Publications by authors named "Seth L Sherman"

108 Publications

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group.

J ISAKOS 2021 May 15;6(3):138-146. Epub 2021 Mar 15.

Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Objectives: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making.

Methods: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.

Results: Key points include that RTS is characterised by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries.

Conclusion: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biological assessment of healing and recovery.
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http://dx.doi.org/10.1136/jisakos-2020-000495DOI Listing
May 2021

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic.

J Am Acad Orthop Surg Glob Res Rev 2020 10 1;4(10):e20.00083. Epub 2020 Oct 1.

From the Oakland University, Rochester (Dr. Hinckel, and Dr. Cavinatto); Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak (Dr. Hinckel, Dr. Cavinatto), MI; the University of Missouri-School of Medicine, Columbia, MO (Mr. Baumann); the Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR (Dr. Ejnisman); the Shoulder and Elbow Surgery, Beaumont Orthopaedic Associates, Beaumont Health (Dr. Martusiewicz); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Tanaka); the Department of Orthopedic Surgery, TRIA Orthopedic Center, University of Minnesota, Gillette Children's Specialty Healthcare, MN (Dr. Tompkins); the Department of Orthopedic Surgery, Stanford University, CA (Dr. Sherman); the Rush University Medical Center, Chicago, IL (Dr. Chahla); the Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, Aurora, CO (Dr. Frank); the Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Yamamoto); CEGH-CEL, Instituto de Biociências, Universidade de São Paulo (Dr. Yamamoto); DASA Laboratories, Sao Paulo, Brazil (Dr. Yamamoto); the Michigan Orthopedic Surgeons, Fellowship Director William Beaumont Sports Medicine Fellowship, Assistant Professor Oakland University William Beaumont School of Medicine, MI (Dr. Bicos); the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Arendt); the Southern California Permanente Medical Group and Torrey Pines Orthopaedic Medical Group, San Diego, CA (Dr. Fithian); and the Knee Preservation, Cartilage Regeneration and OrthoBiologics, Department of Orthopedic Surgery, Indiana University School of Medicine, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, IN (Dr. Farr).

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537824PMC
October 2020

Concomitant Osteotomy Reduces Risk of Reoperation Following Cartilage Restoration Procedures of the Knee: A Matched Cohort Analysis.

Cartilage 2021 May 8:19476035211011515. Epub 2021 May 8.

Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA, USA.

Objective: The objective of this study is to compare the (1) reoperation rates, (2) 30-day complication rates, and (3) cost differences between patients undergoing isolated autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation (OCA) procedures alone versus patients with concomitant osteotomy.

Study Design: Retrospective cohort study, level III.

Design: Patients who underwent knee ACI (Current Procedural Terminology [CPT] 27412) or OCA (CPT 27415) with minimum 2-year follow-up were queried from a national insurance database. Resulting cohorts of patients that underwent ACI and OCA were then divided into patients who underwent isolated cartilage restoration procedure and patients who underwent concomitant osteotomy (CPT 27457, 27450, 27418). Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using ICD-9-CM codes. The cost per patient was calculated.

Results: A total of 1,113 patients (402 ACI, 67 ACI + osteotomy, 552 OCA, 92 OCA + osteotomy) were included (mean follow-up of 39.0 months). Reoperation rate was significantly higher after isolated ACI or OCA compared to ACI or OCA plus concomitant osteotomy (ACI 68.7% vs. ACI + osteotomy 23.9%; OCA 34.8% vs. OCA + osteotomy 16.3%). Overall complication rates were similar between isolated ACI (3.0%) and ACI + osteotomy (4.5%) groups and OCA (2.5%) and OCA + osteotomy (3.3%) groups. Payments were significantly higher in the osteotomy groups at day of surgery and 9 months compared to isolated ACI or OCA, but costs were similar by 2 years postoperatively.

Conclusions: Concomitant osteotomy at the time of index ACI or OCA procedure significantly reduces the risk of reoperation with a similar rate of complications and similar overall costs compared with isolated ACI or OCA.
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http://dx.doi.org/10.1177/19476035211011515DOI Listing
May 2021

High Specialization among Female Youth Soccer Players Is Associated with an Increased Likelihood of Serious Injury.

Med Sci Sports Exerc 2021 Apr 28. Epub 2021 Apr 28.

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA.

Purpose: To assess the associations between serious injury (> 3-month time loss) and level of specialization among high-level female soccer players and to compare the specialization and college commitment ages of female youth soccer players to Division I college and professional soccer athletes.

Methods: Youth, college, and professional female soccer players in the United States playing in the top league at each level were recruited to complete an anonymous online survey. The survey collected information about player demographics, soccer specialization and training patterns, history of serious injuries from soccer, and perceptions surrounding soccer specialization. Comparisons between groups were performed using 2-sample t-tests, chi-squared analyses, and multiple logistic regression models controlling for differences in age. A p-value of less than 0.05 was set as significant.

Results: A total of 1,018 (767 youth, 251 college/professional) athletes completed the survey. Serious injuries affected 23.6% of youth and 51.4% of college/professional athletes. Anterior cruciate ligament (ACL) tears were more prevalent in college/professional players compared to youth athletes (18.3% vs 4.0%; p < 0.001). Highly specialized youth athletes (66.5%) were more likely to have sustained a serious injury from soccer compared to athletes with low specialization (Odds Ratio (OR) = 2.28 [1.38-3.92]; p=0.008) but not moderate specialization (OR = 1.37 [0.83-2.27]; p=0.43). A higher proportion of youth athletes specialized at a young age (< 10 years) compared to college/professional players (44.2% vs 25.9%; p < 0.001).

Conclusion: High specialization in female youth soccer players is associated with an increased likelihood of sustaining a serious injury. Current youth soccer players are specializing earlier and committing to play college soccer at a younger age compared to when current college and professional players did.
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http://dx.doi.org/10.1249/MSS.0000000000002693DOI Listing
April 2021

Reliability of Radiologic Assessments of Clinically Relevant Growth Remaining in Knee MRI of Children and Adolescents With Patellofemoral Instability: Data From the JUPITER Cohort.

