Publications by authors named "Brian R Waterman"

184 Publications

Editorial Commentary: Rotator Cuff Repairs Fail at an Alarmingly High Rate During Long-Term Follow-Up: Graft Augmentation and Biologics May Improve Future Outcomes.

Arthroscopy 2022 Aug;38(8):2413-2416

Wake Forest University School of Medicine (N.A.T.).

Rotator cuff repairs (RCR) frequently fail to heal, particularly those with advanced fatty infiltration, supraspinatus and infraspinatus atrophy, narrowed acromiohumeral distance, and large-to-massive tear size. Unfortunately, the longer the follow up, the more sobering the statistics, with some reported retear rates ranging up to 94%. Importantly, recent long-term radiographic assessments after primary RCR reveal direct correlations between failure and patient-reported outcomes, functional deterioration, and ultimately, progression of glenohumeral arthritis and/or frank cuff tear arthropathy. As shoulder surgeons, we must continue to seek out novel approaches to improve tendon to bone healing and recapitulate the native rotator cuff enthesis. In doing so, we hope to engender more sustained subjective and objective results for our patients over time. Investigations are ongoing into several biomechanical and biological or structural adjuncts, from platelet-rich plasma and bone marrow aspirate concentrate to autograft or allograft structural augments. We must continue to push the envelope and refuse to settle for the current reality and alarmingly high failure rates following RCR.
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http://dx.doi.org/10.1016/j.arthro.2022.04.002DOI Listing
August 2022

Rates of Anterior Cruciate Ligament Rerupture in Adolescent Patients with and without Patella Alta.

J Knee Surg 2022 Jul 7. Epub 2022 Jul 7.

Department of Orthopaedics, William Beaumont Army Medical Center, El Paso, Texas.

The objective of this study was to compare rates of anterior cruciate ligament (ACL) failure among adolescent patients to evaluate patella alta as a high-risk variable. Demographic and surgical data were retrospectively queried for patients ≤18 years of age with primary ACL reconstruction performed at a single academic center between 2011 and 2016 and minimum of 2-year clinical surveillance. Patellar height indices, including Caton-Deschamps index (CDI) and Insall-Salvati index (ISI), were retrospectively calculated from preoperative imaging to assess the presence of patella alta. Failure was defined as (1) ACL graft rerupture, (2) Lachman's grade 2 + , (3) presence of pivot shift, and (4) side-to-side difference of 3 mm on KT-1000 arthrometer. A total of 184 patients (84 females and 100 males) and 192 knees were identified, with an average age of 16.2 ± 1.8 years. Of these, 30 (15.63%) experienced ACL failure. Male sex was the only significant risk factor for rerupture ( = 0.026). The mean CDI was 1.06 ± 0.17 and mean ISI was 1.04 ± 0.15. Of the 49 knees that met criteria for patella alta on radiographic evaluation, rerupture occurred in seven (14.29%). Patella alta was not a significant risk factor for ACL failure among adolescent patients ( = 0.359 and 0.277). Only male sex was associated with increased rates of ACL failure. Age, graft selection technique, fixation construct, and presence of patella alta were not risk factors for reinjury. This study is a therapeutic case series and reflects level of evidence IV.
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http://dx.doi.org/10.1055/s-0042-1749608DOI Listing
July 2022

Biceps Tenodesis Has Greater Expected Value Than Repair for Isolated Type II SLAP Tears: A Meta-analysis and Expected-Value Decision Analysis.

Arthroscopy 2022 Jun 3. Epub 2022 Jun 3.

Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A.. Electronic address:

Purpose: To use an expected-value decision analysis to determine the optimal treatment decision between repair and biceps tenodesis (BT) for an isolated type II SLAP injury.

Methods: An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. To determine outcome probabilities, a decision tree was constructed (repair vs BT) and a meta-analysis was conducted. To determine outcome utilities, we evaluated 70 patients with a chief complaint of shoulder pain regarding age, sex, Shoulder Activity Level, and visual analog scale score in terms of potential outcome preferences. Statistical fold-back analysis was performed to determine the optimal treatment. One-way sensitivity analysis determined the effect of changing the reinjury rate on the expected value of BT.

Results: The overall expected value was 8.66 for BT versus 7.19 for SLAP repair. One-way sensitivity analysis showed that BT was the superior choice if reinjury rates were expected to be lower than 28%. Meta-analysis of 23 studies and 908 patients revealed that the probability of a "well" outcome was significantly greater for BT (87.8%; 95% confidence interval [CI], 74.9%-94.6%; I = 0.0%) than for SLAP repair (62.9%; 95% CI, 55.9%-69.3%; I = 65.9%; P = .0023). The rate of reinjury was 1.5% for BT (95% CI, 0.05%-33.8%; I = 0.0%) and 6.4% for repair (95% CI, 4.2%-9.6%; I = 24%), which was not statistically significantly different (P = .411). A total of 50 participants (mean age, 25.4 years [standard deviation, 8.9 years]; 76% male patients; 50% overhead athletes) met the inclusion criteria. Forty-six percent of participants had a high Shoulder Activity Level score.

Conclusions: Decision analysis showed that BT is preferred over repair for an isolated type II SLAP tear based on greater expected value of BT versus repair. Meta-analysis showed more frequent favorable outcomes with BT. Surgeons can use this information to tailor discussions with patients.

Level Of Evidence: Level IV, meta-analysis of Level I-IV studies.
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http://dx.doi.org/10.1016/j.arthro.2022.05.005DOI Listing
June 2022

Editorial Commentary: Predictors of Best Outcomes After Latissimus Dorsi Transfer for Irreparable Rotator Cuff Tear.

Arthroscopy 2022 06;38(6):1831-1833

The management of patients with massive posterosuperior rotator cuff tears without glenohumeral arthritis remains a challenge to arthroscopic surgeons. A wide variety of treatment options have been described, including latissimus dorsi tendon transfer (LDTT) and lower trapezius tendon transfer. These tendon transfers have been utilized to rebalance the glenohumeral force couple for patients with massive or irreparable posterosuperior rotator cuff tears. Proponents of the latissimus dorsi tendon transfer have touted several theoretical advantages, including improvement of the shoulder fulcrum, optimization of the deltoid function, improved humeral head depression, and restoration of shoulder motion. Currently accepted contra-indications to LDTT include glenohumeral arthritis, irreparable subscapularis tear, axillary nerve palsy and/or deltoid insufficiency. However, few studies have investigated the ideal patient selection for LDTT, particularly as it relates to clinically significant outcomes. Recent literature suggests a high rate of complications and re-tear following LDTT, and studies suggest that older age, previous surgery, true pseuoparalysis, lower low pre-operative acromiohumeral interval (AHI) or AHI reversibility negatively impact results. Ultimately, candidates for tendon transfer should be carefully stratified according to their modifiable and non-modifiable risk factors, and surgeons should understand how pre-operative patient characteristics may affect the treatment options available for this unique patient population. In the setting of supraspinatus and infraspinatus deficiency, we prefer to utilize the lower trapezius tendon transfer, given its more predictable handling characteristics, ease of harvest, and greater function consistency compared to LDTT.
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http://dx.doi.org/10.1016/j.arthro.2022.03.035DOI Listing
June 2022

Editorial Commentary: Increased Graft Thickness With Superior Capsular Reconstruction Results in Improved Acromiohumeral Distance, but Increased Graft Tear Rate and Lateral Acromial Erosion.

