John A. Grant

Comparison of Inside-Out and All-Inside Techniques for the Repair of Isolated Meniscal Tears A Systematic Review

Background: Arthroscopic meniscal repair techniques are continuing to evolve. Most studies to date comparing the healing rate of inside-out to all-inside meniscal repair techniques are confounded by associated anterior cruciate ligament reconstruction or deficiency. Purpose: This review was conducted to compare the effectiveness and complications of the inside-out repair technique to that of the all-inside repair technique in isolated unstable peripheral longitudinal (“bucket-handle”) meniscal tears. Study Design: Systematic review. Methods: Computerized keyword searches of MEDLINE, EMBASE, CINAHL, ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were performed. Two reviewers independently performed searches and article reduction. Studies that included stratified data for isolated unstable longitudinal meniscal tears in stable knees, repaired with either an inside-out or all-inside repair technique, were selected. Data on clinical failure, subjective outcome measures, and complications were summarized. Results: Nineteen studies included data specific to isolated meniscal tears. The rate of clinical failure was 17% for inside-out repairs and 19% for all-inside repairs. Lysholm scores and Tegner activity scores were similar between the 2 repair methods (87.8 vs 90.2 and 5.6 vs 5.5, respectively). The prevalence of nerve injury/irritation was higher with the inside-out technique (9% vs 2%). All-inside techniques had a higher rate of local soft tissue irritation, swelling, and implant migration or breakage. The use of older generation, rigid, all-inside implants is associated with chondral injury. Conclusion: There are no differences in clinical failure rate or subjective outcome between inside-out and all-inside meniscus repair techniques. Complications are associated with both techniques. More nerve symptoms are associated with the inside-out repair and more implant-related complications are associated with the all-inside technique. Clinical Relevance: Rates of structural healing and complications are comparable for inside-out and all-inside repair techniques for isolated meniscal injury. Differences in observed healing rates after meniscal repair may be more dependent on tear pattern and associated anterior cruciate ligament reconstruction rather than an inside-out versus all-inside surgical approach.

Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments.

PURPOSE To develop an evidence-based algorithm for the treatment of combined complete tears of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL). METHODS We performed a systematic review using computerized keyword searches of Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Two reviewers independently performed searches and article reduction. Studies that reported stratified outcomes data after the treatment of combined complete tears of the ACL and MCL were included. Data on clinical measures of laxity, range of motion, and strength, as well as subjective outcome measures, were summarized. RESULTS Five different treatment approaches were reported. Outcomes were better if the ACL was reconstructed and reconstruction was delayed to allow a return of knee range of motion. In many cases, this delay may allow the MCL to heal. MCL repair or reconstruction may be required if valgus instability remains after an appropriate rehabilitation period. CONCLUSIONS ACL reconstruction should be performed in a subacute time frame once full motion has returned. Valgus instability should be assessed at that time and MCL repair or reconstruction performed in those patients with persistent valgus instability. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.

Intra- and inter-rater reliability of the detection of tears of the supraspinatus central tendon on MRI by shoulder surgeons

BACKGROUND The purpose of this study was to determine the intra- and inter-rater reliability of detecting full- and partial-thickness tears of the supraspinatus intramuscular central tendon on magnetic resonance imaging (MRI) by orthopaedic shoulder surgeons. Full-thickness tears of this tendon have previously been associated with the failure of nonsurgical management of rotator cuff tears. METHODS Shoulder MRIs from 40 patients entered into a prospective rotator cuff disease database were independently reviewed by two musculoskeletal (MSK) radiologists in order to determine if there was a partial- or full-thickness tear of the supraspinatus central tendon. The MRIs were randomly sorted and distributed to 16 fellowship-trained shoulder surgeons. The surgeons then similarly diagnosed each patient. After a 1-month interval, surgeons repeated the evaluation with the same set of randomly reordered MRIs. Surgeon intra- and inter-rater reliability was determined with the kappa statistic. Agreement and inter-rater reliability were also determined between the shoulder surgeons and MSK radiologists. RESULTS For full-thickness tears, the intra-rater reliability was excellent (0.86 ± 0.1, 95% confidence interval (CI): 0.81, 0.91) and the agreement was 93.4% ± 4.6, 95% CI: 91.1, 95.8. Inter-rater reliability for both rounds was also excellent (0.77 and 0.74). The agreement between the shoulder surgeons and MSK radiologists was 92.9% ± 3.9, 95% CI: 90.9, 94.9, and the kappa was 0.85 ± 0.08, 95% CI: 0.81, 0.89. Including partial-thickness tears resulted in agreement of 65-92% and kappa values of 0.59-0.72. CONCLUSION The reliability for the MRI detection of full thickness tears of the supraspinatus central tendon among shoulder surgeons and between shoulder surgeons and MSK radiologists was excellent.

