Faculty Bibliography

BACKGROUND/UNASSIGNED:An increased posterior tibial slope (PTS) is a risk factor for primary anterior cruciate ligament (ACL) tears and graft failure, but the PTS has not been well-defined in those who have experienced bilateral ACL injuries. PURPOSE/UNASSIGNED:The primary aim was to compare the PTS, as well as the rate of an elevated PTS (>12° on lateral radiography; >7° on magnetic resonance imaging [MRI]), between patients who have undergone bilateral ACL reconstruction (ACLR) versus unilateral ACLR. A secondary purpose was to examine whether these associations remained consistent on both plain radiography and MRI. STUDY DESIGN/UNASSIGNED:Cross-sectional study; Level of evidence, 3. METHODS/UNASSIGNED:We retrospectively identified patients who underwent primary ACLR at our institution from the years 2012 to 2020. Patients who underwent nonsimultaneous bilateral ACLR (n = 53) were matched to those who underwent unilateral ACLR (n = 53) by age, sex, and body mass index. Exclusion criteria were rotated lateral radiographs, MRI scans of inadequate quality, and concomitant ligament injuries or fractures. Those who had undergone unilateral ACLR with <5-year follow-up were further excluded. There were 3 blinded readers who measured the PTS on lateral radiographs, while the medial PTS (MPTS) and lateral PTS (LPTS) were measured on MRI scans. Bivariate regression was performed to determine the correlation between radiographic and MRI measurements. RESULTS/UNASSIGNED:= .810). CONCLUSION/UNASSIGNED:Patients who underwent bilateral ACLR had a significantly greater PTS on radiography and a significantly greater LPTS on MRI compared with those who underwent unilateral ACLR. The rate of a radiographic PTS >12° was 2.4 times greater among patients undergoing bilateral ACLR compared with those undergoing unilateral ACLR. PTS measurements on radiography demonstrated a weak to negligible correlation with PTS measurements on MRI, suggesting that future normative PTS values should be reported specific to the imaging modality.

BACKGROUND:Acute Rockwood type III-V acromioclavicular (AC) dislocations have been treated with numerous surgical techniques over the years. The purpose of this study was to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) to quantitatively define the optimal treatment for operative AC dislocations. METHODS:A literature search of three databases was performed on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing one of ten treatments for acute Rockwood type III-V AC dislocations (Nonoperative [NO]; Kirschner wire fixation [KW]; Coracoclavicular screw fixation [Scr]; Hook plate [HP]; Open coracoclavicular cortical button [CBO]; Arthroscopic coracoclavicular cortical button [CBA]; Two or more coracoclavicular cortical buttons [CB2]; Isolated graft reconstruction [GR]; cortical button with graft augmentation [CB+GR]; coracoclavicular and acromioclavicular fixation [AC]) were included. Clinical outcomes were compared using a frequentist approach to NMA, with statistical analysis performed using R. Treatment options were ranked using the P-score, which estimates the likelihood that the investigated treatment is the ideal method for an optimal result in each outcome measure on a scale from 0 - 1. RESULTS:From 5362 reviewed studies, 26 studies met the inclusion criteria, with a total of 1581 patients included in the NMA. AC, CB+GR, GR, CB2, CBA, and CBO demonstrated superiority over HP, Scr, KW, and NO treatments at final follow up for Constant-Murley and DASH scores, with AC and CB+GR demonstrating the highest P-scores for Constant (P-score = 0.957 and 0.781, respectively) and GR and CBO with the highest P-scores for DASH (P-score = 0.896 and 0.750, respectively). GR had the highest P-score for VAS (P-score = 0.986). HP, CB2, CB+GR, AC, CBA, and CBO demonstrated superiority with final follow up coracoclavicular distance (CCD) and recurrence, with HP and CB2 having the highest P-score for CCD (P-score = 0.798 and 0.757, respectively) and GR and CB+GR having the highest P-score for recurrence (P-score = 0.880 and 0.855, respectively). KW and Scr had the shortest operative times (P-score = 0.917 and 0.810, respectively), with GR and CBA demonstrating longest operative times (P-score = 0.120 and 0.097, respectively). CONCLUSIONS:While there are multiple fixation options for acute surgical AC dislocations, adding AC fixation or graft augmentation likely improves functional outcomes and decreases CCD and recurrence at final follow up, at the expense of longer operative times.

