be a significant difference in postoperative pain and addition of NSAIDs would result in decreased opioid use.
Method(s): Forty patients scheduled to undergo an arthroscopic shoulder instability repair were randomized to receive Ibuprofen 600mg and a 10-pill rescue prescription of Percocet 5/325mg (n=20) or Percocet 5/325mg (n=20). Primary outcomes were the amount of Percocet tablets used in the first week and VAS on postoperative day (POD) 1, 4, and 7. Statistical analysis was done using independent t-tests and bivariate analysis for correlation. Findings were considered significant at p<0.05.
Result(s): Forty patients with a mean age of 35.08 (+/- 8.48)were enrolled between December 2017 and May 2018. The total amount of opioid consumption was statistically significantly lower in the multimodal group compared to the opioid group (p <0.04) as well as Percocet consumption between POD 0-4 (p <0.04). There were no significant differences in VAS at any point between the two groups. One patient in the Ibuprofen cohort experienced dizziness on POD 1. Two patients in the Percocet cohort experienced nausea and vomiting on POD 1 and POD 4.
Conclusion(s): Multimodal analgesia using NSAIDs with an opioid rescue prescription has resulted in significant reduction in postoperative narcotic consumption. As both cohorts showed similar pain levels, it is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed. The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution

Platelet-rich plasma is used for the treatment of musculoskeletal ailments including rotator cuff pathology with mixed outcomes. Varied cytology and leukocyte counts within platelet-rich plasma may influence the results. The impact of this biological therapy on rotator cuff disease management is poorly understood.

BACKGROUND:Despite advances in technology, graft rupture rates reported in the literature following anterior cruciate ligament (ACL) surgery range from 1.8% to 18%. Recent anatomical studies have identified a lateral structure, the anterolateral ligament (ALL), as a potential source of residual pivoting following ACL reconstruction. The purpose of this report is to review the history surrounding the ALL and recent anatomic studies, identify its biomechanical and clinical implications, and develop a practical approach to utilizing it during ACL reconstruction. METHODS:An extensive review of the historical and current literature surrounding the identification of the ALL, its biomechanical function, reconstruction, and outcomes of ALL reconstruction was performed. DISCUSSION/CONCLUSIONS:After the storm of media coverage surrounding the "new ligament" known as the ALL, much attention was focused on cadaveric dissection, biomechanical analysis, and reconstruction of this structure. Several techniques have been described, and currently studies are being performed both retrospectively and prospectively to evaluate the added benefit of ALL reconstruction to the rotational stability of the knee and outcomes after ACL reconstruction. CONCLUSION/CONCLUSIONS:The ALL is a lateral-based structure that provides rotational stability to the knee in the presence of ACL deficiency. Reconstruction of this ligament may provide added benefit to stability and outcomes following ACL reconstruction in certain patient populations. Further randomized controlled trials are needed to elucidate the true benefit of ALL reconstruction and those patients who should undergo this added procedure.

PURPOSE/OBJECTIVE:To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids following arthroscopic partial meniscectomy. METHODS:This was a single-center, prospective, nonrandomized, comparative observational study. Patients ages 18 to 65 years who were indicated for arthroscopic meniscectomy were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) ibuprofen (600 mg every 6-8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg as needed for breakthrough pain) or (2) 30 to 40 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 8 hours, 24 hours, 48 hours, and 1 week after surgery, which included medication usage, visual analog scale pain score, incidence of adverse events, and patient satisfaction. RESULTS:Sixty-eight patients with mean age 51.2 years (±10.4 years) were enrolled between October 2016 and February 2017. Enrollment in the opioid group continued until 30 patients were enrolled in the NSAID group, and at final analysis there were 28 patients in the NSAID group and 40 in the opioid group. There were no significant differences in sex, visual analog scale pain score, or patient satisfaction between the 2 groups at any time point. Patients in the opioid group had a significantly higher mean opioid consumption on postoperative day 1 (1.1 vs 0.5 tablets, P < .03) and postoperative days 3 to 7 (2.6 vs 0.5 tablets, P < .02) compared with NSAID group patients. There was a trend toward greater total (1 week) opioid usage (4.7 vs 2.0 tablets) in the opioid group; however, this was not statistically significant (P < .08). Fifty-three percent of opioid group patients independently chose to forego their opioid medication for an over-the-counter NSAID and/or acetaminophen instead. No patients requested a medication refill. CONCLUSIONS:We found no significant difference in pain control, satisfaction, and total 1-week opioid use between patients prescribed NSAIDs with opioids and those prescribed opioids alone. All patients used only limited amounts of opioids to control postoperative pain, suggesting we are currently overprescribing opioids after arthroscopic partial meniscectomy. LEVEL OF EVIDENCE/METHODS:Level II, prospective comparative study.

