Good afternoon, I'd like to welcome everyone to the afternoon session. We're going to start with shoulder. I'm Dr. Sarah Edwards from UCSF, and my co-moderator is Matt Provencher from the Steadman Clinic. We're going to start this session with a presentation on postage stamp glenoid fractures after bank cart repair, how many anchors are safe, a biomechanical analysis from Dr. Mario Lobo. Thank you. My name is Mario Lobo. I'm attending at LSU's report. I would like to thank my co-authors for the opportunity and the society for being here. Also, thank you to the MedStar Research Institute for the financial support on that study. So, no relevant conflicts of interest are related to this study, and the anchors used on that study was donated by R-TREX. Okay, so postage stamp fractures, they're not very common. That's not something that we see every day in our practice, but they happen, and they are a hassle of using anchors on our bank cart repairs. So, it has this characteristic fracture pattern that propagates through the anchor sites, and they create that serrated edge that resembles a postage stamp. The literature says that it can be more frequent than we think, ranging from 35% to 70% on all recurrent instability after bank cart repairs, and the risk factors are young males, collision sports, more than three anchors, and osteolysis. So, here's the problem. So, we know from the literature that using three or less anchors on a bank cart repair increases four-fold the risk of recurrent instability. On the other hand, we know that the postage stamp fractures are more common on constructions using three more anchors. So, there is this misconception that using more anchors may add more stability to a bank cart repair. However, we don't consider what kind of—if the size of the anchors matter, if the material is also an implication, as well as the effect of the rigid core, as well as the angle of insertion and the perforation of the medial cortex. So, in order to cope with all those fractures, the best-designed study for that was a biomechanical study using sawbones, and we used 46 synthetic bones that resemble young males, and we tested them in this biomechanical setup using a metallic head to create the fracture. So, we designed some gigs in order to make sure our anchors and holes were all drilled on the same exact angle and the same depth, so we were able to control for all those variables. And we drilled some anchors ranging from three to seven of two different types, the 1.6 all-switcher anchors and the 3.0 build-switcher tacks. We also simulated the medial cortex perforation as well, and we arbitrarily established two thresholds, 70% and 50%, compared to the intact values in order to establish the risk of fracture. So, here's our results. Just by drilling holes, we can see on both shards on top that there is a linear regression on the number of holes you drill. And then, for the 1.6 holes, once you drill more than four holes, then you enter that gray zone. And the same thing with the three millimeter holes. So, if you're drilling more than three, then you enter on that gray zone. And we compared 1.6 to three millimeter holes. That's pretty much a simulation of osteolysis around the anchor, and you can see that there was a significant difference from the four, five, and seven-hole groups. When we put the anchors in, we noticed that the all-switcher anchors, they don't make any difference. So, the energy necessary to create a fracture is pretty much the same, which means that the glenoid can sustain up to five all-switcher anchors. On the rigid core anchors, the three millimeter ones, the core of the anchor strengthens the glenoid, which means that we can use up to four anchors is acceptable. Five, if you want to enter on that light gray zone, which is kind of moderate risk. When we perforate the medial cortex, we realize that that five all-switcher anchor rule does not apply, because once you perforate the medial cortex, we enter that gray zone again, which is moderate risk. And the same thing for the rigid core anchors. When we drill the medial cortex, the four anchor that was initially stated as acceptable is no longer. So, we have to be careful in perforating the medial cortex, especially because the study shows that we perforate the medial cortex more often than we think. As far as the size of the fragment on the fracture, we can see that the number of holes is inversional proportionally to the fracture area, which means more holes, smaller fracture size. And the bigger holes, the bigger the size of the fracture as well. The all-switcher anchors, again, didn't make any difference on the fracture size. And the core anchors, they strengthen the glenoid. But on the other hand, if they break after re-dislocation, those patients, they will have bigger fractures that may need some kind of bone procedure. So, here are the take-home points and some of the limitations. Of course, it's a cell bone study. It's a biomechanical study. We don't take into consideration any soft tissues and healing and tunnel filling. But it is important to study this fracture pattern because it has a direct implication on our banker repairs and the technique we're doing those. So, surgeons, they should prefer smaller size anchors with more inert materials. They should, on the all-switcher anchors group, up to five can be acceptable in an adult young male. On the rigid core anchors, up to four anchors are acceptable. But if they break, the