A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation

Context: Shoulder dislocations are common in contact sports, yet guidelines regarding the best treatment strategy and time to return to play have not been clearly defined. Evidence Acquisition: Electronic databases, including PubMed, MEDLINE, and Embase, were reviewed for the years 1980 through 2015. Study Design: Clinical review. Level of Evidence: Level 4. Results: Much has been published about return to play after anterior shoulder dislocation, but almost all is derived from expert opinion and clinical experience rather than from well-designed studies. Recommendations vary and differ depending on age, sex, type of sport, position of the athlete, time in the sport’s season, and associated pathology. Despite a lack of consensus and specific recommendations, there is agreement that before being allowed to return to sport, athletes should be pain free and demonstrate symmetric shoulder and bilateral scapular strength, with functional range of motion that allows sport-specific participation. Return to play usually occurs 2 to 3 weeks from the time of injury. Athletes with in-season shoulder instability returning to sport have demonstrated recurrence rates ranging from 37% to 90%. Increased bone loss, recurrent instability, and injury occurring near the end of season are all indications that may push surgeons and athletes toward earlier surgical intervention. Conclusion: Most athletes are able to return to play within 2 to 3 weeks but there is a high risk of recurrent instability.

Relationship Between Implant Use, Operative Time, and Costs Associated With Distal Biceps Tendon Reattachment

The suture anchor and transosseous drill hole techniques for reattachment of the distal biceps tendon to the radius have been found to have similar clinical and biomechanical outcomes. However, a comparison of the cost effectiveness of these techniques is lacking. The purpose of this study was to determine whether the use of suture anchors decreases operative time enough to offset the additional cost of the implants. The records of all patients undergoing a distal biceps tendon reattachment were reviewed to determine the method of fixation, operative time, and associated surgical costs. Two surgeons used a technique of fixing the tendon directly to the bone (transosseous group), whereas 3 surgeons used suture anchors. Given the standard nature of the surgical procedure (other than the fixation technique), only the costs that differed between the 2 groups were included. Surgical center costs were obtained from the local outpatient surgical center in 2011 US dollars. Five surgeons treated 70 men (mean age, 45.9±9.2 years). Mean time from injury to surgery was 14 days. Mean operative times for the transosseous and suture anchor groups were 97.6±14.9 and 95.8±25.8 minutes, respectively (P=.74). Two anchors were used in 79% of the anchor cases. The use of anchors cost

Surgical stabilization for first-time shoulder dislocators: a multicenter analysis

474.33 more per patient. However, this value is sensitive to the cost of the individual anchors, intersurgeon variation in operative time, and per-minute value of saved operative time. No operative time was saved with the use of suture anchors. This cost comparison framework can be used to evaluate the balance in surgical resource use due to implant cost vs savings in operative time.

Contralateral Lateral Femoral Condyle Allografts Provide an Acceptable Surface Match for Simulated Classic Osteochondritis Dissecans Lesions of the Medial Femoral Condyle