Authors:
Brian R Waterman

Arthroscopy 2022 06;38(6):1793-1795

For the treatment of irreparable posterosuperior rotator cuff tears of the supraspinatus and infraspinatus, superior capsular reconstruction (SCR) has continued to supplant other less successful and/or reproducible techniques, including partial rotator cuff repair and latissimus tendon transfer. After its initial description utilizing a folded fascia lata autograft with a thickness of up to 8 mm, many in North America adapted their surgical technique to use commercially available human dermal allograft to mitigate donor site morbidity. Early series have revealed the importance of graft thickness in predicting risk of radiographic or clinical failure. As a result, there has been a renewed interest in increasing the thickness of an SCR graft to further prevent superior humeral head translation and diminish subacromial contact pressures and secondary radiographic, or more importantly, clinical failure. Some authors have sought to augment dermal allografts for increased stiffness, whereas other authors have explored the option of adding a separate graft on the undersurface of the acromion for a bursal acromial reconstruction. Although this increased graft thickness may result in improved acromiohumeral distance and clinically significant patient improvement, secondary graft retear and acromial osteolysis may develop due to increased friction or "overstuffing" of the subacromial space.
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http://dx.doi.org/10.1016/j.arthro.2022.03.007DOI Listing
June 2022

Editorial Commentary: Determination of Meaningful, Clinically Significant Outcome Thresholds for Superior Capsular Reconstruction of the Shoulder: Predicting Those Patients Who Improve and Those Who Don't!

Authors:
Brian R Waterman

Arthroscopy 2022 05;38(5):1454-1456

Since the introduction of superior capsular reconstruction (SCR) for the treatment of irreparable rotator cuff tears nearly 10 years ago, we have witnessed widespread adoption by the arthroscopic shoulder community alongside an exponential increase in use within North America. To date, more than 42,000 acellular dermal allografts have been implanted in the United States alone, and our indications and surgical technique have been progressively refined in response to the evolving body of clinical outcomes research. However, with P values set aside, the real question still remains: how do our patients actually do after SCR? With the advent of clinically significant outcomes such as the patient acceptability symptomatic state and substantial clinical benefit, investigators have sought to establish more practical, patient-centered benchmarks for success after an intervention. Rather than just seeking the baseline expectations via the minimally clinically important difference (i.e., "I am better"), substantial clinical benefit (i.e., "I am so much better") and patient acceptability symptomatic state (i.e., "I am 'okay' with how I feel") truly clarify patient satisfaction and provide measurable units of patient improvement. These must be assessed on an individual basis, as aggregated averages introduce outliers that can distort the outcomes. Based on these end points, prognostic factors may allow a more concrete assessment of surgical risk while equipping physicians with appropriate information to guide ideal patient selection and optimize chances of success. Patients of female sex, older age, worker's compensation status, and those with subscapularis involvement are less likely to achieve clinically significant outcomes at minimum 1-year follow-up after SCR. Based on the current study, surgeons should exercise caution in recommending SCR for patients of advancing chronological age and significant subscapularis involvement, particularly if irreparable or untreated.
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http://dx.doi.org/10.1016/j.arthro.2022.02.012DOI Listing
May 2022

Significant Reduction in Short-Term Complications Following Unicompartmental Versus Total Knee Arthroplasty: A Propensity Score Matched Analysis.

J Arthroplasty 2022 Apr 29. Epub 2022 Apr 29.

Virginia Commonwealth University, Department of Orthopaedic Surgery, Richmond, Virginia.

Background: Total knee arthroplasty (TKA) is a gold standard surgical treatment for end-stage arthritis and unicompartmental knee arthroplasty (UKA) is an alternative for localized disease in appropriate patients. Both have been shown to have equivalent complications in the short-term period. We aimed to explore the differences in 30-day complication rates between UKA and TKA using recent data.

Methods: Current Procedural Terminology codes identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent primary TKA or UKA from 2014 to 2018. Propensity score matching addressed demographic differences. Rate of any adverse event (AAE) and complications were compared.

Results: We identified 279,852 patients with 270,786 and 9,066 undergoing TKA and UKA. No significant difference was observed in baseline demographics after matching. The AAE rate differed significantly between TKA (5.07%) and UKA (2.38%) cohorts (P < .001). TKA group experienced more wound dehiscence, cerebrovascular accident, postoperative blood transfusion, deep vein thrombosis, and requirement for postoperative intubation. Rate of extended length of stay differed between the TKA (11.35%) and UKA (4.89%) cohorts (P < .001). Accounting for all other variables, preoperative corticosteroid use, bleeding disorder, and chronic obstructive pulmonary disease increased the risk for AAE for both groups. Increasing American Society of Anesthesiologists class also increased the odds for complication proportionally with increasing age and operative time.

Conclusion: Contrary to previous data, we found a significantly higher 30-day complication rate in TKA patients. TKA patients had a higher likelihood of having an extended length of stay. Multivariable analysis identified preoperative steroid use, bleeding disorder, and chronic obstructive pulmonary disease as risk factors for developing adverse events for both groups.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.arth.2022.04.032DOI Listing
April 2022

Editorial Commentary: Multimodal, Opioid-Free Pain Management After Rotator Cuff Repair May Be Safe and Effective, and Decreases the Risk of Drug Abuse.

Arthroscopy 2022 04;38(4):1086-1088

Wake Forest University School of Medicine.

In 2020, approximately 94,000 people died in the United States due to drug overdose, a grim 78% increase since release of the American Academy of Orthopaedic Surgeons (AAOS) information statement on opioid abuse nearly 5 years ago. Annual opioid-related mortality rates now far surpass those stemming from either car crashes or gun violence. Multiple risk factors exist for opioid misuse and abuse, including a major risk factor under the orthopaedic surgeon's control-exposure to opioid medication. Prescription protocols that decrease a patient's access to narcotic medication could lead to a decrease in overall opioid abuse, while also avoiding second-order effects, such as drug diversion. Multimodal, nonopioid pain protocols often employ peripheral nerve blocks, acetaminophen, nonsteroidal anti-inflammatory medication (NSAIDs), gabapentinoids, and antispasmodic muscle relaxants, and this has yielded promising results after arthroscopic rotator cuff surgery. As good stewards of the musculoskeletal community, we should proactively employ evidence-based practices for establishing realistic postoperative patient expectations, common analgesic care pathways, and standardized pill counts stratified by procedure type.
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http://dx.doi.org/10.1016/j.arthro.2022.01.040DOI Listing
April 2022

Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction.

