Today’s episode is kind of an Overtime / Ask The Sports Docs crossover. One of the PTs that Ashley works closely with asked her why some patients do well after ACL surgery and some don’t fare as well, despite the surgery being identical in terms of technique, graft choice, post-op protocol etc. 

An article was just published in AJSM this month looking at this, specifically investigating factors that impact outcomes after ACL reconstruction. The article that we are reviewing today is titled “Primary Anterior Cruciate Ligament Reconstruction in Level 1 Athletes: Factors Associated With Return to Play, Reinjury, and Knee Function at 5 Years of Follow-up.” This level 2 cohort study aimed to analyze the outcomes of primary ACLR in level 1 athletes and identify preop and intraop factors associated with RTP, ipsilateral ACL reinjury, contralateral ACL injury, and IKDC score at 5 years post-op.

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 We have also been chatting about this episode offline and discussed an article that was recently published looking at preoperative grit scores and postoperative range of motion after ACL reconstruction. Grit score is another objective measurement that we can obtain preoperatively and perhaps use to guide intervention during post-op recovery. 

We actually did an Overtime episode looking at the impact of grit scores on post-op outcomes after ACL reconstruction. That is episode #53 if you want to check it out! But today's second article is titled “Higher Grit Scores Are Associated With Earlier Increases in Knee Flexion Following Anterior Cruciate Ligament Reconstruction With Meniscus Repair in Pediatric Patients.” 

It was published in the April 2023 issue of the Journal of Pediatrics. Pete Fabricant and his team at HSS found that patients with grit scores below the 50th percentile undergoing ACLR + meniscus repair have 5 degrees less total ROM at 3 months compared with those with high grit scores. Though 5 degrees might not seem like a lot, quicker motion recovery in patients with high grit may be a leading indicator of these patients likelihood to achieve other post-op milestones and meet criteria for RTS more quickly. This obvious needs future study to see how grit impacts other factors like strength gains, passing RTP assessments etc.

Welcome to Overtime with the Sports Docs! On each of these mini episodes, we chat about a new article or new surgical technique in the field of sports medicine. We’ll give you our quick take on the most recent data and how this data will be impacting our practice.

Today, we’re talking about posterior cruciate ligament injuries – specifically, surgical treatment; including reconstruction technique and graft choice. We’ll be reviewing an article published this month in AJSM titled, “Single-Bundle Autografts Outperform Single-Bundle Achilles Allograft in PCL Reconstruction in Terms of Posterior Tibial Translation and Clinical Outcomes, but No Differences Exist Between Double-Bundle Grafts.”

LaPrade PCL Stress Test: https://drrobertlaprademd.com/pcl-stress-radiograph-technique-edina-egan-mn/

We get lots of questions from our patients and our listeners each week. And they’re great questions, so rather than responding individually we thought we’d do these mini episodes where highlight some of the best questions and our responses, with some literature to back it up.

Before we jump into our discussion today, we want to quickly update you on something very exciting that is coming up in July. And if you follow us on social media, you probably already know what we are about to say. We will be hosting our podcast series live again for a third year at the AOSSM Annual Meeting in Nashville. We will be doing several live shows per day from within the Field House on Thursday July 10 th and Friday July 11 th. We have some awesome guests lined up so make sure you’re following our socials to see our schedule that will be dropping soon!

Alright, back to our discussion. Let’s start today with a question from a patient: “Should I Have PRP for My Partial Rotator Cuff Tear?"

We get lots of questions from our patients and our listeners each week. And they’re great questions, so rather than responding individually we thought we’d do these mini episodes where highlight some of the best questions and our responses, with some literature to back it up.

Before we jump into our discussion today, we want to quickly update you on something very exciting that is coming up in July. And if you follow us on social media, you probably already know what we are about to say. We will be hosting our podcast series live again for a third year at the AOSSM Annual Meeting in Nashville. We will be doing several live shows per day from within the Field House on Thursday July 10 th and Friday July 11 th. We have some awesome guests lined up so make sure you’re following our socials to see our schedule that will be dropping soon!

Alright, back to our discussion. Let’s start today with a question from a patient: “Should I have surgery for my SLAP tear?”

Today’s episode is going to focus on management of patellar instability – including nonsurgical treatment, MPFL reconstruction techniques and the addition of other procedures including trochleoplasty and osteotomies. We are joined today by two outstanding guests! 