BACKGROUND Anterior shoulder dislocations in young patients are associated with high rates of recurrent instability. Although some surgeons advocate for surgical stabilization after a single dislocation event in this population, there is sparse research evaluating surgical treatment for first-time dislocators. METHODS Patients undergoing surgical stabilization for anterior shoulder instability were prospectively enrolled at multiple institutions from 2015-2017 and stratified by number of dislocations before surgery. Demographic data, preoperative patient-reported outcomes, imaging findings, surgical findings, and procedures performed were compared between groups. Analysis of variance, χ2, and multivariate logistic regression were used for statistical analysis. RESULTS The study included 172 patients (mean age, 25.3 years; 79.1% male patients) for analysis (58 patients with 1 dislocation, 69 with 2-5 dislocations, 45 with >5 dislocations). There were no intergroup differences in demographic characteristics, preoperative patient-reported outcomes, or physical examination findings. Preoperative imaging revealed increased glenoid bone loss in patients with multiple dislocation events (P = .043). Intraoperatively, recurrent dislocators were more likely to have bony Bankart lesions (odds ratio [OR], 3.26; P = .024) and biceps pathology (OR, 6.27; P = .013). First-time dislocators more frequently underwent arthroscopic Bankart repair and/or capsular plication (OR, 2.22; P = .016), while recurrent dislocators were more likely to undergo open Bristow-Latarjet procedures (OR, 2.80; P = .049) and surgical treatment for biceps pathology (OR, 5.03; P = .032). CONCLUSIONS First-time shoulder dislocators who undergo stabilization are more likely to undergo an arthroscopic procedure and less likely to have bone loss or biceps pathology compared with recurrent dislocators. Future studies are needed to ascertain long-term outcomes of surgical stabilization based on preoperative dislocation events.

Deliberative Prescription Opioid Misuse Among Adolescents andEmerging Adults: Opportunities for Targeted Interventions

Objectives: The purpose of this study was to determine whether contralateral lateral femoral condyle (LFC) allografts can provide an acceptable surface topography match for classic osteochondritis dessicans (OCD) lesions of the medial femoral condyle (MFC). Achievement of an acceptable donor-recipient articular surface match (1 mm deviation) has been associated with physiological joint stresses and predictably positive clinical outcomes. It was hypothesized that LFC and MFC allografts would show no differences in step-off height or surface deviation in all four quadrants of the graft. Methods: ample size calculation suggested ten groups of fresh frozen size-matched human condyles, each group consisting of a donor MFC, donor LFC, and recipient MFC. A 20 mm circular osteochondral “defect” simulating a “classic” OCD lesion was created in the recipient MFC. Its most anterior position was 1 cm posterior and 1 cm medial to the roof of the intercondylar notch. A randomly selected donor MFC or LFC plug was then harvested and transplanted using standard procedure (Fig 1A). The transplanted condyle was scanned with nano-CT, reconstructed (Fig 1B), registered to an initial scan of the recipient MFC, and processed with a custom MATLAB program to determine the surface root mean squared deviation (dRMS) between the native and donor surfaces (Fig 1C), percent area unacceptably proud (>1 mm; %Aproud) and sunken (<-1 mm; %Asunk). Scans were uploaded into DragonFly software where step-off height (hRMS), percent circumference unacceptably proud (>1 mm; %Cproud) and sunken (< -1 mm; %Csunk) were measured (Fig 1D). The process was then repeated for the other allograft plug. Two-way mixed ANOVAs with Sidak corrections for multiple comparisons (α=0.05) were used. Exempt status was obtained from the University’s IRB. Results: Both MFC and LFC plugs showed acceptable step-off heights in all four quadrants. Neither allograft type nor location within the defect had a main effect on step-off height (hRMS). In general, plugs were more unacceptably sunken than proud, though no differences in %Csunk were seen between allograft types or locations within the defect. In LFC plugs, %Cproud was significantly greater laterally (by the intercondylar notch) compared to all other locations around the plug (p<0.0001), while no differences were seen based on location in MFC plugs. The cartilage surface deviationn (dRMS), %Aproud, and %Asunk were not significantly affected by allograft type or location (Table 1). Conclusion: Previous studies demonstrated that contralateral LFCs provide acceptable surface topography matches for centrally located defects of the MFC. In evaluating the utility of LFC allografts for more laterally located lesions characteristic of OCD, it was found that, similarly, allograft type does not have an effect on surface deviation or step-off height. With comparable surface deviations, both MFC and LFC allografts can be expected to present similar stresses on the knee joint and achieve predictably positive clinical outcomes, thus improving donor availability and reducing surgical wait times for matches. LFC plugs did not differ from MFC plugs in overall %Aproud, %Asunk, %Cproud, or %Csunk suggesting that well placed LFC plugs, like MFC plugs, may result in few post-surgical complications. Higher step-off heights of LFC plugs near the intercondylar notch may contribute to higher joint stresses and may serve as an area of focus in future studies. Figure 1. (A) en-face view of transplanted osteochondral allograft adjacent to the intercondylar notch. (B) 3D reconstruction of nano-CT image showing the four regional quadrants of the allograft considered in this study