Orthop J Sports Med 2021 Apr 13;9(4):2325967121991110. Epub 2021 Apr 13.

Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA.

Background: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient's skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy.

Purpose: The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability.

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

Methods: Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability.

Results: Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements).

Conclusion: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable.
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http://dx.doi.org/10.1177/2325967121991110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047867PMC
April 2021

Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures.

Cartilage 2021 Mar 20:1947603521993219. Epub 2021 Mar 20.

Hospital for Special Surgery, New York, NY, USA.

Objective: To create a treatment algorithm for focal grade 3 or 4 cartilage defects of the knee using both classic and novel cartilage restoration techniques.

Design: A comprehensive review of the literature was performed highlighting classic as well as novel cartilage restoration techniques supported by clinical and/or basic science research and currently being employed by orthopedic surgeons.

Results: There is a high level of evidence to support the treatment of small to medium size lesions (<2-4 cm) without subchondral bone involvement with traditional techniques such as marrow stimulation, osteochondral autograft transplant (OAT), or osteochondral allograft transplant (OCA). Newer techniques such as autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate implantation have also been shown to be effective in select studies. If subchondral bone loss is present OAT or OCA should be performed. For large lesions (>4 cm), OCA or matrix autologous chondrocyte implantation (MACI) may be performed. OCA is preferred over MACI in the setting of subchondral bone involvement while cell-based modalities such as MACI or particulated juvenile allograft cartilage are preferred in the patellofemoral joint.

Conclusions: Numerous techniques exist for the orthopedic surgeon treating focal cartilage defects of the knee. Treatment strategies should be based on lesion size, lesion location, subchondral bone involvement, and the level of evidence supporting each technique in the literature.
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http://dx.doi.org/10.1177/1947603521993219DOI Listing
March 2021

Assessment and Trends of the Methodological Quality of the Top 50 Most Cited Articles on Patellar Instability.

Orthop J Sports Med 2021 Jan 29;9(1):2325967120972016. Epub 2021 Jan 29.

Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA.

Background: Studies with a low level of evidence (LOE) have dominated the top cited research in many areas of orthopaedics. The wide range of treatment options for patellar instability necessitates an investigation to determine the types of studies that drive clinical practice.

Purpose: To determine (1) the top 50 most cited articles on patellar instability and (2) the correlation between the number of citations and LOE or methodological quality.

Study Design: Cross-sectional study.

Methods: The Scopus and Web of Science databases were assessed to determine the top 50 most cited articles on patellar instability between 1985 and 2019. Bibliographic information, number of citations, and LOE were collected. Methodological quality was calculated using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS). Mean citations and mean citation density (citations per year) were correlated with LOE, MCMS, and MINORS scores.

Results: Most studies were cadaveric (n = 10; 20.0%), published in the (n = 13; 26.0%), published between 2000 and 2009 (n = 41; 82.0%), and conducted in the United States (n = 17; 34.0%). The mean number of citations and the citation density were 158.61 ± 59.53 (range, 95.5-400.5) and 12.74 ± 5.12, respectively. The mean MCMS and MINORS scores were 59.62 ± 12.58 and 16.24 ± 3.72, respectively. No correlation was seen between mean number of citations or citation density versus LOE. A significant difference was found in the mean LOE of articles published between 1990 and 1999 (5.0 ± 0) versus those published between 2000 and 2009 (3.12 ± 1.38; = .03) and between 2010 and 2019 (3.00 ± 1.10; = .01).

Conclusion: There was a shift in research from anatomy toward outcomes in patellar instability; however, these articles demonstrated low LOE and methodological quality. Higher quality studies are necessary to establish informed standards of management of patellar instability.
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http://dx.doi.org/10.1177/2325967120972016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869164PMC
January 2021

Acute Patellofemoral Dislocation: Controversial Decision-Making.

Curr Rev Musculoskelet Med 2021 Feb 1;14(1):82-87. Epub 2021 Feb 1.

Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA, USA.

Purpose Of Review: The topic of acute patella dislocations is controversial. Discussions revolve around which individuals need early surgery, identification of risk factors, and rehabilitation protocol. The purpose of this review is to discuss the current recommendations for non-operative and/or operative management of first-time dislocators.

Recent Findings: Recent studies have made it clear that not all patellar dislocations are the same, not all patients do well with conservative treatment, and risk stratification can identify individuals at high risk of recurrence who would benefit from early surgical intervention. Risk factors that have been identified include younger age, skeletally immature, contralateral instability, trochlear dysplasia, patella alta, increased tibial tubercle-trochlear groove distance, and increased patella tilt. The PAPI (Pediatric and Adolescent Patellar Instability) RCT study and JUPITER (Justifying Patellar Instability Treatment by Early Results) prospective cohort study have been carefully developed, are under way, and will provide further guidance. In summary, the management of acute patellar dislocations is evolving. Surgery for patients with osteochondral loose bodies should include fixation as well as soft tissue stabilization. The standard of care for patients with an acute patellar dislocation without osteochondral loose bodies or fracture is non-operative treatment. However, imaging for all first-time dislocators is indicated to stratify risks and determine risk profile. If an individual is at high risk, soft tissue stabilization may be considered. Still, most patients will be treated non-operatively.
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http://dx.doi.org/10.1007/s12178-020-09687-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930146PMC
February 2021

ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades.

Knee Surg Sports Traumatol Arthrosc 2021 Jan 24. Epub 2021 Jan 24.

Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA, USA.

Purpose: Anterior cruciate ligament reconstruction (ACLR) aims to restore knee function and stability, allowing patients to return to the activities they enjoy and minimize further injury to the meniscus and cartilage and their ultimate progression to osteoarthritis. This study aims to present the evolution of graft choice over the last three decades according to members of the ACL Study Group (SG).

Methods: Prior to the January 2020 ACL SG biannual meeting, a survey was administered consisting of 87 questions and 16 categories, including ACLR graft choice. A similar questionnaire has been administered prior to each meeting and survey results from the past 14 meetings (1992 through 2020, excluding 1994) are included in this work. Survey responses are reported as frequencies in percentages to quantify changes in practice over the surgery period.