size of the fracture will be bigger. And be careful with the medial cortex perforation. Thank you. Thank you. Matt's still eating, so I'm going to go ahead. Our next speaker is Benjamin Rothrop from the University of Pittsburgh, speaking about long-term outcomes following arthroscopic posterior shoulder stabilization. Minimum 10-year follow-up. Good afternoon. I'm Ben Rothrop from the University of Pittsburgh. Thanks to my co-authors and to the organizers for the opportunity to present our work. Our disclosures are available on the app, but none is relevant to this presentation. Posterior shoulder instability represents 2 to 18 percent of all shoulder instability, with recent studies suggesting the upper limit may be more accurate. And while conservative measures are first-line treatment, persistent symptoms are most commonly treated with arthroscopic capsular repair, which has been found to consistently improve pain stability, permitting return to sport at some level in approximately 90 percent of cases, and return to sport at pre-injury levels in approximately 68 percent of cases, as reported in a very recent meta-analysis from McMaster. That said, long-term outcome after surgery that is greater than 10 years are unknown. Our group has published one of the larger case series on posterior shoulder stabilization with this cohort of 200 shoulders at 3-year follow-up published in 2013. Now, with this cohort greater than 10 years out from surgery, it was the purpose of the current investigation to determine objective and subjective long-term outcomes after arthroscopic posterior shoulder stabilization. It was hypothesized that current shoulder function would remain superior to preoperative function, with reduced benefit for those who underwent revision surgery. The aforementioned cohort underwent surgery between 1998 and 2009 and included athletes at any sporting level or position, including contact and throwing athletes with unidirectional posterior instability. Patients with multidirectional instability and or voluntary subluxations were excluded. Data were collected using online questionnaires and review of medical records with patient characteristics including those listed here. Patients assessed their current and preoperative shoulder status according to ASES and KJAK scales, as well as subjective ratings of pain, stability, strength, and range of motion. Patients reported the ability to return to sport at any level and pre-injury level, as well as whether they were currently involved in the same sport. And lastly, patients assessed if surgery was worthwhile. We also assessed preoperative MRIs for glenoid bone, cartilage, and labral version, as well as glenoid and labral width, as we've previously described. Complete results were available for 55 shoulders in total at an average follow-up of 15.4 years. Subgroup analyses compared contact versus non-contact athletes, throwers versus non-throwers, and those who did and did not undergo revision surgery. There were 34 males to 19 females with an average age at surgery of 23 years. Athletes were in college, high school, and recreational levels. Across the total population, current shoulder status on all clinical measures remains statistically improved from preoperative status. For the same outcome measures described above, there were no group differences between contact and non-contact athletes, or throwers and non-throwers, although throwers trended towards more, or excuse me, worse preoperative and current KJAK scores. For those who did and did not undergo revision surgery, current shoulder values remained significantly improved compared to preoperative values. While for revised shoulders, there was no statistical significant difference in shoulder status comparing current and preoperative values, but current status was significantly improved from the shoulder status after failure, but prior to revision surgery. To distill this very busy table, 60% of patients returned to sport at some level, 35% at pre-injury level, and 21% were currently involved in the same sport. That said, a minority of patients stated that the inability to return to sport was due to persistent shoulder symptoms. Rather, graduation and age were the most cited reasons. Contact and non-contact athletes had similar return to sport rates, while throwers returned to sport less commonly. Notably, throwers returned to sport at pre-injury levels at a rate less than half that for non-throwers, although these differences did not reach statistical significance. Finally, revised and non-revised shoulders had similar return to sport patterns. As with our past studies, smaller glenoid bone width on MRI was a risk factor for revision surgery, while previously identified risk factors such as age, sex, follow-up time, sport type, and position type were not found to be significant risk factors. To summarize, we found persistent improvements in pain stability and function in our previously studied patient cohort, now at an average follow-up of 15.4 years. Contact and non-contact athletes had similar outcomes, as did throwers and non-throwers, while throwers tended to have lower CAGEOC scores and return to sport rates. Revised shoulders did worse than non-revised shoulders on most clinical outcomes, but had similar return to sport rates. To our knowledge, this is the first long-term follow-up of posterior shoulder capsule labral repair, and our results were similar, if slightly worse, than the larger