Arthrosc Sports Med Rehabil 2022 Jan 28;4(1):e103-e113. Epub 2022 Jan 28.

Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A.

Despite advancements in our understanding of anterior cruciate ligament (ACL) injury prevention and nonsurgical management, ACL reconstruction continues to occur at an alarming rate. Among athletic patients, individuals participating in basketball, soccer, and football have the highest incidence of ACL injury, often requiring surgical intervention. To ensure the optimal treatment strategy for return to sport and prevention of secondary graft re-tear, it is important to tailor to the specific demands of the injured athlete and apply evidence-based best practices and rehabilitation principles. The purpose of this review is to provide readers with a brief background regarding ACL injuries, a focused review of clinical outcome studies after ACL reconstruction, and an updated framework with expert-guided recommendations for postoperative rehabilitation and return to sporting activity. Currently, there is no gold standard for rehabilitation after ACL reconstruction, highlighting the need for robust studies evaluating the best modalities for athlete rehabilitation, as well as determining the efficacy of new tools for improving therapy including blood flow restriction therapy and neuromuscular electrical stimulation. Based on clinical experience, a renewed focus on objective, criteria-based milestones may maximize the ability of return to preinjury levels of athletic function.
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http://dx.doi.org/10.1016/j.asmr.2021.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811493PMC
January 2022

Biomechanical Analysis of the Throwing Athlete and Its Impact on Return to Sport.

Arthrosc Sports Med Rehabil 2022 Jan 28;4(1):e83-e91. Epub 2022 Jan 28.

Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A.

Throwing sports remain a popular pastime and frequent source of musculoskeletal injuries, particularly those involving the shoulder and elbow. Biomechanical analyses of throwing athletes have identified pathomechanic factors that predispose throwers to injury or poor performance. These factors, or key performance indicators, are an ongoing topic of research, with the goals of improved injury prediction, prevention, and rehabilitation. Important key performance indicators in the literature to date include shoulder and elbow torque, shoulder rotation, kinetic chain function (as measured by trunk rotation timing and hip-shoulder separation), and lower-extremity mechanics (including stride characteristics). The current gold standard for biomechanical analysis of the throwing athlete involves marker-based 3-dimensional) video motion capture. Emerging technologies such as marker-less motion capture, wearable technology, and machine learning have the potential to further refine our understanding. This review will discuss the biomechanics of throwing, with particular attention to baseball pitching, while also delineating methods of modern throwing analysis, implications for clinical orthopaedic practice, and future areas of research interest.

Level Of Evidence: V, expert opinion.
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http://dx.doi.org/10.1016/j.asmr.2021.09.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811517PMC
January 2022

Editorial Commentary: Subpectoral Biceps Tenodesis Is a Safe Alternative to Arthroscopic Repair for Unstable SLAP Tear in the Young Athlete: Should We Do the Last Operation First?

Authors:
Brian R Waterman

Arthroscopy 2022 02;38(2):313-314

The clinical significance of structural pathology affecting the biceps-superior labrum complex may be highly variable. Among younger, physically active patients with symptomatic superior labrum anterior-posterior (SLAP) tears that have failed to respond to nonoperative treatment, we continue to lack clear high-level evidence to guide surgical decision making, including a decision between arthroscopic SLAP repair or primary biceps tenodesis for more unstable, type II lesions. Rates of patient satisfaction, return to play, return to prior level of activity, and secondary revision rate are widely reported, and we lack consensus for surgical best practice treatment. With the high rate of postoperative stiffness and revision reoperation and inconsistent functional outcomes after modern arthroscopic shoulder SLAP repair with knotless anchor technology, subpectoral biceps tenodesis may emerge as a primary alternative for treating the young athlete with unstable SLAP tears.
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http://dx.doi.org/10.1016/j.arthro.2021.10.019DOI Listing
February 2022

Editorial Commentary: The Nonoperative Instability Severity Index Score Can, in Part, Help to Predict Failure After Nonoperative Management of Anterior Shoulder Instability: Fix Them All Versus Wait and See?

Arthroscopy 2022 01;38(1):28-30

Wake Forest Baptist Health.

The optimal management of anterior shoulder instability remains a heated topic of debate, particularly after first-time shoulder dislocation. From expedited rehabilitation to arthroscopic Bankart repair and Latarjet coracoid transfer, the shoulder community has staunchly defended its approach with carefully tailored data describing patient satisfaction, instability recurrence, revision surgery, and timeline to return to play or preinjury activity. However, not all patients require surgical stabilization, and a "wait-and-see" approach can often result in favorable outcome. The Nonoperative Instability Severity Index Score has been proposed as a unique tool to stratify risk for failure among athletes after an anterior shoulder instability event. While not a standalone tool for predicting further shoulder dislocation in a broader athletic population, the Nonoperative Instability Severity Index Score reflects a movement toward personalized medicine, where clinical decision making is executed on the individual level based on unique risk factors and circumstances.
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http://dx.doi.org/10.1016/j.arthro.2021.07.034DOI Listing
January 2022

Health Conditions, Substance Use, Physical Activity, and Quality of Life in Current and Former Baseball Players.

Orthop J Sports Med 2021 Nov 23;9(11):23259671211056645. Epub 2021 Nov 23.

Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK.

Background: A comprehensive understanding of lifestyle (health conditions and substance use), health-related quality of life (HRQoL), flourishing (holistic representation of health), and physical activity can inform stakeholders (players, coaches, and clinicians) and help improve long-term health across the life span.

Purpose: To describe health conditions (comorbidities or diagnoses), substance use, physical activity, HRQoL, and flourishing in current and former collegiate and professional baseball players and to assess the relationship between playing position and HRQoL/flourishing in former baseball players.

Study Design: Descriptive epidemiology study.

Methods: Eligible participants were those ≥18 years old with ≥1 season of collegiate or professional baseball experience. Participants completed a survey on health conditions (asthma, diabetes, hypertension, hypercholesterolemia, and depression), substance use (tobacco, alcohol, and energy drinks), physical activity (International Physical Activity Questionnaire-Short Form), HRQoL (Veterans Rand 12-Item Health Survey [VR-12] physical and mental component scores), and flourishing (Flourishing Scale). Adjusted multivariable regressions were performed for HRQoL and flourishing.