25 The need for establishment of a minimally clinical important difference and standardization of pre and post-operative assessment

BACKGROUND One in five adolescents and emerging adults have reported prescription opioid misuse (POM), posing significant risks for opioid-related adverse outcomes. Devising prevention strategies requires a better understanding of the decisional factors underlying risky misuse behavior. This research examined the associations between past opioid use behavior, opioid risk knowledge and perceptions, and intentional POM decisions. METHODS Participants aged 15-23years completed surveys assessing past prescription opioid use and misuse, opioid risk knowledge, opioid risk perceptions, and pain relief preferences (i.e., analgesic benefit vs. risk aversion preference). The outcome, Willingness to Misuse (i.e., intentional decisions to use a prescription opioid in a non-compliant manner) was measured using hypothetical pain decision scenarios. RESULTS Surveys were completed by 972 adolescents and young adults. In total, 44% had taken a prescription opioid and 32% of these reported past POM. Willingness to Misuse was significantly associated with lower opioid misuse risk perceptions (β = .75 [95% CI .66-.86]) and past opioid misuse (β = 1.81 [95% CI 1.13-2.91]) but not simple risk knowledge (β = .81 [95% CI .58-1.11]. The probability of future misuse was highest for those who reported past opioid misuse and had low risk perceptions (58.7% [95% CI 51.3-65.8]) and high pain relief preferences (53.4% [95% CI 45.3%-61.3%]). CONCLUSIONS Findings suggest that simple knowledge of prescription opioid risks is insufficient to curtail misuse among adolescents and emerging adults. Rather, it may be important to heighten opioid risk perceptions and strengthen opioid risk aversion values when prescribing opioid analgesics to better prevent future misuse in this high risk population.

Descriptive Epidemiology of the MOON Shoulder Instability Cohort

Objectives To compare the outcomes between autograft and allograft reconstruction in patients with PCL deficiency. During the extraction of data and its comparison and interpretation in the development of this meta-analysis, the lack of standardisation in patient follow-up with regards to length of follow-up, modalities measured, and reports of adverse events were notable. Many studies were thus excluded due to failure to meet preset inclusion criteria. The subsequent data analysis therefore became limited in its translation towards guiding clinical and surgical practice. The development of a standardised pre and post-operative assessment and follow-up criteria will not only benefit patients, but will also ensure that future systematic reviews conducted will carry a higher impact towards guiding clinical practice. Method Medline, EMBASE, and the Cochrane Library databases were searched from January, 1980 until December 1 st, 2016 to identify all relevant articles. Clinical outcomes including International Knee Documentation Committee (IKDC), Tegner and Lysholm scores, joint laxity and posterior tibial displacement were evaluated. Dichotomous outcomes were pooled into odds ratios while continuous outcomes were pooled into weighted mean differences (MD) using random effects meta-analysis. Results We conducted a systematic review looking at outcomes of isolated PCL reconstruction comparing autograft vs allograft sources. Clinical outcomes including International Knee Documentation Committee (IKDC), Lysholm and Tegner scores, joint laxity, and posterior tibial displacement were evaluated. Amongst the 145 unique articles found through the screening process, 25 studies, with a combined patient population of 900, were deemed eligible for inclusion in this study. Post-operative improvement was observed regardless of graft source. Pooled findings revealed that autografts demonstrated a statistically significant post-operative activity as measured by Tegner scores (MD: 0.5, 95% CI 0.03, 0.9; p=0.04) and a reduced posterior laxity (MD: −1.2, 95% CI −1.6,–0.8; p<0.00001). Conclusions However, despite a statistically significant improvement, there is difficulty establishing a clinically significant improvement. This stems from the absence of a standardised guideline of measuring pre-operative and post-operative functions. One example is the inconsistent usage of IKDC scores between studies, a failure of reporting both pre and post-operative IKDC scores, and subjective reporting as either ‘normal’ or ‘abnormal’ rather than following a protocol. Thus, the development of a systematic approach to assess patients before and after operations, along with establishment of an agreed minimally clinical important difference will lend to more impactful data analysis and ease of generating guidelines.