Results: In 1992, the most frequent graft choice for primary ACLR was bone-patellar tendon-bone (BTB) autograft, at nearly 90%. Hamstring tendon (HT) autografts have increased in popularity, currently over 50%, followed by just under 40% BTB autograft. Recently, quadriceps tendon (QT) autograft has increased in popularity since 2014.

Conclusion: Autograft (HT, BTB, QT) is an overwhelming favorite for primary ACLR over allograft. The preference for HT autograft increased over the study period relative to BTB autograft, with QT autograft gaining in popularity in recent years. Graft selection should be individualized for each patient and understanding the global trends in graft choice can help orthopaedic surgeons discuss graft options with their patients and determine the appropriate graft for each case.

Level Of Evidence: Level V, Expert Opinion.
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http://dx.doi.org/10.1007/s00167-021-06443-9DOI Listing
January 2021

Inflammatory Mechanisms in the Development of Osteoarthritis.

Instr Course Lect 2021 ;70:537-550

Osteoarthritis was traditionally thought of as a noninflammatory disease, but improved molecular techniques have recognized a significant inflammatory component. An initial joint injury or biomechanical imbalance leads to local tissue damage and inflammation, which is propagated by the innate immune system. The production of damage-associated molecular patterns (DAMPs) results in the activation of immune-modulated mechanisms, leading to the production of catabolic factors that can damage native joint structures such as cartilage. DAMPs may originate from extracellular matrix degradation products, intracellular components of lysed cells, complement, or joint crystals-even plasma proteins can enter through an inflamed synovium and further perpetuate the inflammatory process. Therapeutic interventions have traditionally focused on symptom management; however, there is potential for pharmacologic modification of the disease process in osteoarthritis through novel anti-inflammatory agents.
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January 2021

Joint Preservation Techniques for the Knee in 2020: The Utility of Biologics, Osteotomies, and Cartilage Restoration Procedures.

Instr Course Lect 2021 ;70:319-336

Joint preservation strategies in young, active patients are a challenge, particularly in those with combined cartilage and meniscal deficiency. Concomitant malalignment and/or ligamentous insufficiency are not uncommon and further add to the complex nature of these patients. In patients who require surgery, a complete treatment strategy must be developed and implemented because unaddressed pathology typically leads to poor outcomes over time. In addition to reconstructive procedures, biologic therapies both as nonsurgical treatments and surgical augments offer promise, but their indications and place in orthopaedics continue to evolve. A comprehensive approach to this difficult patient population, including understanding all underlying pathologies, the natural history of each condition, and the appropriate treatment for each pathology, is necessary for successful joint preservation treatment in the young and active population.
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January 2021

Cartilage Disease of the Patellofemoral Joint: Realignment, Restoration, Replacement.

Instr Course Lect 2021 ;70:289-308

Chondral lesions of the patellofemoral joint are common, and when symptomatic they can be difficult to manage. Not only are there various degrees of injury with multiple etiologies, but patellofemoral anatomy is complex and the patient's lower extremity alignment may contribute to the pathology. Treatment depends on the location, size, and depth of the lesion and may require realignment or concomitant stabilizing procedures. Tibial tubercle osteotomy can be performed in isolation or combined with various cartilage-based treatments, including marrow stimulation techniques, autologous chondrocyte implantation, osteochondral autograft, and osteochondral allograft. End-stage lesions, failed primary patellofemoral cartilage restoration with diffuse involvement, or isolated primary patellofemoral arthritis may be amenable to treatment with patellofemoral arthroplasty. Recent investigations in properly indicated patients using advanced techniques have shown that management of patellofemoral cartilage disease is now more effective and predictable than in the past.
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January 2021

How to Address the Medial Patellofemoral Ligament, Tibial Tubercle, and Articular Cartilage in Patients With Recurrent Patellar Instability.

Instr Course Lect 2021 ;70:273-288

Patellofemoral instability is a common pathology especially in the adolescent female population. Prompt diagnosis and management is critical to prevent future episodes of instability as well as to reduce the risk of cartilaginous injury to the patellofemoral articular surface. Initial management of a first-time patellar dislocation has historically been nonsurgical; however, the presence of intra-articular loose bodies or osseocartilaginous injury may require surgical intervention. More recent evidence has shown patients with specific risk factors such as skeletal immaturity, an incompetent medial soft-tissue sleeve, family history of patellar dislocation, elevated tibial tubercle to trochlear groove distance, patella alta, and high-grade trochlear dysplasia experience high rates of re-dislocation after initial nonsurgical management. Based on this, the provider needs to consider these risk factors and the possibility of initial surgical management in these patient populations following a first-time patellar dislocation. Surgical options for management of patellar instability and cartilaginous injury include medial patellofemoral ligament repair, medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, and various cartilaginous repair/restoration procedures. It is important to be knowledgeable about the clinical and anatomic/radiographic risk factors associated with patients presenting with patellar instability, the algorithm for treatment, the indications and surgical technique for medial patellofemoral ligament reconstruction and tibial tubercle osteotomy, and management of cartilaginous injury to the patellofemoral joint.
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January 2021

Significantly Lower Infection Risk for Anterior Cruciate Ligament Grafts Presoaked in Vancomycin Compared With Unsoaked Grafts: A Systematic Review and Meta-analysis.

Arthroscopy 2021 05 24;37(5):1683-1690. Epub 2020 Dec 24.

Department of Orthopaedic Surgery, Stanford University Medical Center, Redwood City, California, U.S.A.. Electronic address:

Purpose: To compare postoperative infection rates following ACL reconstruction performed with grafts presoaked in vancomycin versus those without vancomycin.

Methods: A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for therapeutic level I to III studies that compared outcomes of presoaking ACL grafts with vancomycin versus without vancomycin in human patients. Included graft types were tendon autografts or allografts, and included studies documented infection with a minimum follow-up of 30 days. Postoperative infection rates and knee-specific patient-reported outcome scores were extracted from each study and compared between groups. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Coleman Methodology Score (MCMS). Infection rates and retear rates were pooled and weighted for meta-analysis using a random-effects model. All P values were reported with an α level of 0.05 set as significant.