Purpose: The aim of this study is to identify markers of early failure of anterior cruciate ligament graft reconstruction (ACLR) based on preoperative MR imaging.
Material(s) and Method(s): We identified 26 patients with early ACLR graft failure (<2 years) who underwent revision between 2011-2015 in a retrospective review of our database. Exclusion criteria included graft choice other than autografts (n=4) and non available preoperative MRI (n=3). Nineteen patients with early ACLR failure were included in the study group. The control group consisted of 38 subjects who underwent ACLR with a minimum of 2 years of clinical follow up and no evidence of graft failure matched by age, sex, BMI and graft type. Preoperative MRI obtained within 8 weeks (range 1-8) following initial trauma were reviewed blinded to the ACLR failure by an experienced (20 years) musculoskeletal radiologist for intra and periarticular lesions including: anterolateral ligament (ALL) injuries (stretch, partial, complete), medial meniscus tear (MM), lateral meniscus tear (LM) tear, posteromedial corner injury (PMC), posterolateral corner injury (PLC) injury, medial collateral ligament tear (MCL), and lateral collateral ligament tear (LCL). Logistic regression analysis was performed.
Result(s): Mean time to ACLR failure was 14 months (range, 1-24 months). Mean follow up of those in the control group was 38 months (range, 2561). Medial meniscus (MM) tear was the best predictor of early ACLR failure (Accuracy=66.7%, p=0.08) followed by the lateral meniscus (p=0.13). MM was a significant predictor of ACLR failure (p=0.02) with odds ratio (OR) 4.2 and 95% confidence interval (CI) [1.19 14.9]. All other variables were not associated with ACLR failure (p>0.20).
Conclusion(s): MM tears were the best predictor of early failure of ACLR. Thus, preserving the integrity of theMMduringACLR procedure may be crucial in minimizing the risk for early ACLR failure

Purpose: To evaluate the prevalence and association of anterolateral ligament (ALL) rupture with other meniscal and ligamentous injuries of the knee in patients with complete acute traumatic anterior cruciate ligament (ACL) tear.
Material(s) and Method(s): Based on retrospective review of our orthopedic surgery database, 57 patients M45:F12, mean age 21 (range:13-34) with acute post traumatic ACL rupture who underwent ACLR seen between 2011 and 2015 were enrolled in this cohort. Preoperative MR examinations was performed by an experienced (20 years) MSK radiologist assessing these variables: anterolateral ligament (ALL) rupture, MM tear, LM tear tear, posteromedial corner injury (PMC), posterolateral corner injury (PLC) injury, MCL tear, and lateral collateral ligament tear (LCL). Odds ratios and their 95% confidence interval were used to assess the associations of ALL with other injuries in the knee. To rule out confounding factors we used the Cochran Mantel Haenszel method in an analysis stratified by gender and BMI (normal, overweight).
Result(s): Most commonly reported lesions were of the MM 63%, and PLC 64%. ALL partial or complete tears and Segond avulsion fracture were reported in 28 patients (49%). Anterolateral lesions were associated with a 10 fold decreased risk of MM tear (odds ratio [OR] = 0.10, 95% [CI]=[0.028, 0.38]) and a 4.6 fold increased risk of LCL tear (OR=4.68, 95% CI=[1.28 17.1]). Neither gender nor BMI were confounding for the associations of ALL with MM and LCL tears. No other statistically significant associations betweenALL rupture and LM, PMC, PLC and MCL injury were found.
Conclusion(s): Failure of the ALL during acute traumatic ACL rupture is often associated with tear of the LCL. This may have a protective effect over theMMdue to potential 'capsular release' ewith increased mobility of the MM and decreased risk of clipping/tearing between the approximating medial compartment surfaces during pivot shift trauma