 Dr. Miho Tanaka is a Professor of Orthopedic Surgery at Harvard Medical School and the Director of the women sports medicine program at Mass General Brigham.  She is also the head team physician for the New England Revolution and team physician for the Boston Red Sox, Boston ballet and Boston Glory.

Dr. Beth Shubin Stein is an orthopaedic surgeon at the Hospital for Special Surgery and Professor of Orthopaedic Surgery at Weill Cornell Medical College. She is also the Co-Director of the women’s sports medicine center at HSS and the Director of the Patellofemoral Center at HSS.

So, without further ado, let’s get to the Field House!

Today’s episode is going to focus on the workup of a patient with a suspected multiligamentous knee injury as well as a surgical approach that follows – including acute versus delayed surgery, repair versus reconstruction, surgical technique and order of operations in the OR. We are joined today by two outstanding guests! 

Dr. Matt Provencher is an orthopedic surgeon at the Steadman Clinic in Vail Colorado, Principle Investigator at the Steadman Philippon Research Institute and assistant Editor-in-Chief of Arthroscopy.  He is very active in academic societies and serves on the Board of Directors for AOSSM, AANA and SOMOS.

Dr. Armando Vidal is also an orthopedic surgeon at the Steadman Clinic in Vail and is the Vice President of the Medical Staff of Vail Health Hospital.  He is was previously the head team physician for the Denver Nuggets, and  former team physician for the University of Colorado men's basketball and the University of Denver men's hockey.

So, without further ado, let’s get to the Field House!

Our last poster is titled Outcomes and Return to Sport Following Arthroscopic Bankart Repair for Anterior Shoulder Instability in Contact versus Non-contact Athletes: A Systematic Review and Meta-Analysis.  We’ve spoken a lot about the surgical treatment for anterior shoulder instability on this podcast – most recently with Dr. Brian Lau.  That is episode #48 and 49 if you want to check it out.

This study focused on outcomes of arthroscopic Bankart repair for the treatment of anterior shoulder instability, specifically comparing outcomes in contact athletes versus noncontact athletes.  This systematic review included 18 studies with 1-year minimum follow-up.

The authors found that contact and noncontact athletes had similar rates of return to sport as well as similar rates of return to preinjury level of play.  However, they also found that contact athletes demonstrated significantly greater rates of recurrent instability, at 28% compared to 8% in noncontact athletes.  Contact athletes also demonstrated significantly greater need for revision surgery, at 12% compared to 3% in noncontact athletes.

Our next poster is titled Sleep in Orthopaedic Surgeons: A Prospective Longitudinal Study of the Effect of Home Call on Orthopedic Attending and Resident Sleep. Recurrent episodes of partial sleep deprivation resulting from call schedules are commonly seen in physicians. This has been shown to cause decreased mental effectiveness while at work, which corresponds with a blood alcohol level of 0.08%. 

Sleep deprivation has been associated with adverse personal health events, with an increased risk of diabetes, heart disease, stroke and risk of death. Additionally, sleep deprivation has been demonstrated to have a negative clinical impact, including decreased surgical performance, increased errors, and greater risks of accidents.

Despite the known negative impacts of poor sleep, the effect of home orthopedic call on surgeon sleep has not been well quantified.  The purpose of the study was to quantify the impact of resident and attending physician home call on sleep performance – specifically total sleep, slow-wave sleep and rapid eye movement sleep – as well as heart rate variability. 

Sixteen orthopedic residents and 14 attendings at a level 1 academic trauma hospital wore WHOOP 3.0 straps for a period of 1 year. The WHOOP strap is wearable device that tracks all 4 stages of sleep and monitors wake events, efficiency and respiratory rate. The authors recorded total sleep, slow-wave sleep and REM sleep.  Slow-wave sleep is considered to be the most restorative sleep stage and plays an important role in growth, memory and immune function.

This study showed that overall, attendings slept significantly less than residents, at 6 hours compared to 6.7 hours.  When on home call, resident total sleep decreased by 20%, REM sleep decreased by 12%, and slow-wave sleep decreased by 12%.  For attendings, total sleep on-call decreased by 10%, REM sleep decreased by 7% and slow-wave sleep decreased by 4%.