cohort at three-year follow-up, from which the current cohort was recruited. There were several limitations, including a sizable portion of the population that was lost to follow-up. We used clinical outcome measures that were used in previous studies from our group, but they are certainly not comprehensive. And finally, we were unable to compare the long-term outcomes of this patient cohort directly with their earlier assessments, as published in previous papers. So to conclude, arthroscopic capsule labral repair for posterior shoulder instability provided durable improvement in pain stability and function at average 15.4 and minimum 10-year follow-up. Thank you. Thanks, Ben. Appreciate it. So our next paper is, thank you, Return to Sport Testing Versus Time-Based Clearance in Posterior Shoulder Instability. Robin Dunn, University of Pittsburgh. Just FYI, Pittsburgh does not own all the posterior instability out there. So we're trying to, yeah. Despite our best efforts to do so. Well, thank you very much. I'm going to be presenting on a novel return-to-sport testing protocol that we have been using as opposed to time-based clearance. So these are some disclosures. You can go to the app. So just a little bit of background. Traditionally, for return-to-sports protocols for most shoulder instability surgeries, historically they have involved testing the patient's strength, range of motion, and usually allowing patients to return to sport after a somewhat arbitrary amount of time where we think, okay, yeah, they're probably ready to get back. Borrowing from some ideas in other realms, specifically ACL reconstruction, we noted that objective parameters measuring strength and agility in the knee has been shown to decrease the rate of graft failure. Similarly, some of my colleagues have adopted this and have published on the results of utilizing a similar objective return-to-sport testing in anterior shoulder instability. So our question was, is this something that we could potentially apply to posterior shoulder instability, which, although less common, is quite a burden. I'll continue with this. So our purpose was to investigate the use of a validated objective return-to-sport testing protocol on recurrence of pain and symptoms after posterior shoulder stabilization. And our hypothesis was that this would potentially cause a decrease in the recurrence rate. This is a little bit of a busy slide. But the take-home here is that so the overall structure of our study was that it was a retrospective case-controlled study. We had minimum one-year follow-up. All patients were under the age of 30. The case group was 20 consecutive patients undergoing arthroscopic posterior shoulder stabilization. We excluded all patients who had open surgery or multidirectional instability. They had to have completed a post-op rehab. And return-to-sport testing was performed at six months after surgery. Our control group was about twice as big. 42 matched consecutive historical cases from previous years before we implemented this. They didn't undergo any sort of objective return-to-sport testing. Failure we defined as recurrence of symptoms, pain, or reoperation rate during the follow-up period. And on the right is the overview of the overall protocol. I'll go briefly over some of the tests that we used in the return-to-sport testing. And first is strength, measuring isokinetic internal and external rotation using a biodex machine, as well as external rotation endurance testing while prone. Functional testing consisted of a closed kinetic chain upper extremity test that involved essentially alternating hand positions while doing a push-up. And then unilateral seated shot put testing. Demographics showed that there was no significant differences among groups. Distribution of sports, there was a slightly higher rate of competitive athletes, specifically contact athletes, in the return-to-sport group. Really, most of our data, the recurrent instability rate was fairly low in both groups, running about 4 to 5 percent, which was not statistically significantly different between the groups. Overall reoperation rate was zero. So, in brief, our study showed no significant differences in this limited case control study in failure rates between cohorts who underwent objective return-to-sport testing versus the time-based rehab. There was a slightly higher proportion of competitive athletes in the return-to-sport testing group. The return-to-sport testing may be less critical, we think, than for reducing failure rates after posterior shoulder instability for a couple of reasons. First off, in anterior shoulder dislocation, failure event can be quite prominent with an objective dislocation, in addition to just subjective instability, whereas in posterior shoulder instability, it's really pain is one of the most prominent features. As well, our results were hindered by the overall low reoperation rate, which means that our study was likely somewhat underpowered. Just went over those. In conclusion, criteria-based return-to-sport testing can detect subtle strength and functional deficits that can guide rehab and can be a viable alternative to time-based clearance. However, we did not detect a statistically significant difference in return-to-sport rates after posterior shoulder stabilization between the two groups. Thanks so much for your time. So I've got a technique video next, then we'll get into some questions and answers. So, glenoid bone