Results: Overall, 260 baseball players opened the survey, and 214 (current players, 97; former players, 117) participated for an 82% response rate. Of the former players, 32% had hypertension or hypercholesterolemia. In addition, 26% of current players had used smokeless tobacco (median, 3 years; interquartile range [IQR], 1-5 years) as compared with 34% of former players (median, 15 years; IQR, 5-25 years). In addition, 14% of current players had used electronic cigarettes (median, 2 years; IQR, 0-4 years) as opposed to 3% of former (median, 3 years; IQR, 2-4 years). Energy drinks were consumed by 31% and 14%, respectively, of current and former players on at least a weekly basis. Current baseball players performed 8667 metabolic equivalents per week of physical activity as opposed to 3931 in former players. Pitching was associated with worse VR-12 Mental Component Scores (-5.0; 95% confidence interval, -9.0 to -1.0). Playing position was not related to VR-12 Physical Component Scores or flourishing in former baseball players.

Conclusion: The similar smokeless tobacco prevalence between current and former baseball players suggests that they may start using tobacco products during baseball participation and continue after retirement. Similar reported HRQoL as compared with the general US population and high flourishing and physical activity levels suggest that baseball players may present with good musculoskeletal and psychological health.
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http://dx.doi.org/10.1177/23259671211056645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8647246PMC
November 2021

Editorial Commentary: Repairing Retracted Rotator Cuff Tears: Histologically Different, but Success Still Achievable With "Failure in Continuity".

Arthroscopy 2021 12;37(12):3432-3433

Wake Forest University School of Medicine.

Failure after rotator cuff repair continues to occur despite advances in our understanding of the native tendon enthesis. Recurrent postoperative tendon defects are common, and the impact of nonhealing on postoperative outcomes remains controversial. Rotator cuff tears (RCT) of all patterns commonly present with some degree of retraction, and it is, therefore, critical to understand and examine the biology and biomechanics of the retracted RCT to address why a repaired tendon may fail. An article in this issue reports on retracted tears forming more disorganized fibrous tissue with similar biomechanical properties compared to nonretracted tear tissue. It provides insight into what lies "beneath the surface" after retracted rotator cuff repair, but it is unclear whether the fibrous tissue formed after their acute partial tendon excision adequately reflects the tissue found in more chronic, retracted human rotator cuff tears, particularly with varying degrees of retraction. Facilitating a more favorable "scar-forming" environment and optimizing this postoperative fibrous tissue may be crucial to improving rotator cuff repairs in the future.
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http://dx.doi.org/10.1016/j.arthro.2021.09.004DOI Listing
December 2021

Cement augmentation of suture anchors in the proximal humerus during rotator cuff repair improves pullout strength: a systematic review.

J ISAKOS 2021 11 21;6(6):349-355. Epub 2021 Jun 21.

Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA.

Importance: Rotator cuff pathology is a growing concern in the ageing population. If cement augmentation of suture anchors improves pullout strength, its application can potentially be applied in cases of poor bone quality to prevent anchor failure.

Objective: To evaluate the biomechanical benefits and fixation strength of cement-augmented versus non-augmented suture anchors in the proximal humerus during rotator cuff repair (RCR).

Evidence Review: A systematic review of PubMed, Embase and Cochrane Library was performed to identify all published articles reporting on biomechanical analysis of suture anchors in the shoulder in a cadaveric model. Inclusion criteria required fresh-frozen specimens, placement in the footprint of the proximal humerus, and comparative assessment of fixation constructs with or without polymethylmethacrylate (PMMA) or bioabsorbable composite cement augmentation. Biomechanical testing procedure, cement augmentation method and pullout force were assessed.

Findings: After review of 105 abstracts, seven full manuscripts met inclusion criteria. Six of seven studies reported statistically significant differences in mean pullout force between augmented (three PMMAs, three composites, one PMMA vs composite) and non-augmented anchors. Of two studies evaluating cycles to failure, both found a significant increase in the augmented versus non-augmented anchors. Of two studies stratifying by anchor position, both investigations identified significant differences in mean pullout strength between augmented and non-augmented anchors at the posteromedial and anterolateral anchor positions.

Conclusions And Relevance: Cement augmentation of suture anchors in cadaveric humeri for RCR improves pullout strength regardless of cement type used or anchor position. Cement augmentation may provide a viable option for future clinical application.

Level Of Evidence: IV, systematic review.
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http://dx.doi.org/10.1136/jisakos-2020-000603DOI Listing
November 2021

Machine Learning and Statistical Prediction of Pitching Arm Kinetics.

Am J Sports Med 2022 01 15;50(1):238-247. Epub 2021 Nov 15.

Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Background: Over the past decade, research has attempted to elucidate the cause of throwing-related injuries in the baseball athlete. However, when considering the entire kinetic chain, full body mechanics, and pitching cycle sequencing, there are hundreds of variables that could influence throwing arm health, and there is a lack of quality investigations evaluating the relationship and influence of multiple variables on arm stress.

Purpose: To identify which variables have the most influence on elbow valgus torque and shoulder distraction force using a statistical model and a machine learning approach.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: A retrospective review was performed on baseball pitchers who underwent biomechanical evaluation at the university biomechanics laboratory. Regression models and 4 machine learning models were created for both elbow valgus torque and shoulder distraction force. All models utilized the same predictor variables, which included pitch velocity and 17 pitching mechanics.

Results: The analysis included a total of 168 high school and collegiate pitchers with a mean age of 16.7 years (SD, 3.2 years) and BMI of 24.4 (SD, 1.2). For both elbow valgus torque and shoulder distraction force, the gradient boosting machine models demonstrated the smallest root mean square errors and the most precise calibrations compared with all other models. The gradient boosting model for elbow valgus torque reported the highest influence for pitch velocity (relative influence, 28.4), with 5 mechanical variables also having significant influence. The gradient boosting model for shoulder distraction force reported the highest influence for pitch velocity (relative influence, 20.4), with 6 mechanical variables also having significant influence.

Conclusion: The gradient boosting machine learning model demonstrated the best overall predictive performance for both elbow valgus torque and shoulder distraction force. Pitch velocity was the most influential variable in both models. However, both models also revealed that pitching mechanics, including maximum humeral rotation velocity, shoulder abduction at foot strike, and maximum shoulder external rotation, significantly influenced both elbow and shoulder stress.

Clinical Relevance: The results of this study can be used to inform players, coaches, and clinicians on specific mechanical variables that may be optimized to mitigate elbow or shoulder stress that could lead to throwing-related injury.
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http://dx.doi.org/10.1177/03635465211054506DOI Listing
January 2022

Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts.

