Faculty Bibliography

PURPOSE/OBJECTIVE:Given the wide variation that exists in the amount and duration of postoperative opioid medication prescribed by orthopedic surgeons, the purpose of the current study was to analyze the opioid prescribing patterns at our institution for adolescent patients undergoing outpatient sports medicine procedures Methods: A total of 468 adolescent patients (between the ages of 13 and 18 years old) who underwent outpatient shoulder, hip, or knee arthroscopy (including ACL reconstruction) between 2016 and 2018 were retrospectively identified, and demographic data were collected. Opioid prescriptions following surgery were converted to morphine milligram equivalents (MME) for direct comparison. Prescribing patterns of the 44 surgeons included in our cohort were evaluated with respect to procedures performed and overall surgical volume. High-dose prescriptions were defined as ≥ 300 MME (equivalent to 40 tabs of oxycodone/ acetaminophen [Percocet] 5/325 mg) and low-dose prescriptions were defined as < 300 MME. RESULTS:The mean discharge prescription following outpatient arthroscopy in this patient population was 299.8 ± 271 MME. When each individual case-type was analyzed, there were significant positive correlations between surgeonvolume and MME prescribed following shoulder arthroscopy (r = 0.387, p < 0.001) and knee arthroscopy, (r = 0.350, p < 0.001). Results of logistic regression demonstrated that for every 10 additional cases performed, the odds that a given surgeon would prescribe ≥ 300 MME postoperatively increased by a factor of 1.14 (p < 0.001). There were no significant correlations observed following hip arthroscopy, anterior cruciate ligament reconstruction, or meniscus repair. Over the course of the observation period, a significant reduction in opioid prescribing was seen among the participating surgeons. CONCLUSION/CONCLUSIONS:Surgeons who perform a greater volume of outpatient shoulder and knee arthroscopy on adolescent patients were more likely to prescribe high opioid dosages postoperatively. Awareness of existing variation in narcotic prescribing patterns for patients in this age group is important for quality of care and safety improvement amidst the opioid epidemic.

Objectives: The purpose of the current study was to evaluate the clinical outcomes and rates of return to play in patients who underwent an osteochondral allograft (OCA) procedure for a symptomatic osteochondral defect in the knee.
Method(s): A retrospective review of patients who underwent an OCA for an osteochondral defect of the knee, between June 2011 and March 2019 was performed. Return to play, the level of return and the timing of return were assessed. Additionally, the reasons for being unable to return were evaluated. A p-value of < 0.05 was considered to be statistically significant.
Result(s): Overall, there were 103 patients who underwent OCA at our institution and met our inclusion and exclusion criteria. The mean age was 31.8 +/- 11 years, and 63.9% were male, with a mean of 44.2 +/- 23.3 month follow-up. The overall rate of return to play was found to be 63.1% (N=65), while the rate of RTP at the same or higher level was 32.0% (N = 33). With respect to the patients who were unable to return to their desired sport, reasons cited included pain in the operative knee (N = 18, 47.3%), physical inability to perform in the desired sport (N = 8, 21.1%), and fear of re-injury (N = 6, 15.8%).
Conclusion(s): Overall, there was a poor rate of return to play following OCA. Additionally, the majority of patients were unable to return to play at their pre-injury level

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: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.

PURPOSE OF REVIEW/OBJECTIVE:Given the continued controversy among orthopedic surgeons regarding the indications and benefits of arthroscopic partial meniscectomy (APM), this review summarizes the current literature, indications, and outcomes of partial meniscectomy to treat symptomatic meniscal tears. RECENT FINDINGS/RESULTS:In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for APM or non-surgical intervention depending on the tear pattern and symptoms. Non-surgical management for meniscal pathology includes non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), and intraarticular injections to reduce inflammation and relieve symptoms. There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of APM compared to PT or sham surgery in symptomatic degenerative meniscal tears. These most notably include the 2013 Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial, the 2018 ESCAPE trial, and the sham surgery-controlled Finnish Degenerative Meniscal Lesion Study (FIDELITY), which failed to identify substantial benefits of APM over nonoperative treatment or even placebo surgery. Despite an abundance of literature exploring outcomes of APM for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following APM. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant OA. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most RCTs show that exercise therapy may be non-inferior to APM in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of APM before proceeding to surgical management.