The authors concluded that orthopedic surgery residents and attendings exhibit low baseline sleep, and taking home call reduces this even further.  On home call nights, Residents and Attendings experienced a significant decrease in total sleep, REM sleep and short wake sleep.  The authors suggested that further research is required in order to determine how to ensure excellent patient care, maximize educational environments and develop strategies for resilience.

Our next poster is titled Characterization of Concussions in the National Basketball Association and the 90-day Period Following Return to Play: Analysis of Musculoskeletal Injury Risk and Player Performance. This study was performed at the Mayo Clinic in Arizona and sought to determine the incidence of musculoskeletal injury in the immediate 90-day period following return to play from concussion.  The secondary outcomes were to evaluate player performance within the 90-day.  As well as time lost after musculoskeletal injury.

Concussions have steadily garnered increased attention over recent years. We actually did an episode with Dr. Rachel Frank focused on concussions and sideline evaluation.  This is episode 98 if you want to go check it out.  That episode focused primarily on identifying and appropriately managing concussions.  This study aims to evaluate the impact of a concussion on risk of musculoskeletal injury. 

Concussions have previously been shown to have persistent neurological effects that may lead to slower reaction times and may compromise postural stability in high-level athletes. Therefore, it stands to reason that a player may be at greater risk for musculoskeletal injury and may exhibit poorer performance upon return from a concussion.

The authors identified NBA players who sustained a concussion between 2015-20 22 using a publicly available database.  The database was also queried to identify any musculoskeletal injury in the 90-day period following return to play after the concussion, as well as time lost after the subsequent injury. 

Performance statistics were obtained from each players preinjury season and post-injury season.  Each concussed player was matched with a non-concussed control player using position, win shares, player efficiency rating and points per game as metrics.

So, what did this study find?  A total of 70 concussions were identified during this time period. 70% of concussed players sustained a musculoskeletal injury in the 90-day period following return to play.  Compared with controls, the odds of sustaining a musculoskeletal injury in the concussed cohort were 11.3 times greater.  There was no significant difference between the type and location of injury, with ankle injuries being the most common in both groups.

Now let’s talk about performance.  Interestingly, there were no significant changes in points per game, minutes played per game or true shooting percentage between the concussed and control groups.  When compared with the controls, no changes in performance statistics were significantly different. Games missed after subsequent musculoskeletal injury were similar between the concussed and control groups.

Our next AAOS 2025 Annual Meeting poster is titled Mid-term Follow-up of Patellofemoral Osteochondral Allograft Transplantation. This study was performed by Dr. Bill Bugbee and his team at the Scripps Clinic. Dr. Bugbee was a guest on our show back in November 2023.  That is episode 59 and 60, if you want to go check it out.  In that episode, we discussed osteochondral allograft transplantation for various cartilage defects of the knee, including medial and lateral tibiofemoral, which are the more common locations for OCA transplantation.  This study focuses specifically on outcomes of OCA transplantation for patellofemoral cartilage defects.

This study identified 127 patients undergoing OCA transplantation in the patellofemoral compartment – 51 to the patella, 47 to the trochlea and 29 bipolar patella and trochlea.  The most common indication was a degenerative cartilage lesion at 47%, followed by a traumatic cartilage injury at 25% and osteochondritis dissecans at 15%.  All patients had a minimum follow-up of 2 years.  OCA failure was defined as any reoperation that involved removal of the allograft.  Patient reported outcomes were also assessed pre-op and post-op, including the IKDC score and KOOS score.

So, what did this study find?  First, reoperations occurred in 39% of the knees.  Rate of reoperation was not statistically significant between patella, trochlea and bipolar grafts.  Second, OCA failures occurred in 16% of the knees at a median 4.4 years following the index surgery, and the most common revision procedure was arthroplasty.  Although it did not reach statistical significance, trochlear grafts had a lower failure rate of 9% compared to patellar grafts at 20% and bipolar grafts at 21%.

Overall, graft survivorship at 5 and 10 years was 91% and 82%, respectively.  Patients with patellar, trochlear and bipolar grafts all had significant improvement in IKDC scores and KOOS scores from preop to the latest follow-up and no statistically significant differences were observed between the groups.  Overall, 77% of patients reported being satisfied with the results of the OCA transplantation with no statistically significant differences in satisfaction between the groups.

Also check out:

Episode 91: Dr. Tom DeBerardino 0n Advances in Patellofemoral Cartilage Restoration