Results: The initial search yielded 144 articles (44 duplicates, 100 screened, 29 full-text review). Ten articles (21,368 subjects [7,507 vancomycin and 13,861 no vancomycin], 67% males, mean ± standard deviation age 29.5 ± 1.5 years) were included and analyzed. Eight of the 10 studies included only autografts, with 94.5% of grafts being hamstring autografts. Soaking grafts in vancomycin resulted in significantly fewer infections (0.013% versus 0.77%; odds ratio 0.07; 95% confidence interval 0.03, 0.18; P < .001). Only 2 studies included patient-reported outcomes, and both demonstrated no difference in International Knee Documentation Committee scores 1 year after surgery for patients with grafts presoaked in vancomycin versus without vancomycin.

Conclusions: Soaking ACL tendon grafts with vancomycin before implantation is associated with a nearly 15 times decrease in odds of infection compared with grafts not soaked in vancomycin. Few studies investigated patient-reported outcomes and retear rates after soaking ACL grafts in vancomycin.

Level Of Evidence: III, systematic review of level III studies.
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http://dx.doi.org/10.1016/j.arthro.2020.12.212DOI Listing
May 2021

Platelet-Rich Plasma Augmentation for Isolated Arthroscopic Meniscal Repairs Leads to Significantly Lower Failure Rates: A Systematic Review of Comparative Studies.

Orthop J Sports Med 2020 Nov 20;8(11):2325967120964534. Epub 2020 Nov 20.

Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, USA.

Background: Studies have reported relatively high failure rates of isolated meniscal repairs. Platelet-rich plasma (PRP) has been suggested as a way to increase growth factors that enhance healing.

Purpose: To compare (1) meniscal repair failures and (2) patient-reported outcomes after isolated arthroscopic meniscal repair augmented with and without PRP.

Study Design: Systematic review; Level of evidence, 3.

Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Multiple databases were searched for studies that compared outcomes of isolated arthroscopic meniscal repair augmented with PRP versus without PRP in human patients. Failures and patient-reported outcome scores were reported for each study and compared between groups. Study heterogeneity was assessed using for each outcome measure before meta-analysis. Study methodological quality was analyzed. Continuous variable data were reported as mean and standard deviation from the mean. Categorical variable data were reported as frequency with percentage. All values were reported with significance set at < .05.

Results: Five articles were analyzed (274 patients [110 with PRP and 164 without PRP]; 65.8% male; mean age, 29.1 ± 4.6 years; mean follow-up, 29.2 ± 22.1 months). The risk of meniscal repair failure ranged from 4.4% to 26.7% for PRP-augmented repairs and 13.3% to 50.0% for repairs without PRP. Meniscal repairs augmented with PRP had significantly lower failure rates than repairs without PRP (odds ratio, 0.32; 95% CI, 0.12-0.90; = .03). One of the 5 studies reported significantly higher outcomes in the PRP-augmented group versus the no-PRP group for the International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee injury and Osteoarthritis Outcome Score (KOOS) ( < .05 for all). The remaining 4 studies reported no significant difference between groups with regard to outcomes for the IKDC, Lysholm knee scale, visual analog scale for pain, or Tegner activity level.

Conclusion: Although the studies were of mostly of low quality, isolated arthroscopic meniscal repairs augmented with PRP led to significantly lower failure rates (10.8% vs 27.0%; odds ratio, 0.32; = .03) as compared with repairs without PRP. However, most studies reported no significant differences in patient-reported outcomes.
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http://dx.doi.org/10.1177/2325967120964534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682240PMC
November 2020

Force-Time Waveform Shape Reveals Countermovement Jump Strategies of Collegiate Athletes.

Sports (Basel) 2020 Dec 2;8(12). Epub 2020 Dec 2.

Department of Kinesiology and Sport Sciences, University of Miami, Coral Gables, FL 33146, USA.

The purpose of this study was to relate the shape of countermovement jump (CMJ) vertical ground reaction force waveforms to discrete parameters and determine if waveform shape could enhance CMJ analysis. Vertical ground reaction forces during CMJs were collected for 394 male and female collegiate athletes competing at the National Collegiate Athletic Association (NCAA) Division 1 and National Association of Intercollegiate Athletics (NAIA) levels. Jump parameters were calculated for each athlete and principal component analysis (PCA) was performed on normalized force-time waveforms consisting of the eccentric braking and concentric phases. A -means clustering of PCA scores placed athletes into three groups based on their waveform shape. The overall average waveforms of all athletes in each cluster produced three distinct vertical ground reaction force waveform patterns. There were significant differences across clusters for all calculated jump parameters. Athletes with a rounded single hump shape jumped highest and quickest. Athletes with a plateau at the transition between the eccentric braking and concentric phase (amortization) followed by a peak in force near the end of the concentric phase had the lowest jump height and slowest jump time. Analysis of force-time waveform shape can identify differences in CMJ strategies in collegiate athletes.
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http://dx.doi.org/10.3390/sports8120159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7761544PMC
December 2020

Management of Large Focal Chondral and Osteochondral Defects in the Knee.

J Knee Surg 2020 Dec 1;33(12):1187-1200. Epub 2020 Dec 1.

Knee Preservation and Cartilage Restoration Center, OrthoIndy, Indianapolis, Indiana.

Large, focal articular cartilage defects of the knee (> 4 cm) can be a source of significant morbidity and often require surgical intervention. Patient- and lesion-specific factors must be identified when evaluating a patient with an articular cartilage defect. In the management of large cartilage defects, the two classically utilized cartilage restoration procedures are osteochondral allograft (OCA) transplantation and cell therapy, or autologous chondrocyte implantation (ACI). Alternative techniques that are available or currently in clinical trials include a hyaluronan-based scaffold plus bone marrow aspirate concentrate, a third-generation autologous chondrocyte implant, and an aragonite-based scaffold. In this review, we will focus on OCA and ACI as the mainstay in management of large chondral and osteochondral defects of the knee. We will discuss the techniques and associated clinical outcomes for each, while including a brief mention of alternative treatments. Overall, cartilage restoration techniques have yielded favorable clinical outcomes and can be successfully employed to treat these challenging large focal lesions.
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http://dx.doi.org/10.1055/s-0040-1721053DOI Listing
December 2020

The use of biologics in professional and Olympic sport: a scoping review protocol.