Am J Sports Med 2021 Nov 12:3635465211045705. Epub 2021 Nov 12.

NYU Langone Health, New York, New York, USA.

Bone tunnel-related complications are frequently encountered during revision anterior cruciate ligament reconstruction (ACLR). Issues with tunnel positioning, enlargement, containment, and hardware interference may complicate surgery and compromise outcomes. As a result, several strategies have emerged to address these issues and optimize results. However, a systematic, unified approach to tunnel pathology in revision ACLR is lacking. The purpose of this review is to highlight the current state of the literature on bone tunnel complications and, although extensive literature on the subject is lacking, present an updated approach to the evaluation and management of tunnel-related issues in revision ACLR.
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http://dx.doi.org/10.1177/03635465211045705DOI Listing
November 2021

Editorial Commentary: The Evolution of Regional Anesthesia in Arthroscopic Rotator Cuff Repair: From Throbbing Shoulders to Paralyzed Diaphragms.

Arthroscopy 2021 11;37(11):3238-3240

Wake Forest Baptist Health.

Rotator cuff repair may result in significant postoperative pain. Although opioids were once the gold standard, addiction and other side effects are of significant concern. Nonsteroidal anti-inflammatory drugs reduce pain, sleep disturbance, and need for opioids, but they may impair soft tissue healing. The use of gabapentinoids is equivocal. Intralesional analgesia carries a risk of glenohumeral chondrolysis. Cryotherapy is beneficial, but it is often not covered by insurance companies. Suprascapular nerve block addresses innervation of only 70% versus interscalene block, but the latter has a higher incidence of unintended, temporary motor and sensory deficits of the upper extremity and hemidiaphragmatic paresis, despite similar pain scores. Although neurodeficits and diaphragmatic hemiparesis resolve by 3 weeks, temporary complications affect length of hospital stay, initiation of physical therapy, and patient satisfaction. These variables contribute to the challenge of postoperative pain control amid a growing wave of modalities aimed at improving the extent and duration of patient-focused analgesia, especially the application of continuous block infusions.
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http://dx.doi.org/10.1016/j.arthro.2021.06.011DOI Listing
November 2021

Editorial Commentary: Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction Leads to Improved Patient-Reported Outcomes, But Patient Satisfaction Is a Harder Threshold to PASS.

Arthroscopy 2021 10;37(10):3036-3038

Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A.

There are numerous described techniques for surgical management of high-grade acromioclavicular (AC) joint injuries, and the associated clinical outcomes can be quite variable. Contemporary techniques are typically directed at anatomic reconstruction of the coracoclavicular (CC) ligaments through either an arthroscopy-assisted or an open approach. Most patients treated with acute surgery improve, whereas in chronic cases, the majority improve, but a significant number have persistent recurrent deformity due to loss of anatomic reduction. In addition, whether acute or chronic, over one quarter of patients do not have a PASS (patient acceptable symptomatic state). Of interest, PASS may not primarily be related to the final deformity in terms of coracoclavicular distance, and investigation is still required in terms of the effect of anteroposterior or rotational instability of the AC joint after injury and surgery. Finally, PASS values for AC separation are not well established, resulting in a current limitation of the strength of applying threshold values to this pathology.
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http://dx.doi.org/10.1016/j.arthro.2021.06.008DOI Listing
October 2021

Reverse Total Shoulder Arthroplasty with Concurrent Latissimus Dorsi Tendon Transfer.

Curr Rev Musculoskelet Med 2021 Oct 28;14(5):297-303. Epub 2021 Sep 28.

Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.

Purpose Of Review: Reverse total shoulder arthroplasty (rTSA) has emerged as an effective treatment option for patients with rotator cuff arthropathy resulting from irreparable rotator cuff tears. However, patients with combined loss of abduction and external rotation may still experience functional deficits after rTSA. One option to address this has been the latissimus dorsi tendon transfer (LDTT), or modified L'Episcopo procedure. The purpose of this review is to describe the role of LDTT with rTSA and to critically evaluate the evidence on whether a supplemental LDTT ultimately improves patient function.

Recent Findings: Patients with an intact rotator cuff demonstrated a significant increase in active external rotation following rTSA compared to those with a deficient rotator cuff following rTSA. Compared to their pre-operative baseline assessments, patients who undergo rTSA with LDTT report significant improvements in active external rotation. However, a randomized trial comparing rTSA patients with and without LDTT failed to demonstrate a significant difference in active external rotation or patient-reported outcomes between groups. Observational studies have shown that patients experience significant improvements in active range of motion and various patient-reported outcome measures following rTSA with latissimus dorsi tendon transfer. When directly comparing rTSA with LDTT to rTSA alone, the current literature fails to demonstrate a statistically significant difference in active external rotation or patient-reported outcomes at short-term follow-up. Further randomized controlled trials are required to fully understand the potential benefits of added tendon transfer in the rTSA patient population.
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http://dx.doi.org/10.1007/s12178-021-09715-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497675PMC
October 2021

Persistent joint pain and arm function in former baseball players.

JSES Int 2021 Sep 29;5(5):912-919. Epub 2021 Jun 29.

Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK.

Background: Baseball has specific sport and positional demands that may modify joint pain compared with other sports. Persistent joint pain reduces function and is an underlying reason for seeking medical care. The pain and functional status of players after they stop competitive play are unknown. Such knowledge can assist clinicians in creating personalized physical examinations and interventions for baseball players as they transition to retirement. The purpose of this study was to (1) evaluate persistent joint pain and arm function in former baseball players and (2) determine whether playing position is associated with increased odds of joint pain and reduced arm function in former baseball players.

Methods: A cross-sectional survey was performed. Eligibility criteria consisted of (1) played ≥1 collegiate baseball season, (2) aged ≥18 years, and (3) formerly played baseball (currently retired). Outcomes assessed included persistent joint pain and Single Assessment Numeric Evaluation (SANE). Explanatory variables included playing position (position, two-way, or pitcher). Multivariable logistic and linear regressions were performed. Models were adjusted for age, body mass index, arm dominance, playing standard, years played baseball, and injury and surgery history.

Results: A total of 117 former baseball players participated (age: 36.8 [13.7] years). The mean dominant SANE score was 70.2 (standard deviation 24.1), and the mean nondominant SANE score was 85.2 (standard deviation 19.4). There was no difference in dominant arm SANE scores when stratified by arm injury history (4.6 [95% confidence interval: -14.9, 5.8]) or arm surgery history (-3.8 [95% confidence interval: 13.4, 5.8]). The shoulders had the greatest persistent joint pain prevalence (28% of all participants) and elbows (21% of all participants). There was no relationship between dominant arm pain or function and playing position.

