The OJSM Hot Corner

Historically, ACL repair resulted in poor outcomes and this procedure fell out of favor while ACL reconstruction became the gold-standard surgical approach for a torn ACL. Recently, thanks in part to the advent of more modern techniques, ACL repair has regained interest in the Sports Medicine community as a potentially viable option in certain situations that may provide advantages in comparison to ACL reconstruction. To this point, the literature comparing these two surgeries with modern techniques has been heterogenous in terms of quality and design, and results have been mixed. Drs. Kyle Kunze, MD and Benedict Nwachukwu, MD, MBA and their team from Hospital of Special Surgery (HSS) bring us this systematic review and meta-analysis to cull the best literature available. Their findings indicate that, while ACL repair may have an evolving role in our toolbox, its failure rate remains higher than that of ACL reconstruction and thus should be approached with caution.

One of the long-standing assumptions in Sports Medicine is that anterosuperior labral variants including the Buford Complex and Sublabral Foramen are non-pathologic, normal anatomic variants of the shoulder joint.  But is this true?  Dr. Eric Edmonds from Rady Children’s Hospital in San Diego challenges this assumption and our accepted practice of ignoring these findings when observed arthroscopically.

Failure of shoulder stabilization surgery continues to plague contact athletes. Football players are thus at high risk of a repeat shoulder dislocation even after a well-done surgery to stabilize that joint. Such is the nature of a sport with violent and unpredictable collisions. Dr. Andrew Pennock, MD and his team at Rady Children’s in San Diego investigated the outcomes for high school football players who underwent arthroscopic stabilization surgery. They anticipated finding that the younger the player at the time of surgery, the higher risk of recurrence throughout his high school career. What they didn’t anticipate finding was that a high percentage of players who opted not to return to football did so because of fear. While we have seen this fear factor impact athletes after ACL reconstruction, the magnitude of this effect in this population was surprising.

Second ACL injuries, whether it be a tear of the ipsilateral ACL graft or the native contralateral ACL, continue to be of great concern to patients and sports medicine practitioners particularly during the first 1-2 years after surgery. Sending a patient back too early to play is widely considered a major risk factor for this 2nd injury. As health care providers, we take pride in the joy and confidence a patient expresses as he/she advances through a rehab process towards his/her goals. However, when it comes to ACL reconstruction rehab, overconfidence may put the patient at risk, and perhaps slow and steady wins the race. We welcome Dr. Takehiko Matsushita, MD, PhD from Kobe University in Japan to discuss his study investigating the relationship between psychological readiness to return to sport and the risk of a 2nd ACL injury. His findings show that the biggest favor we can do for a patient who accelerates through the ACL recovery period quickly and confidently may be to slow him/her down.

The right surgery for recurrent patellofemoral instability remains a topic of controversy.  While medial patellofemoral ligament reconstruction (MPFLr) is the standby surgical procedure for this condition, many adjuncts including tibial tubercle osteotomy (TTO) are performed concurrently with the hope of improving the chances of success.  Historically, a tibial tubercle-trochlear groove (TT-TG) distance greater than 20 mm has triggered surgeons to perform TTO, however recent evidence suggests this may be unnecessarily aggressive.  We welcome Dr. Mininder Kocher, MD, MPH from Boston Children’s and Harvard Medical School to discuss his study evaluating the outcomes of MPFLr alone versus MPFLr + TTO in patients with recurrent patellofemoral instability with a tibial tubercle-trochlear groove (TT-TG) distance greater than 20 mm.

Despite our technological advances in ACL surgery, the rehabilitation period remains challenging, particularly when it comes to lingering quadriceps weakness. Blood Flow Restriction (BFR) Therapy has been introduced as a potential means to speed up the return of quad function. We welcome Dr. Kelechi Okoroha from the Mayo Clinic to discuss his high-level study, “Effects of Perioperative Blood Flow Restriction Therapy Program on Early Quadriceps Strength and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction.” By utilizing BFR in both the pre- and post-operative periods following ACL reconstruction, Dr. Okoroha and his team did demonstrate a benefit in strength and patient reported outcomes.

Proper treatment of Type III AC Joint Separations has been a topic of ongoing debate. In OJSM’s August edition, Drs. Mark Tauber, Phillipp Moroder and their team from the German Shoulder Center in Munich, Germany, published, “Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment of Acute Rockwood Type 3 Acromioclavicular Injury,” a high-level study that showed no difference in outcomes between surgical and nonsurgical management of this injury. We are joined by two of the finest surgeons in California’s Central Valley, Shoulder/Elbow Specialist Dr. Julia Lee, MD from Sierra Pacific Orthopedics and Traumatologist Dr. JT Christensen, MD from Kaiser Permanente to discuss this study and share their insights and practices.

Once an exotic procedure, hip arthroscopy is now a commonplace surgery with an expanding footprint in Sports Medicine. One of the basic steps of hip arthroscopy is a capsulotomy to allow adequate access to the hip joint. Closure of the capsule, however, has been a point of controversy. While expert opinion has long touted the benefits of capsular closure, the technical difficulty of this step and the fact that it comes at the end of a time-sensitive surgery may explain why it is not performed universally. We welcome Dr. Jorge Chahla, MD, PhD from Rush University to discuss his team’s systematic review and meta-analysis comparing outcomes of repaired versus unrepaired capsules during hip arthroscopy. Dr. Chahla presents compelling evidence that capsular closure leads to better outcomes and is the way to go.

Meniscal root tears are a problem. They can occur without trauma, they can only be diagnosed on MRI but occur commonly in a patient population where MRI is not routinely utilized, they don’t respond reliably to partial menisectomy, and they result in rapid degeneration of the knee joint. What we don’t know is how rapid is that arthritic progression. Dr. Caitlin Chambers from the University of Minnesota and her team address this question with their study, “Association of Medial Meniscus Root Tears and Nonroot Tears with Worsening of Radiographic Knee Osteoarthritis.” She joins us to discuss her results and gives advice on managing patients with this problematic meniscal tear pattern.

Platelet-Rich Plasma (PRP) remains a topic of controversy in Sports Medicine. One of the limitations surrounding this therapy is the paucity of high-quality data to support or refute its efficacy. We welcome Dr. Dean Wang, MD from UC Irvine to discuss his study looking at the fragility of the highest quality data we have on PRP. A fragile study is one in which the study’s conclusion would change with the reversal of only a few outcomes. Our medical community holds randomized-controlled trials in high regard, however if these studies are fragile, how much can we rely on them to be true?