Bone Jt Open 2020 Nov 17;1(11):715-719. Epub 2020 Nov 17.

Department of Orthopaedic Surgery, Stanford University School of Medicine, California, USA.

Aims: The use of biologics in the treatment of musculoskeletal injuries in Olympic and professional athletes appears to be increasing. There are no studies which currently map the extent, range, and nature of existing literature concerning the use and efficacy of such therapies in this arena. The objective of this scoping review is to map the available evidence regarding the use of biologics in the treatment of musculoskeletal injuries in Olympic and professional sport.

Methods: Best-practice methodological frameworks suggested by Arksey and O'Malley, Levac et al, and the Joanna Briggs Institute will be used. This scoping review will aim to firstly map the current extent, range, and nature of evidence for biologic strategies to treat injuries in professional and Olympic sport; secondly, to summarize and disseminate existing research findings; and thirdly, to identify gaps in existing literature. A three-step search strategy will identify peer reviewed and non-peer reviewed literature, including reviews, original research, and both published and unpublished ('grey') literature. An initial limited search will identify suitable search terms, followed by a search of five electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Web of Science, and Google Scholar) using keyword and index terms. Studies will be screened independently by two reviewers for final inclusion.

Dissemination: We will chart key concepts and evidence, and disseminate existing research findings to practitioners and clinicians, through both peer reviewed and non-peer reviewed literature, online platforms (including social media), conference, and in-person communications. We will identify gaps in current literature and priorities for further study.
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http://dx.doi.org/10.1302/2633-1462.111.BJO-2020-0159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684394PMC
November 2020

Superior Capsular Reconstruction: A Systematic Review of Surgical Techniques and Clinical Outcomes.

Arthroscopy 2021 02 20;37(2):720-746. Epub 2020 Nov 20.

Department of Orthopaedic Surgery, Stanford University, Stanford, California, U.S.A.

Purpose: To evaluate surgical techniques and clinical outcomes of arthroscopic superior capsular reconstruction (SCR) for the treatment of massive irreparable rotator cuff tears.

Methods: A systematic review was registered with PROSPERO and performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Scopus, and Cochrane databases were searched. Studies investigating SCR with reported surgical techniques were included. Animal studies, cadaveric studies, review studies, and letters to the editor were excluded. The technical aspects of the surgical techniques for SCR were analyzed in each article, which included graft type, glenoid fixation method, greater tuberosity fixation method, graft passage technique, suture management, margin convergence, concomitant procedures, and postoperative rehabilitation protocol. Clinical outcomes, when available, were also analyzed.

Results: We screened 365 articles, of which 29 described surgical techniques for SCR. According to the Modified Coleman Methodology Score, 24 articles were rated as poor (score < 55), 4 were rated as fair (score between 55 and 69), and 1 was rated as good (score between 70 and 84), with an average score of 25.8 ± 20.9. The most commonly performed technique for SCR used the following: an acellular dermal allograft, 2 biocomposite suture anchors for glenoid fixation, transosseous-equivalent double-row suture anchor fixation for greater tuberosity fixation with 2 biocomposite medial-row anchors and 2 biocomposite lateral-row anchors, the double-pulley technique combined with an arthroscopic grasper and/or pull suture to pass the graft into the shoulder, the performance of both anterior and posterior margin convergence, and a native rotator cuff repair when possible. Only 8 studies reported clinical outcomes, and they showed that SCR provides significant improvement in patient-reported outcomes, significant improvement in shoulder range of motion, variable graft failure rates, low complication rates, and variable reoperation rates. There were no studies comparing outcomes among the various surgical techniques.

Conclusions: Many surgical techniques exist for arthroscopic SCR. However, no superior technique was shown because there were no studies comparing clinical outcomes among these various techniques.

Level Of Evidence: Level V, systematic review of Level III, IV, and V studies.
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http://dx.doi.org/10.1016/j.arthro.2020.09.016DOI Listing
February 2021

Consensus on Rehabilitation Guidelines among Orthopedic Surgeons in the United States following Use of Third-Generation Articular Cartilage Repair (MACI) for Treatment of Knee Cartilage Lesions.

Cartilage 2020 Oct 30:1947603520968876. Epub 2020 Oct 30.

Penn Center for Advanced Cartilage Repair and Osteochondritis Dissecans Treatment, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Objective: The aim of this study was to evaluate levels of consensus in rehabilitation practices following MACI (autologous cultured chondrocytes on porcine collagen membrane) treatment based on the experience of an expert panel of U.S. orthopedic surgeons.

Design: A list of 24 questions was devised based on the current MACI rehabilitation protocol, literature review, and discussion with orthopedic surgeons. Known areas of variability were used to establish 4 consensus domains, stratified on lesion location (tibiofemoral [TF] or patellofemoral [PF]), including weightbearing (WB), range of motion (ROM), return to work/daily activities of living, and return to sports. A 3-step Delphi technique was used to establish consensus.

Results: Consensus (>75% agreement) was achieved on all 4 consensus domains. Time to full WB was agreed as immediate (with bracing) for PF patients (dependent on concomitant procedures), and 7 to 9 weeks in TF patients. A progression for ROM was agreed that allowed patients to reach 90° by week 4, with subsequent progression as tolerated. The panel estimated that the time to full ROM would be 7 to 9 weeks on average. A range of time was established for release to activities of daily living, work, and sports, dependent on lesion and patient characteristics.

Conclusions: Good consensus was established among a panel of U.S. surgeons for rehabilitation practices following MACI treatment of knee cartilage lesions. The consensus of experts can aid surgeons and patients in the expectations and rehabilitation process as MACI surgery becomes more prevalent in the United States.
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http://dx.doi.org/10.1177/1947603520968876DOI Listing
October 2020

Comparison of Autologous Chondrocyte Implantation and Osteochondral Allograft Transplantation of the Knee in a Large Insurance Database: Reoperation Rate, Complications, and Cost Analysis.