Conclusion: This is the first study to demonstrate an increase in dominant arm disability in former baseball players. The high prevalence of persistent arm pain and poor arm function among former baseball players is concerning considering participants were younger than 40 years of age. No differences were observed in arm function when stratifying by arm history, surgery, or position demonstrating the potential relationship between baseball participation and arm disability after cessation of play. Clinicians should consider working with baseball players to develop long-term strategies to maintain joint health, especially in the throwing arm, when baseball players are transitioning to retirement. Future research is needed to understand the long-term effectiveness of clinical treatments and the implications of specific arm injuries such as ulnar collateral ligament tears on persistent arm pain and function.
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http://dx.doi.org/10.1016/j.jseint.2021.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411053PMC
September 2021

The Impact of COVID-19 on the Orthopaedic Sports Medicine Fellowship Application Process.

Arthrosc Sports Med Rehabil 2021 Aug 29;3(4):e1237-e1241. Epub 2021 May 29.

Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana.

Over the last year, coronavirus disease 2019 (COVID-19) has spread across the world as a global pandemic, bringing unprecedented changes to the healthcare landscape for patients and physicians. Medical trainees have been similarly affected, as medical schools throughout the United States have implemented remote learning-based curriculums and withdrawn third- and fourth-year students from in-hospital clerkships. Of particular importance is the impact of COVID-19 on current orthopaedic surgery residents applying to subspecialty fellowship programs. Because of the highly transmissible nature of the virus and current social distancing restrictions, orthopaedic sports medicine fellowship interviews are being held virtually during the 2020-2021 application cycle. This transition to videoconference interviewing may de-emphasize an applicant's unique personality or interpersonal interactions that are traditionally captured in a variety of settings during the interview day. In turn, this may lead to increased prioritization of various aspects of the application, such as the applicant's residency program, letters of recommendation, and research productivity. Matching to a sports medicine fellowship program is an inherently competitive process and the COVID-19 pandemic presents novel challenges to orthopaedic residents in their efforts to successfully match. The purpose of this review is to describe the changes made to the orthopaedic sports medicine fellowship interview process resulting from COVID-19 during the 2020-2021 application cycle and discuss how these changes may impact the future fellowship application process. This review discusses the changes made to the orthopaedic sports medicine fellowship interview process caused by COVID-19 during the 2020-2021 application cycle. This review also assesses how such changes may impact the future application process and proposes potential adaptations to the current virtual interview format if it should become the new standard moving forward.
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http://dx.doi.org/10.1016/j.asmr.2021.04.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8365211PMC
August 2021

Cartilage Restoration for Tibiofemoral Bipolar Lesions Results in Promising Failure Rates: A Systematic Review.

Arthrosc Sports Med Rehabil 2021 Aug 24;3(4):e1227-e1235. Epub 2021 Jun 24.

Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A.

Purpose: The purpose of the present study is to systematically review the available literature for management of bipolar lesions within the tibiofemoral joint and determine whether tibiofemoral cartilage restoration is an effective treatment modality.

Methods: PubMed and MEDLINE databases were queried between 2000 and 2020 using the following keywords: "osteochondral" and "knee" and "microfracture," "autologous chondrocyte implantation (ACI)," or "transplantation." Articles were reviewed for the presence of a bipolar or "kissing" tibiofemoral lesion and reported lesion size, concomitant procedures, failure rates, and time to failure.

Results: After screening 1,295 articles, there were 4 articles available for analysis and a total of 152 knees involving the management of bipolar tibiofemoral lesions. Age ranged from 14 to 60 years, and mean follow-up was between 12 and 240 months. There was 1 retrospective cohort study (36 knees) and 3 case series (mean, 38.7 ± 17.5 knees). There were 58 knees treated with bipolar osteochondral allograft (OCA) transplantation, 58 knees treated with bipolar ACI, 20 knees treated with femoral OCA and tibial debridement, and 16 knees treated with femoral OCA and tibial microfracture. There were 37 failures (24.3%): 16 patients (10.5%) were converted to unicompartmental or total knee arthroplasty, 4 restorative procedures (2.6%) were revised, and 8 patients (1.6%) had unsatisfactory outcomes only. The remaining 15 failures (9.9%) had an unspecified combination of objective failure. The mean rate of failure ranged between 0% and 44.1% (  = 83.2%). The mean time to failure ranged between 2.7 and 4.1 years (  = 79.1%).

Conclusions: Cartilage restoration, through both ACI and OCA, had failure rates between 0% and 44% in patients with bipolar lesions of the tibiofemoral compartment. Although a higher level of evidence is required to prove efficacy, the current study demonstrates midterm survivorship rates between 55% and 100%, which may delay the need for secondary arthroplasty.

Level Of Evidence: Level IV, systematic review of Level IV studies.
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http://dx.doi.org/10.1016/j.asmr.2021.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8365214PMC
August 2021

Cartilage Restoration of Bipolar Lesions Within the Patellofemoral Joint Delays Need for Arthroplasty: A Systematic Review of Rates of Failure.

Arthrosc Sports Med Rehabil 2021 Aug 14;3(4):e1189-e1197. Epub 2021 Jun 14.

Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.

Purpose: The purpose of the present review is to systematically review the available literature for failure rates and complications of cartilage restoration of bipolar chondral defects in the patellofemoral (PF) joint to assess the ability to treat these lesions without arthroplasty.

Methods: PubMed and MEDLINE databases were queried between 2000 to 2020 using the keywords "osteochondral" and "knee" and "microfracture," "autologous chondrocyte implantation (ACI)," or "transplantation." Patient selection included patients with bipolar chondral lesions of the patellofemoral joint that were treated with cartilage restoration procedures. Treatment of PF joints were reviewed for surgical indications/technique, rates of failure, defect characteristics, and time to failure. For the purposes of this study, failure was defined by each individual author on their respective studies.

Results: After screening 1,295 articles, there were 8 publications analyzed quantitatively and 10 articles analyzed both quantitatively and qualitatively. A total of 249 knees involved bipolar lesions of the patellofemoral joint. The weighted average age was 36.5 ± 10.4 years, and weighted average follow-up was 89.0 ± 31.7 months. There were failures in 0% to 50% of cases, revision procedures in 0% to 10% of cases, conversion to arthroplasty in in 0% to 50% of cases, and unsatisfactory outcome without revision in 0% to 8.3% of cases. The range in average failure rate was 0% to 50.0% (I = 68.0%), whereas the range in average time to failure was 2.9 to 6.8 years (I = 79.0%).

Conclusion: From the available data, established cartilage restoration procedures may provide favorable patient-reported function, avoidance of secondary surgery, and joint preservation in at least 80% of patients at short- to mid-term follow-up.