PURPOSE/OBJECTIVE:The current investigation evaluated the relationship between the synovial fluid cytokine microenvironment at the time of isolated anterior cruciate ligament (ACL) reconstruction and the presence of subsequent chondral wear and radiologic evidence of osteoarthritis (OA) on cartilage-specific MRI sequences at a minimum of 5-year follow-up. METHODS:Patients who underwent primary ACL reconstruction with no baseline concomitant cartilage or meniscal defects and had synovial fluid samples obtained at the time of surgery were retrospectively identified. Patients with a minimum of 5 years of postoperative follow-up were contacted and asked to complete patient-reported outcome (PRO) measures including Visual Analog Scale (VAS) for pain, Lysholm Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Tegner Activity Scale, along with postoperative magnetic resonance imaging (MRI). The concentration of ten biomarkers that have previously been suggested to play a role in cartilage degradation and inflammation in the joint space was measured. Linear regression controlling for age, sex, and body mass index (BMI) was performed to create a model using the synovial fluid concentrations at the time of surgery to predict postoperative semiquantitative cartilage lesion size and depth on MRI at a minimum of 5 years follow up. RESULTS:The patients were comprised of eight males (44.4%) and ten females (55.6%) with a mean age at the time of surgery of 30.8 ± 8.7 years (range 18.2-44.5 years). The mean follow-up time was 7.8 ± 1.5 years post-operatively (range 5.7-9.7 years). MCP-1, VEGF, and IL-1Ra were found to have significant associations with the presence of postoperative cartilage wear (p < 0.05). No correlations were demonstrated among the biomarker concentrations at the time of injury with PRO scores at final follow-up (NS). CONCLUSION/CONCLUSIONS:Synovial fluid inflammatory biomarker concentrations at the time of injury can predict progression of early-stage post-traumatic osteoarthritis at a mean of almost 8 years post-operatively. Findings from this study may help identify treatment targets to alter the natural history of cartilage loss following anterior cruciate ligament injury. LEVEL OF EVIDENCE/METHODS:Level III, retrospective cohort study.

PURPOSE/UNASSIGNED:The purposes of this study were to determine why athletes did not return to play (RTP) following operative management of superior-labrum anterior-posterior (SLAP) tears, compare these athletes to those who did RTP, and evaluate the SLAP-Return to Sport after Injury (SLAP-RSI) score to assess the psychological readiness of athletes to RTP after operative management of SLAP tears. METHODS/UNASSIGNED:A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 24-month follow-up was performed. Outcome data, including visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, patient satisfaction, and whether they would undergo the same surgery again was collected. Additionally, the rate and timing of return to work (RTW), the rate and timing of RTP, SLAP-RSI score, and VAS during sport were evaluated, with subgroup analysis among overhead and contact athletes. The SLAP-RSI is a modification of the Shoulder Instability-Return to Sport after Injury (SI-RSI) score, with a score >56 considered to be a passing score for being psychologically ready to RTP. RESULTS/UNASSIGNED: = .001) were all associated with greater likelihood of return to sports at final follow-up. CONCLUSIONS/UNASSIGNED:Following the operative management of SLAP tears, patients who are unable to RTP exhibit poor psychological readiness to return, which may be due to residual pain in overhead athletes or fear of reinjury in contact athletes. Lastly, the SLAP-RSI tool in combination with ASES proved to be useful in identifying patients' psychological and physical readiness to RTP. LEVEL OF EVIDENCE/UNASSIGNED:Level IV, prognostic case series.

PURPOSE/UNASSIGNED:To evaluate functional outcomes and satisfaction in patients who underwent telerehabilitation (telerehab) compared with in-person rehabilitation after arthroscopic meniscectomy. METHODS/UNASSIGNED:A randomized-controlled trial was conducted including patients scheduled to undergo arthroscopic meniscectomy for meniscal injury by 1 of 5 fellowship-trained sports medicine surgeons between September 2020 and October 2021. Patients were randomized to receive telerehab, defined as exercises and stretches provided by trained physical therapists over a synchronous face-to-face video visit or in-person rehabilitation for their postoperative course. International Knee Documentation Committee Subjective Knee Form (IKDC) score and satisfaction metrics were collected at baseline and 3 months postoperatively. RESULTS/UNASSIGNED: = .044) if there were in the in-person group. Satisfaction differed significantly between the 2 groups at the end of their rehabilitation course, and only 64% of those in the telerehab group would elect to undergo telerehab again for future indications. Furthermore, they believed that future rehabilitation would benefit from a hybrid model. CONCLUSIONS/UNASSIGNED:Telerehab showed no difference versus traditional in-person rehabilitation in terms of functional outcomes up to 3 months after arthroscopic meniscectomy. However, patients were less satisfied with telerehab. LEVEL OF EVIDENCE/UNASSIGNED:I, randomized controlled trial.

The anterior cruciate ligament (ACL) is the primary restraint to tibial internal rotation and is supported by secondary stabilizers, including the iliotibial band (ITB), anterolateral ligament (ALL), anterolateral capsule, and lateral meniscus, which provide additional rotational control. Combined injury to primary and secondary rotational stabilizers can lead to anterolateral rotatory instability. This can best be demonstrated in patients with large pivot-shifts. Biomechanical studies have demonstrated that ACL reconstruction (ACLR) alone does not restore native kinematics in the setting of a combined injury. Concomitant anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET) techniques have been evaluated as a possible solution. Both the LET and ALLR may help restore rotational control, with the LET being slightly more powerful due to its more horizontal force vector based on biomechanical studies. However, there may be a slight risk of overconstraint with both techniques, more pronounced with the LET. Clinical studies evaluating the techniques for both primary and revision ACLR have generally found both to be safe and effective, leading to decreased rates of re-rupture and improved outcome scores. Either technique is a reasonable addition to ACLR when additional rotational control is indicated, though the LET may be more reproducible.