Cartilage 2020 Oct 27:1947603520967065. Epub 2020 Oct 27.

Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA, USA.

Objective: To compare (1) the reoperation rates, (2) risk factors for reoperation, (3) 30-day complication rates, and (4) cost differences between autologous chondrocyte implantation (ACI) and osteochondral allograft transplantation (OCA) of the knee in a large insurance database.

Design: Subjects who underwent knee ACI (Current Procedural Terminology [CPT] code 27412) or OCA (CPT code 27415) with minimum 2-year follow-up were queried from a national insurance database. Reoperation was defined by ipsilateral knee procedure after index surgery. Multivariate logistic regression models were built to determine the effect of independent variables (age, sex, tobacco use, obesity, diabetes, and concomitant osteotomy) on reoperation rates. The 30-day complication rates were assessed using ICD-9-CM codes. The cost of the procedures per patient was calculated. Statistical comparisons were made. All values were reported with significance set at < 0.05.

Results: A total of 909 subjects (315 ACI and 594 OCA) were included (mean follow-up 39.2 months). There was a significantly higher reoperation rate after index ACI compared with OCA (67.6% vs. 40.4%, < 0.0001). Concomitant osteotomy at the time of index procedure significantly reduced the risk for reoperation in both groups (odds ratio [OR] 0.2, < 0.0001 and OR 0.2, = 0.009). The complication rates were similar between ACI (1.6%) and OCA (1.2%) groups ( = 0.24). Day of surgery payments were significantly higher after ACI compared with OCA ( = 0.013).

Conclusions: Autologous chondrocyte implantation had significantly higher reoperation rates and cost with similar complication rates compared with OCA. Concomitant osteotomy significantly reduced the risk for reoperation in both groups.
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http://dx.doi.org/10.1177/1947603520967065DOI Listing
October 2020

Administrative Databases Used for Sports Medicine Research Demonstrate Significant Differences in Underlying Patient Demographics and Resulting Surgical Trends.

Arthroscopy 2021 01 20;37(1):282-289.e1. Epub 2020 Sep 20.

Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.. Electronic address:

Purpose: To discern differences between the PearlDiver and MarketScan databases with regards to patient demographics, costs, reoperations, and complication rates for isolated meniscectomy.

Methods: We queried the PearlDiver Humana Patient Records Database and the IBM MarketScan Commercial Claims and Encounters database for all patients who had record of meniscectomy denoted by Current Procedure Terminology 29880 or 29881 between January 1, 2007, and December 31, 2016. Those that had any other knee procedure at the same time as the meniscectomy were excluded, and the first instance of isolated meniscectomy was recorded. Patient demographics, Charlson Comorbidity Index, reoperations, 30- and 90-day complication rates, and costs were collected from both databases. Pearson's χ test with Yate's continuity correction and the Student t test were used to compare the 2 databases, and an alpha value of 0.05 was set as significant.

Results: We identified 441,147 patients with isolated meniscectomy from the MarketScan database (0.36% of total database), approximately 10 times the number of patients (n = 49,924; 0.20% of total database) identified from PearlDiver. The PearlDiver population was significantly older (median age: 65-69) than the MarketScan cohort, where all patients were younger than 65 (median age: 52; P < .001). Average Charlson Comorbidity Index was significantly lower for MarketScan (0.172, standard deviation [SD]: 0.546) compared with PearlDiver (1.43, SD: 2.05; P < .001), even when we restricted the PearlDiver cohort to patients younger than 65 years (1.02, SD: 1.74; P < .001). The PearlDiver <65 years subcohort also had increased 30- (relative risk 1.53 [1.40-1.67]) and 90-day (relative risk 1.56 [1.47-1.66]) postoperative complications compared with MarketScan. Overall, laterality coding was more prevalent in the PearlDiver database.

Conclusions: For those undergoing isolated meniscectomy, the MarketScan database comprised an overall larger and younger cohort of patients with fewer comorbidities, even when examining only subjects younger than 65 years of age.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2020.09.013DOI Listing
January 2021

Microfracture for the Treatment of Symptomatic Cartilage Lesions of the Knee: A Survey of International Cartilage Regeneration & Joint Preservation Society.

Cartilage 2020 Sep 10:1947603520954503. Epub 2020 Sep 10.

Department of Orthopaedic Surgery, Division of Sports Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.

Objective: The purpose of this study was to describe the current practice trends for managing symptomatic cartilage lesions of the knee with microfracture among ICRS (International Cartilage Regeneration & Joint Repair Society) members.

Design: A 42-item electronic questionnaire was sent to all ICRS members, which explored indications, surgical technique, postoperative management, and outcomes of the microfracture procedure for the treatment of symptomatic, full thickness chondral and osteochondral defects of the knee. Responses were compared between surgeons from different regions and years of practice.

Results: A total of 385 surgeons answered the questionnaire. There was a significant difference noted in the use of microfracture among surgeons by region ( < 0.001). There was no association between the number of years in practice and the self-reported proportion of microfracture cases performed ( = 0.37). Fifty-eight subjects (15%) indicated that they do not perform microfracture at all. Regarding indication for surgery, 56% of surgeons would limit their indication of microfracture to lesions measuring 2 cm or less. Half of the surgeons reported no upper age or body mass index limit. Regarding surgical technique, 90% of surgeons would recommend a formal debridement of the calcified layer and 91% believe it is important to create stable vertical walls. Overall, 47% of surgeons use biologic augmentation, with no significant difference between regions ( = 0.35) or years of practice ( = 0.67). Rehabilitation protocols varied widely among surgeons.

Conclusions: Indications, operative technique, and rehabilitation protocols utilized for patients undergoing microfracture procedures vary widely among ICRS members. Regional differences and resources likely contribute to these practice pattern variations.
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http://dx.doi.org/10.1177/1947603520954503DOI Listing
September 2020

Surgeon practice patterns for pre-soaking ACL tendon grafts in vancomycin: a survey of the ACL study group.