Level Of Evidence: Level IV, systematic review of Level IV studies.
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http://dx.doi.org/10.1016/j.asmr.2021.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8365210PMC
August 2021

Lower Extremity Biomechanics Predicts Major League Baseball Player Performance.

Orthop J Sports Med 2021 Jul 8;9(7):23259671211015237. Epub 2021 Jul 8.

Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA.

Background: Although lower extremity biomechanics has been correlated with traditional metrics among baseball players, its association with advanced statistical metrics has not been evaluated.

Purpose: To establish normative biomechanical parameters during the countermovement jump (CMJ) among Major League Baseball (MLB) players and evaluate the relationship between CMJ-developed algorithms and advanced statistical metrics.

Study Design: Cohort study; Level of evidence, 3.

Methods: MLB players in 2 professional organizations performed the CMJ at the beginning of each baseball season from 2013 to 2017. We collected ground-reaction force data including the eccentric rate of force development ("load"), concentric vertical force ("explode"), and concentric vertical impulse ("drive") as well as the Sparta Score. The advanced statistical metrics from each baseball season (eg, fielding independent pitching [FIP], weighted stolen base runs [wSB], and weighted on-base average) were also gathered for the study participants. The minimal detectable change (MDC) was calculated for each CMJ variable to establish normative parameters. Pearson coefficient analysis and regression trees were used to evaluate associations between CMJ data and advanced statistical metrics for the players.

Results: A total of 151 pitchers and 138 batters were included in the final analysis. The MDC for "load," "explode," "drive," and the Sparta Score was 10.3, 8.1, 8.7, and 4.6, respectively, and all demonstrated good reliability (intraclass correlation coefficient > 0.75). There was a weak but statistically significant correlation between the Sparta Score and wSB ( = 0.23; = .007); however, there were no significant correlations with any other advanced metrics. Regression trees demonstrated superior FIP with higher Sparta Scores in older pitchers compared with younger pitchers.

Conclusion: There was a positive but weak correlation between the Sparta Score and base-stealing performance among professional baseball players. Additionally, older pitchers with a higher Sparta Score had statistically superior FIP compared with younger pitchers with a similar Sparta Score after adjusting for age.
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http://dx.doi.org/10.1177/23259671211015237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274116PMC
July 2021

Relationship Between Clinical Scapular Assessment and Scapula Resting Position, Shoulder Strength, and Baseball Pitching Kinematics and Kinetics.

Orthop J Sports Med 2021 Mar 18;9(3):2325967121991146. Epub 2021 Mar 18.

Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Background: Scapular assessment is important in examining overhead athletes, but there is inconsistency in scapular clinical assessment and its relation to pathology.

Purpose: To determine the relationship between clinical scapular assessment and biomechanical scapula resting position, shoulder strength, and pitching shoulder kinematics and kinetics.

Study Design: Descriptive laboratory study.

Methods: Two clinicians performed scapular assessments and graded the scapula as presence or absence of scapular dyskinesis. Shoulder external rotation (ER) and internal rotation (IR) strength were collected. The 3-dimensional biomechanics of the scapula resting position (upward/downward rotation, IR/ER, and anterior/posterior tilt) were assessed while participants stood at rest, and pitching kinematics (maximum shoulder ER, shoulder abduction, shoulder horizontal abduction, shoulder rotation velocity) and kinetics (maximum shoulder distraction force) were assessed when participants pitched off the portable pitching mound that was engineered to meet major league specifications.

Results: A total of 33 high school baseball pitchers (age, 16.3 ± 1.2 years; height, 184.0 ± 6.9 cm; weight, 76.8 ± 20.8 kg; hand dominance: left, 9 [27%]; right, 24 [73%]; pitch velocity, 34.7 ± 2.3 m/s) participated in this study. Of them, 15 participants had scapular dyskinesis, and 18 had normal scapulothoracic rhythm. No differences were observed for upward/downward rotation or anterior/posterior tilt, shoulder ER, shoulder abduction, or shoulder distraction force, based on the presence of scapular dyskinesis. Pitchers with scapular dyskinesis demonstrated significantly greater scapular resting IR position (effect size [ES], 0.80; 95% CI, 0.06 to 1.54; = .020), greater nondominant shoulder ER to IR strength ratio (ES, 0.49; 95% CI, -0.02 to 1.00; = .018), and decreased shoulder rotation velocity (ES, 14.66; 95% CI: 12.06 to 17.25; = .016). Pitchers with greater anterior tilt demonstrated greater shoulder rotation velocity ( = -0.48; = .006).

Conclusion: Pitchers with scapular dyskinesis had greater scapular IR, greater nondominant shoulder ER to IR strength ratio, and reduced shoulder rotation velocity.

Clinical Relevance: Scapular assessment may be more influenced by differential IR than upward rotation or anterior tilt. Scapular dyskinesis has no competitive performance advantage among amateur athletes. Greater understanding is needed to decipher the critical threshold between beneficial and maladaptive scapular movement patterns.
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http://dx.doi.org/10.1177/2325967121991146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8239341PMC
March 2021

Posterior Tibial Slope: Understand Bony Morphology to Protect Knee Cruciate Ligament Grafts.

Arthroscopy 2021 07;37(7):2029-2030

Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A.. Electronic address:

Improved understanding of the biomechanical significance and clinical repercussions of tibial slope on cruciate ligament function has sparked a newfound clinical interest in this morphological feature. Using either magnetic resonance imaging or lateral tibia radiographs, the anterior-posterior angulation of the tibial plateau relative to the tibial shaft can be measured. Clinical and biomechanical studies have reported that increased posterior tibial slope (PTS) places significantly increased tension on the native and reconstructed anterior cruciate ligament (ACL), leading to an increased risk of failure. It has also been suggested that increased PTS of the lateral tibial plateau has a greater impact on ACL forces and anterior tibial translation than PTS of the medial tibial plateau. Conversely, a decreased PTS has been shown to be a risk factor for recurvatum deformity, posterior cruciate ligament (PCL) injury, and posterior tibial translation and has been linked to single bundle PCL reconstruction failure. In the setting of ACL insufficiency with a PTS greater than 12°, anterior closing wedge osteotomy has been shown to be protective for ACL reconstructions. Alternatively, some surgeons have advocated for the addition of lateral extraarticular stabilization procedures in the setting of increased PTS. Further, in the setting of PCL insufficiency with an anteriorly directed, or flat, PTS, anterior opening wedge osteotomy has shown encouraging results. In addition, double bundle PCL reconstructions should be strongly considered in the setting of anteriorly directed, or flat, tibial slope.
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http://dx.doi.org/10.1016/j.arthro.2021.05.006DOI Listing
July 2021

Primary Medial Patellofemoral Ligament Reconstruction in Military Servicemembers: Can We Reliably Restore Preinjury Function and Stability?