PURPOSE/OBJECTIVE:To correlate the histopathologic appearances of resected long head of the biceps tendon (LHBT) specimens following biceps tenodesis, with pre-operative MRI and arthroscopic findings, with attention to the radiologically normal biceps. MATERIAL AND METHODS/METHODS:Retrospective analysis of patients who had undergone preoperative MRI, subsequent arthroscopic subpectoral tenodesis for SLAP tears and histopathologic inspection of the excised sample between 2013 and 16. Those with a normal MRI appearance or mildly increased intrasubstance signal were independently analyzed by 2 blinded radiologists. A blinded orthopedic surgeon and pathologist reviewed all operative imaging and pathologic slides, respectively. RESULTS:Twenty-three LHBT resected samples were identified on MRI as either normal (Reader 1 n = 15; Reader 2 n = 14) or demonstrating low-grade increased signal (Reader 1 n = 8; Reader 2 n = 9). Of these, 86.9% demonstrated a histopathological abnormality. 50% of samples with histopathological abnormality demonstrated normal appearance on MRI. The most common reported histopathology finding was myxoid degeneration (73.9%) and fibrosis (52.2%). The most common arthroscopic abnormality was fraying (18.2%) and erythema (13.6%). Utilizing histopathology as the gold standard, the two radiologists demonstrated a sensitivity of 35.0% v 42.9%, specificity of 66.7% v 100%, PPV of 87.5% v 100%, and NPV of 13.3% v 14.3%. Corresponding arthroscopic inspection demonstrated a sensitivity of 31.6%, specificity of 66.6%, PPV 85.7% and NPV of 13.3%. There was moderate agreement between the two radiologists, κ = 0.534 (95% CI, 0.177 to 0.891), p = 0.01. CONCLUSION/CONCLUSIONS:Histopathological features of low grade tendinosis including mainly myxoid degeneration and fibrosis are frequently occult on MR imaging.

Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.

Emerging musculoskeletal applications for local administration of autologous bone marrow aspirate concentrate (BMAC) include treatment of fractures, osteonecrosis, osteochondral injuries, osteoarthritis, ligament injury, tendon injury, and tendonopathies. Ultrasound-guided technique for various BMAC injection sites is detailed in this technical report and our preliminary clinical experience outlined.Five patients, 1 woman and 4 men, were treated with 6 peri/intratendinous (n = 4) or intraarticular (n = 2) BMAC injections between July 5, 2015 and December 31, 2016 for the clinical indications of common hamstrings origin tendinosis (n = 4), hip labral tear (n = 1), and osteochondral lesion of the talus (n = 1).All procedures were technically successful, with BMAC locally administered to the therapeutic target and no procedural complications observed. Clinical follow-up was available for 5 of 6 procedures. Four of 5 injections resulted in self-reported symptomatic improvement (clinical follow-up range, 2-12 months). One 72-year-old man with right common hamstrings origin tendinosis reported no improvement after BMAC injection.The technology is now available to support ultrasound-guided, autologous BMAC administration by the musculoskeletal interventionalist for common indications. Our initial clinical experience is consistent with early reports in the literature. This technique is well tolerated by symptomatic patients on an outpatient basis, and rates of self-reported symptomatic relief are high. Mechanism of action, long-term safety, and long-term clinical efficacy remain largely undefined.

PURPOSE/OBJECTIVE:To utilize MRI to assess the relationship between BMI, peripheral soft tissue composition about the knee, and surgical outcomes in patients undergoing primary ACL reconstruction. It was hypothesized that a fatty periarticular soft tissue composition may be better than BMI at predicting poor outcomes after ACL reconstruction. METHODS:Fifty-eight patients who underwent primary acute ACL reconstruction were identified from the surgical database and their data were retrospectively reviewed. Patients were selected based on availability of 2-year IKDC outcome scores, BMI data, and preoperative MRI studies. To approximate peripheral soft tissue composition, novel measurements of axial MRI images were employed using PACS ROI measurement tool. Relationships were assessed between IKDC outcome scores and measures of body habitus including BMI, total knee area, knee fatty-connective tissue area, and fatty-connective tissue to bone size ratio. RESULTS:(range 18.5-36.9). Median IKDC score was 81.0 (range 46-100). BMI was correlated with total knee area (R = 0.72) and periarticular fat (R = 0.53). Neither continuous BMI (n.s.) nor total knee area (n.s.) was predictor of IKDC outcomes scores. Periarticular fatty-connective tissue trended towards predicting negative outcomes (n.s.). Periarticular fatty-connective tissue to bone size ratio was a significant negative predictor of IKDC scores (p = 0.03). Patients with more fat than bone on axial MRI (ratio > 1, N = 34) reported a lower mean IKDC score compared to patients with a ratio < 1 (N = 24) (77.2 vs. 87.7, p = 0.0028). The top quartile (N = 14) of these ratios reported a mean IKDC score of 68.9, compared to 87.3 of the bottom quartile (p = 0.0001). CONCLUSIONS:Periarticular soft tissue composition, as approximated by the novel MRI analysis of this study, is a better predictor of outcomes following ACL reconstruction than is BMI. This information can be utilized in guiding surgeon and patient expectations following surgery, either via a direct application of these measurements or heightened awareness of the importance of peripheral body habitus. LEVEL OF EVIDENCE/METHODS:III.