Knee Surg Sports Traumatol Arthrosc 2021 Jun 9;29(6):1920-1926. Epub 2020 Sep 9.

Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA.

Purpose: To survey members of The ACL study group to determine the current practice patterns surrounding the technique of pre-soaking ACL grafts in vancomycin.

Methods: A web-based questionnaire was distributed to members of the ACL Study Group. Questions included the use of vancomycin solution for graft soaking during ACL reconstruction, their protocol for soaking the graft, vancomycin concentration utilized, graft choices, and concerns with the technique.

Results: Sixty-six (57%) ACL surgeons completed the survey. Approximately one-third (37.9%) of respondents currently pre-soak their ACL grafts in vancomycin prior to implantation, with 60% of these surgeons being from Europe. Seventy-six percent have adopted this practice within the past 5 years. The majority of surgeons wrap the graft in a vancomycin-soaked gauze prior to implantation (56%), soak for a variable amount of time before implantation (56%), use a concentration of 5 mg/mL (68%), and soak hamstring grafts (92%). Concerns included the mechanical properties of the graft (35%), cost of vancomycin (23%), availability (12%), and antibiotic resistance (9%).

Conclusion: This survey demonstrates that 37.9% of ACL study group members currently utilize vancomycin to pre-soak ACL tendon grafts as a means to decrease post-operative infection risk, with the majority of surgeons having implemented this practice within the past 5 years. The biggest concern towards using vancomycin was the mechanical properties of the graft after soaking.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-020-06265-1DOI Listing
June 2021

Soaking of Autologous Tendon Grafts in Vancomycin Before Implantation Does Not Lead to Tenocyte Cytotoxicity.

Am J Sports Med 2020 10 8;48(12):3081-3086. Epub 2020 Sep 8.

Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, California, USA.

Background: Surgical site infections (SSIs) after anterior cruciate ligament (ACL) reconstruction procedures are an unfortunate complication. Soaking grafts in vancomycin before implantation has been reported to reduce the incidence of postoperative SSI after ACL reconstruction. There is potential for vancomycin to compromise graft integrity because of tenocyte toxicity.

Purpose: To examine the in vitro toxicity of varying doses of vancomycin on human tenocytes.

Study Design: Controlled laboratory study.

Methods: Human patellar tenocytes were isolated and expanded in vitro. Tenocytes in culture were exposed to vancomycin at 5 different concentrations (400, 1600, 3200, 6400, and 12,800 μg/mL) and 3 time intervals (2, 6, and 24 hours). The control for all series was tenocyte exposure to only culture medium for each time interval. After treatment, a 10% Cell Counting Kit-8 solution in cellular growth medium was applied to the cells to examine cytotoxicity. A live/dead assay was used to assess tenocyte viability through fluorescence microscopy and flow cytometry. Results were analyzed statistically using multivariable logistic regression models with Tukey honest significant difference post hoc tests.

Results: Vancomycin did not cause significant changes in tenocyte viability after 2 and 6 hours of incubation at any concentration between 0 and 12,800 µg/mL. Incubation with vancomycin for 24 hours led to a significant decrease in cell viability at higher concentrations.

Conclusion: Tenocytes derived from human patellar tendons exposed to relatively high concentrations of vancomycin for short periods of time do not demonstrate significant cell death and toxicity.

Clinical Relevance: Exposing tendons to vancomycin for a short period of time, such as before ACL reconstruction, is not likely to cause tenocyte toxicity because of vancomycin administration.
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http://dx.doi.org/10.1177/0363546520951815DOI Listing
October 2020

Costs, Complications, and Reoperations Associated With Primary Arthroscopic Rotator Cuff Repair With or Without Acromioplasty and/or Biceps Tenodesis.

Arthrosc Sports Med Rehabil 2020 Aug 29;2(4):e369-e376. Epub 2020 Jul 29.

Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California, U.S.A.

Purpose: To evaluate the reoperations, complications, and costs up to 5 years following arthroscopic rotator cuff repair (RCR) alone, with acromioplasty (acro), with biceps tenodesis (BT), or with both acro and BT.

Methods: We queried the MarketScan database to identify patients who underwent RCR from 2007 to 2016. Patients were stratified into groups based on concomitant procedures (acro and/or BT) performed on the same day as index RCR. Reoperations, complications, and costs were followed for 5 years post-index procedure. Patients without laterality codes were excluded. A multivariate logistic regression analysis was used to control for confounding factors.

Results: This study identified 147,838 patients (mean age, 53.1 years; standard deviation, 8.3 years) who underwent primary RCR. Patients were stratified into 4 groups: (1) RCR only, (2) RCR + acro, (3) RCR + BT, and (4) RCR + acro + BT. Patients in the RCR only group experienced the highest rate of unadjusted overall postoperative complications (17.2%) versus the other groups (RCR + acro 16.4%, RCR + BT 15.1%, RCR + acro + BT 16.2%, < .0161). The RCR only group also experienced a significantly greater number of reoperations on the ipsilateral shoulder ( < .0001), whereas the RCR + acro + BT had the highest costs at all timepoints. In the regression analysis, there was no significant differences between complications and reoperations between any groups. After adjusting for covariates, the performance of a BT with an RCR and acromioplasty led to increased costs (odds ratio, 1.47, 1.37-1.59, < .001).

Conclusions: Concomitant biceps tenodesis does lead to higher total healthcare costs, both in the shorter and longer terms. When adjusting for confounding factors, the performance of concomitant biceps tenodesis with rotator cuff repair does not lead to a difference in postoperative complication rate or risk for revision surgery.

Level Of Evidence: economic analysis.
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http://dx.doi.org/10.1016/j.asmr.2020.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451851PMC
August 2020

Risk of Subsequent Knee Arthroplasty After Sports Medicine Procedures.

J Am Acad Orthop Surg Glob Res Rev 2020 08;4(8):e20.00125

From the Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA.

Introduction: Approximately 10% of men and 13% of women older than the age of 60 are affected by symptomatic osteoarthritis of the knee. Anatomic repair or reconstruction after knee injury has been a central tenet of surgical treatment to reduce the risk of osteoarthritis. The purpose of this study was to examine common sports medicine procedures of the knee and determine the proportion of patients who subsequently undergo total knee arthroplasty (TKA).