IMPORTANCE/OBJECTIVE:There have been several recent systematic reviews of quadriceps tendon autografts (QT), which have not shown any significant difference in outcomes between QT and hamstring tendon autograft (HS) for ACL reconstruction (ACLR). However, several recent comparative studies have been published comparing QT to HS for ACLR. AIM/OBJECTIVE:The purpose of this study is to perform a systematic review and meta-analysis of the studies comparing QT to HS for ACLR. EVIDENCE REVIEW/METHODS:Two independent reviewers performed the literature search based on the PRISMA guidelines, with a senior author arbitrating discrepancies. Cohort studies comparing QT with HS were included. FINDINGS/RESULTS:There were 15 studies comparing 611 patients with QT to 543 patients with HS, with a mean of 27.4 months follow-up. QT resulted in a significantly lower rate of graft re-rupture (2.5% vs 8.7%, p = 0.01), and donor site morbidity (17.6% vs 26.2%, p = 0.02). There was a significant difference in favour of QT for the positive pivot shift test (Grade I/II: 15.8% vs 23.0%, p = 0.02), but not in the rate of the positive Lachman test (Grade I/II: 18.3% vs 26.7%, p = 0.16). Additionally, there was no difference in the side to side difference in knee stability (1.8 mm vs 2.0 mm, p = 0.48). Functionally, both grafts had similar functional outcomes in terms of the IKDC score (88.0 vs 87.9, p = 0.69), and Lysholm score (89.3 vs 87.6, p = 0.15). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Our study showed that QT has a lower re-rupture rate than HS in ACLR, with lower donor site morbidity. QT appeared to be slightly better for residual pivot shift, but there was no difference in patient-reported outcomes. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Patient-reported allergies (PRAs) are often stigmatized as a potential nonmodifiable risk factor for increased pain and worse functional outcomes following surgery. However, there is a dearth of literature directly assessing the impact of PRAs on outcomes in sport surgeries such as medial patellofemoral ligament reconstruction (MPFLR). The purpose of our study was to determine whether PRAs were associated with worse outcomes following MPFLR. METHODS:We conducted a retrospective review of patients who underwent MPFLR at our institution from 2011 to 2019. Patients were included if they had at least 12 months of follow-up. PRAs were obtained from preoperative medical assessments and categorized by drug class. Demographic and perioperative data were obtained from electronic medical records. Postoperative outcomes were measured using a telephone survey and included recurrent instability, Visual analog scale (VAS) for pain, VAS for sports, Kujala score, MPFL-Return to Sport after Injury (MPFL-RSI) score, and overall satisfaction score. Multiple linear regression was used to determine association between PRAs and outcome measures, and p-values less than 0.05 were considered significant. RESULTS:The cohort included 141 MPFLR. Most patients were female (98, 70%) with an average age of 25 years (range 12-56 years). Average follow-up time was 47 months. Forty-seven patients (33%) reported at least one PRA. There were no significant differences in postoperative pain, functional outcomes, satisfaction, or return to sport between patients with or without PRAs (all p > 0.05). Absence of antibiotic PRAs was predictive of higher VAS (p < 0.007), but there were no other differences. There were no significant differences in outcomes between patients without PRAs, PRAs without a concomitant psychiatric disorder, or PRAs with a concomitant psychiatric disorder (all p > 0.05). CONCLUSIONS:In conclusion, PRAs with or without concomitant psychiatric diagnoses are not associated with worse postoperative pain, functional outcomes, or satisfaction following MPFLR with allograft, dispelling common misconceptions that increased number of allergies or psychiatric diagnoses lead to inferior surgical outcomes. Presence of antibiotic allergies was associated with lower VAS postoperative pain score. Future research should investigate the relationship between PRAs and other surgeries in the field of sports medicine.

Despite multiple advances in techniques for posterior cruciate ligament reconstruction (PCL-R), residual posterior laxity continues to be a commonly reported complication. Multiple studies demonstrated a decreased or flat posterior tibial slope, increases posterior laxity, and forces placed across the native and reconstructed PCL. Anterior opening wedge high tibial osteotomies (aOW-HTO) can be used to increase posterior tibial slope, thereby reducing tibial sag and posterior laxity. Depending on the technique used, anterior opening wedge osteotomies can lead to changes in patellar height, affecting patient pain and satisfaction. The purpose of this article is to describe a technique for an aOW-HTO with a tibial tubercle osteotomy and concomitant PCL-R to increase the posterior tibial slope while minimizing changes to patellar height.

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:To evaluate the variation in tibial tubercle sagittal alignment in patients with and without patellofemoral (PF) cartilage wear. METHODS:This was a single-centre, retrospective review of patients that underwent a cartilage restoration procedure for isolated PF cartilage wear from 2014 to 2020. Patients were matched in a 1:2 ratio for age, sex and BMI to partial meniscectomy patients as controls. The sagittal TT-TG (sTT-TG) distance was measured on preoperative axial T2 magnetic resonance imaging (MRI) and was defined as the distance between a point at the nadir of the trochlear cartilage and the most anterior point of the tibial tubercle. RESULTS:One hundred and forty patients (47 cartilage restoration, 94 meniscectomy) were included. Mean age, BMI, and height for the total cohort were 34.01 ± 8.7, 26.6 ± 6.4, and 173.0 ± 17.7 respectively, with 78 males (55%) and 63 females (45%). There were no significant differences between groups for age, BMI or sex (n.s). The cartilage restoration group (- 2.5 mm ± 5.9) was found to have a significantly more posterior (negative) sTT-TG compared to the meniscectomy group (1.72 mm ± 6.7) (p < 0.001). Interrater reliability was excellent (ICC = 0.931, p < 0.001). Patients with less than - 3.4 mm sTT-TG were 2.74 times more likely to have a cartilage restoration procedure compared to those with greater than - 3.4 mm (OR 2.7, 95% CI 1.3-5.85). Patients with < - 10 mm posterior translation were 13.7× (CI 1.6-111.1) more likely to have a cartilage restoration procedure. CONCLUSION/CONCLUSIONS:Patients that underwent isolated cartilage restoration procedures had a significantly more posterior tibial tubercle than partial meniscectomy controls based on the sagittal TT-TG. The more posterior the tubercle, the more likely the patient had a cartilage restoration procedure. Surgeons should consider the sTT-TG measurement in patients presenting with anterior knee pain, particularly patellofemoral lesions. LEVEL OF EVIDENCE/METHODS:III.