Introduction: While OCA has been shown to result in good long-term outcomes, there is still a considerable failure rate present with room for improvement. Objectives: The purpose of this study is to evaluate the impact that osteochondral allograft cartilage thickness has on contact pressures, and to simulate whether a mismatch of the subchondral bony interface relative to the host-recipient site results in altered biomechanics. Methods: Properties of articular cartilage and bone were incorporated into a finite element model to create a simulated osteochondral lesion (diameter: 10 mm, height: 10 mm, cartilage thickness: 2 mm, subchondral bone thickness: 8 mm). Five osteochondral plugs were constructed to fill the defect, with cartilage-to-bone ratios between 1:9 and 1:1. The plugs were inserted and given a static downward force of 5000 N. Resultant stresses and displacements were measured. Results: The 2:8 cartilage-to-bone ratio plug, matched with the recipient site, was deemed optimal based on its resultant stress and displacement. The 1:9 plug displaced less than the 2:8 match and endured greater stress per unit of cartilage volume, whereas the 3:7 plug also displayed similar displacement to the 1:9 plug but had greater cartilage volume and was able to distribute less stress per unit of cartilage volume. The 4:6 plug displaced to a similar extent as the 3:7 plug but displayed a unique pattern of strain. The 5:5 plug was considered nonfunctional, as the majority of displacement was seen in the cartilage of the recipient site rather than in the plug itself. Conclusions: The relationship between the cartilage-to-bone ratio in osteochondral allografts and that of their surroundings significantly impacts the distribution of stresses and predilection for micromotion at the repair site.

With an increased appreciation of the importance an intact meniscus has on normal knee kinematics and function, more meniscal tears are being treated with a repair rather than partial meniscectomy. There are several techniques for repairing torn meniscal tissue, including the outside-in, inside-out, and all-inside repairs. Each technique comes with its advantages and drawbacks. The inside-out and outside-in techniques allow for greater control of the repair using knots outside the joint capsule; however, they pose a risk for neurovascular injury and require additional incisions. Arthroscopic all-inside repairs have seen increasing popularity, but with current techniques, fixation is achieved either with intra-articular knots or extra-articular implants, leading to variable outcomes and the potential for postoperative complications. This technical note describes the use of SuperBall, an all-inside meniscus repair device that provides an all-arthroscopic approach, no intraarticular knots or implants, and surgeon-guided tensioning of the meniscus repair.

Purpose: Arthroscopic Bankart repair (ABR) may be more effective than nonoperative management for patients with anterior shoulder instability following first-time dislocation. The purpose of the study was to determine the most cost-effective treatment strategy by evaluating the incremental cost-effectiveness ratio (ICER) for ABR versus nonoperative treatment. Methods: This cost-effectiveness study utilized a Markov decision chain and Monte Carlo simulation. Probabilities, health utility values, and outcome data regarding ABR and nonoperative management of first-time shoulder instability derived from level I/II evidence. Costs were tabulated from Centers for Medicaid & Medicare Services. Probabilistic sensitivity analysis was performed using >100,000 repetitions of the Monte Carlo simulation. A willingness-to-pay (WTP) threshold was set at $50,000. Results: The expected cost for operative management higher than nonoperative management ($32,765 vs $29,343). However, ABR (5.48 quality-adjusted life years (QALYs)) was the more effective treatment strategy compared to nonoperative management (4.61 QALYs). The ICER for ABR was $3943. Probabilistic sensitivity analysis showed that ABR was the most cost-effective strategy in 100% of simulations. Discussion: ABR is more cost-effective than nonoperative management for first-time anterior shoulder dislocation. The threshold analysis demonstrated that when accounting for WTP, ABR was found to be the more cost-effective strategy.

BACKGROUND:Recent interest has surged in the anterolateral ligament (ALL) and complex (ALC) of the knee. Its existence and role in rotary stability of the knee, particularly in the setting of anterior cruciate ligament (ACL) reconstruction, remains a contentious and controversial topic. UNDERSTANDING THE ALC/UNASSIGNED:We must review our history and recognize the pioneers who pushed our understanding of the ALL forward before it was popularly recognized as a discrete structure. Additionally, given that many eponyms remain in common use related to the ALC, we must standardize our nomenclature to prevent misuse or misunderstanding of terms in the literature. In this review, modern understanding of the anterolateral ligament complex (ALC) is traced to 1829 by exploring eponymous terms first in anatomy and then in surgical technique. Understanding our history and terminology will allow us to better understand the ALC itself. CONCLUSION/CONCLUSIONS:This review aims to provide historical context, define terminology, and provide insight into the clinical relevance of the ALC.