Methods: The MarketScan database was queried from the period of January 2007 through December 2016. Patients were identified, who underwent a procedure of the knee, as defined by Current Procedural Terminology codes relating to nonarthroplasty procedures of the knee. Patients in whom laterality could not be confirmed or underwent another ipsilateral knee procedure before TKA were excluded from this study. The primary outcome of this study was the overall rate of TKA after index knee surgery. Time from index procedure to TKA was a secondary outcome. A multivariate regression analysis was used to control for covariates such as age, sex, and comorbidity status.

Results: A total of 843,749 patients underwent one of the 13 common sports medicine procedures of the knee. The procedure with the highest unadjusted rate of subsequent TKA was arthroscopic osteochondral allograft (5.81%), whereas anterior cruciate ligament (ACL) reconstruction with meniscus repair demonstrated the lowest rate of subsequent TKA (0.01%). When adjusting for confounding factors, the regression analysis identified meniscal transplantation (odds ratio [OR] = 3.06, P < 0.0001) as having the highest risk of subsequent TKA, followed by osteochondral autograft (OR = 1.74, P = 0.0424) and arthroscopic osteochondral allograft (OR = 1.49, P < 0.0001). ACL reconstruction with meniscus repair (OR = 0.02, P < 0.0001), ACL reconstruction alone (OR = 0.17, P < 0.0001), ACL with meniscectomy (OR = 0.20, P < 0.0001), and meniscal repair (OR = 0.65, P < 0.0001) had the lowest rate of subsequent TKA. ACL reconstruction with meniscus repair had the longest period from index procedure to TKA at 2827 days.

Conclusion: ACL reconstruction and meniscus preservation demonstrated an extremely low rate of conversion to TKA when compared with patients who needed salvage interventions such as meniscus and cartilage transplantation. None of the salvage interventions delayed the need for a TKA. Meniscal transplantation had the highest risk of all procedures of going on to a TKA.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430232PMC
August 2020

Linked Double-Row Equivalent Arthroscopic Rotator Cuff Repair Leads to Significantly Improved Patient Outcomes.

Orthop J Sports Med 2020 Jul 16;8(7):2325967120938311. Epub 2020 Jul 16.

Sports Orthopedic and Rehabilitation, Redwood City, California, USA.

Background: Biomechanical studies have demonstrated that arthroscopic rotator cuff repair using a linked double-row equivalent construct results in significantly higher load to failure compared with conventional transosseous-equivalent constructs.

Purpose: To determine the patient-reported outcomes (PROs), reoperation rates, and complication rates after linked double-row equivalent rotator cuff repair for full-thickness rotator cuff tears.

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

Methods: Consecutive patients who underwent linked double-row equivalent arthroscopic rotator cuff repair with minimum 2-year follow-up were included. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score at final follow-up. Secondary outcomes included the Simple Shoulder Test (SST), shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, visual analog scale (VAS), reoperations, and complications. Clinical relevance was defined by the minimally clinically important difference (MCID). Comparisons on an individual level that exceeded MCID (individual-level scores) were deemed clinically relevant. Comparisons between preoperative and postoperative scores were completed using the Student test. All values were reported with significance set at < .05.

Results: A total of 42 shoulders in 41 consecutive patients were included in this study (21 male patients [51.2%]; mean age, 64.5 ± 11.9 years; mean follow-up, 29.7 ± 4.5 months). All patients (100%) completed the minimum 2-year follow-up. The rotator cuff tear measured on average 15.2 ± 8.9 mm in the coronal plane and 14.6 ± 9.8 mm in the sagittal plane. The ASES score improved significantly from 35.5 ± 18.2 preoperatively to 93.4 ± 10.6 postoperatively ( < .001). The QuickDASH ( < .001), SST ( < .001), and VAS ( < .001) scores also significantly improved after surgery. All patients (42/42 shoulders; 100%) achieved clinically relevant improvement (met or exceeded MCID) on ASES and SST scores postoperatively. There were no postoperative complications (0.0%) or reoperations (0.0%) at final follow-up.

Conclusion: Arthroscopic repair of full-thickness rotator cuff tears with the linked double-row equivalent construct results in statistically significant and clinically relevant improvements in PRO scores with low complication rates (0.0%) and reoperation rates (0.0%) at short-term follow-up.
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http://dx.doi.org/10.1177/2325967120938311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366410PMC
July 2020

The effect of silicone ankle sleeves and lace-up ankle braces on neuromuscular control, joint torque, and cutting agility.

J Orthop 2020 Jul-Aug;20:359-366. Epub 2020 Jul 6.

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Objective: To evaluate the effects of silicone ankle sleeves (SASs) and lace-up ankle braces (LABs) on neuromuscular control, net joint torques, and cutting agility in healthy, active individuals.

Design: Markerless motion-capture technology tracked subjects fitted with SASs, LABs, or no brace while they performed the movements: Y-excursion, left cutting, right cutting, single-leg drop vertical jump (SLDVJ), 45-degree bound, and single-leg squat (SLS).

Setting: University Laboratory.

Participants: Ten healthy, active individuals (5 males and 5 females, mean ± SD 23.60 ± 1.43 years of age).

Main Outcome Measures: Degrees of joint range of motion (ROM), Newton-meters of joint torque, time to perform a cutting maneuver.

Results: SASs and LABs resulted in significantly different knee and ankle ROM and hip internal rotation in the SLDVJ, SLS, Y-excursion, cutting maneuver, and 45-degree bound when compared to control (p < .05). Both ankle and knee torque were significantly reduced in the 45-degree bound and cutting movements with both types of PABs (p < .05). There were minimal differences between the SASs and LABs for all conditions. There were no statistically significant differences in cutting times for any of the 3 conditions.

Conclusion: Both SAS and LAB positively impacted neuromuscular control, reduced net joint torque, and neither impaired cutting agility when compared to control.
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http://dx.doi.org/10.1016/j.jor.2020.05.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355724PMC
July 2020