Orthop J Sports Med 2021 Jun 11;9(6):23259671211013334. Epub 2021 Jun 11.

Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA.

Background: Medial patellofemoral ligament (MPFL) reconstruction for patellar instability is a commonly performed procedure with a reported high rate of return to preinjury activity. However, no previous study has assessed the functional outcomes of military servicemembers undergoing MPFL reconstruction.

Hypothesis: Primary MPFL reconstruction confers patellar stability, but with limited return to preinjury function and ability to maintain unrestricted military active duty status.

Study Design: Case series; Level of evidence, 4.

Methods: Using the Management Analysis and Reporting Tool database, we conducted a retrospective review of active duty servicemembers throughout the US Department of Defense Health System who underwent primary MPFL reconstruction between 2012 and 2015. Demographic variables were recorded as well as ability to return to impact activities-defined as running, jumping, rucking with a load >40 pounds (18 kg), and returning to airborne operations-and to remain on active duty status. The rates of recurrent instability and the need for subsequent surgeries were identified and assessed for statistical significance using uni- and multivariate analyses. Patients were evaluated for a minimum of 2 years postoperatively.

Results: Of the 213 patients who underwent primary MPFL reconstruction, including 34 with concomitant tibial tubercle osteotomy, 19 (8.9%) patients developed recurrent instability. The presence of bilateral patellar instability was associated with higher recurrence rate. Patients with bilateral instability comprised 47.3% of those with recurrence but only 24.9% of patients without recurrence ( = .019). Impact activity restrictions were present in 57.6% of patients (n = 121), with 86 patients (52.1%) undergoing medical separation from the military. Patients who were prescribed activity restriction before surgery were significantly more likely to have postoperative activity restrictions (64.5%; = .019), and junior enlisted servicemembers were more likely to be medically separated from service postoperatively than higher ranking senior enlisted members or officers.

Conclusion: Only 42.4% of US military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity after surgery. Bilateral instability negatively affected return to impact activities. Military servicemembers, particularly junior enlisted members, should be counseled on this poor prognosis for a full return to unrestricted activity postoperatively.
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http://dx.doi.org/10.1177/23259671211013334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202279PMC
June 2021

Randomized Trial of Arthroscopic Rotator Cuff With or Without Acromioplasty: No Difference in Patient-Reported Outcomes at Long-Term Follow-Up.

Arthroscopy 2021 10 30;37(10):3072-3078. Epub 2021 Apr 30.

Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A.

Purpose: To evaluate long-term patient-reported outcomes and revision surgery after arthroscopic rotator cuff repair with or without acromioplasty.

Methods: Between 2007 and 2011, prospectively enrolled patients undergoing arthroscopic repair for full-thickness rotator cuff tears, with any acromial morphology, were randomized into either acromioplasty or nonacromioplasty groups. Patients with revision surgery, subscapularis involvement, advanced neurologic conditions, or death were excluded. Baseline and long-term follow-up questionnaires, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA), Visual Analog Scale (VAS) for pain, and Constant scores were obtained. Rates of symptomatic retear, revision rotator cuff surgery, or secondary reoperation were recorded. Averages with standard deviation were calculated, and t-tests were used to compare outcomes of interest between cohorts.

Results: In total, 69 of 90 patients (76.7%) were available at 92.4 months (± 10.5). There were 23 of 32 patients in the acromioplasty cohort and 24 of 37 patients in the nonacromioplasty cohort. Mean age for the nonacromioplasty cohort was 56.9 (± 7.6) years, whereas acromioplasty was 59.6 (± 6.8) years. Comparison of baseline demographics and intraoperative information revealed no significant differences, including age, sex, Workers' Compensation, acute mechanism of injury, tear size, degree of retraction, and surgical technique (e.g., single- vs. double-row). At final follow-up, there were no statistically significant differences according to ASES (P = .33), VAS pain (P = 0.79), Constant (P = .17), SST (P = .05), UCLA (P = .19), and Short Form-12 (SF-12) (P = .79) in patients with and without acromioplasty. Two patients with acromioplasty (5.6%) and 3 patients without acromioplasty (9.1%) sustained atraumatic recurrent rotator cuff tear with secondary repair (P = .99), and there was no significant difference in retear rates or patient-reported outcome measures by acromial morphology.

Conclusions: This randomized trial, with mean 7.5-year follow-up, found no difference in validated patient-reported outcomes, retear rate, or revision surgery rate between patients undergoing rotator cuff repair with or without acromioplasty.

Level Of Evidence: II, prospective randomized controlled trial.
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http://dx.doi.org/10.1016/j.arthro.2021.04.041DOI Listing
October 2021

Open reduction and internal fixation (ORIF) versus ORIF and primary subtalar arthrodesis for complex displaced intraarticular calcaneus fractures: An expected value decision analysis.

OTA Int 2018 Sep 13;1(2):e005. Epub 2020 Sep 13.

William Beaumont Army Medical Center, Department of Orthopaedics, N Piedras, El Paso, TX.

Objectives: To determine the optimal patient-oriented treatment between open reduction and internal fixation (ORIF) with or without primary subtalar arthrodesis (PSTA) for patients with displaced intraarticular calcaneus fractures (DIACFs, OTA 82-C3 and C4).

Design: Expected value decision analysis.

Setting: Academic military treatment facility.

Participants: One hundred randomly selected volunteers.

Intervention: Hypothetical clinical scenario involving ORIF versus ORIF with PSTA.

Main Outcome Measurements: Decision analysis was used to elucidate the superior treatment option based on expected patient values, composed of: the product of the average outcome probabilities established by previously published studies and the average ascribed patient utility values for each outcome probability. One-way sensitivity analysis was performed to quantify the amount of change required for the inferior treatment to equal or surpass the superior option.

Results: Expected values for ORIF and ORIF with PSTA were 8.96 and 18.06, respectively, favoring ORIF with PSTA. One-way sensitivity analysis was performed by artificially decreasing the rate of secondary fusion following isolated ORIF thus increasing its overall expected value. Adjusting the rate of secondary fusion to 0%, the expected value of ORIF with PSTA nearly doubled that of ORIF (18.06 vs 9.45). Similarly, when adjusting the moderate and severe complication rates following ORIF with PSTA to 100%, the expected value of ORIF with PSTA still exceeded that of ORIF (15.45 vs 8.96, and 13.52 vs 8.96, respectively).

Conclusion: Expected value decision analysis favors ORIF with PSTA as the optimal treatment for complex DIACF.
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http://dx.doi.org/10.1097/OI9.0000000000000005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953466PMC
September 2018
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