loss, how do I manage it? My disclosures are on the website and the app. So, how do we manage it? One of the ways we do this is the Latter-Jay procedure, and we're going to go through a few of the techniques here in terms of how to do this and how I think about making this successful and reproducible in your practice. So, number one, patient setup and approach. It's absolutely critical. When we look at setup, we want to make sure that the patient is in the beach chair. We put two towels under that medial border of the scapula. Why is that? We want to deliver that anterior portion of the glenoid out to you so you can get screws as parallel as possible when you're putting the Latter-Jay in place. It also facilitates getting to that anterior glenoid. When you're in the beach chair position, ask me how I know this. We want to make sure we watch that perineal nerve and buttocks. So I pad this area, and when you have a larger patient, this pad can actually lean up against that perineal nerve. You want to make sure that that's padded very well. That's okay. But the positioning is really critical, and when you're looking at that special positioners, you want to make sure. There you go. Thank you. So when we're into the delta pectoral space, you can see this really nicely. We've got those neurovascular structures. They're medial. You handle the cephalic vein, kind of dealer's choice if you want to take that medially or laterally. You then get down to the subscapularis and conjoint tendon. Some people do not prefer to put a retractor under the conjoint. I do, just gently, but you have to be careful because that musculocutaneous end vessels are right under there pretty closely. We do know that if you take down the subscapularis doing this, it results in lesser outcomes and fatty atrophy of the subscap. Now, you don't want to compromise that for position of your bone graft, and you want to make sure that that bone graft's in a great position. So sometimes in a very big player, a la football, NFL, et cetera, you may want to take down that top portion of the subscapularis if you need to. This is a study we did that looked at the latter J after you take down that coracoid, and guess what? There's a lot of scary stuff right under that coracoid, and you can see it's basically exposed, if you will, once you take down that coracoid in the conjoint tendon. So you have to be really careful, and especially if you're dealing with a revision situation, a latter J, that can be a significant issue. The musculocutaneous is closest to the pec minor, but we also make sure that we mobilize that from the fascial attachments on the posterior side of that conjoint to make sure that that musculocutaneous nerve is free. And believe me, the musculocutaneous nerve does not take a joke, and we have seen a few cases. I've had maybe 2 over 20 years of partial musculocutaneous nerve palsy. It does exist. It will keep you up at night, I promise you, but the good news is they all come back for the most part unless there's some significant insult. So what about the coracoid harvest and preparation? This is a study we looked at at really what the CA ligaments look like, and so we looked at that from the conjoint tendon to where the trapezoid and the conoid ligaments are, and we looked at male and female specimens, and you can see in a male we had about 28 millimeters until we got to that trapezoid ligament, which is closest anteriorly, and a female was 22 millimeters. And so you want to be careful of that, and usually we're in the 22 to 23 millimeters, 25 millimeters, and I showed a sagittal saw, and you roll your hand from medial to lateral, and then you complete it with a curved osteotome. You know you have enough coracoid if you have taken just enough into the bone spike, and so here's this nice, gentle sagittal saw roll that pointed homin that you see at the top there right behind the trapezoid ligament that I put right into that interval. It holds really well, and you can expose this, and you can see you just do this really nice hand roll just to do the top cortex, the medial cortex, the lateral cortex, and then we take that osteotome. The nice thing about this blade, although it's not my favorite one because it doesn't cut that great, the nice thing about that blade is it's 25 millimeters from the hub of the saw until the 90-degree angle, so it's a really nice guide so you don't take too much bone. So next is coracoid harvest and preparation, and here you can see I switch out to a very thin, flat sagittal saw, and the goal here is to decorticate. Gilles Walsh talks about this all the time. He's a very big fan of decortication. Why? Probably because of healing. He's seen it. He has a very low complication rate and a very high success rate, and you can do a combination of bovie dissection, knife dissection to get the soft tissue here. I just think I'm kind of going through everything to get the bone off, and you want to take that off so you get a nice exposed subcortical area. While you're doing this, you have to decide just before you make that cut which way we're going to do this, whether you want the lateral surface, meaning the traditional Laterge to be your glenoid surface, or you want the inferior surface, being the congruent arc, to be your surface. Now, on the congruent arc, you have to be careful. On a smaller patient, ask me how I know this, you can crack out through the coracoid when you're putting screws in because it can be quite thin. It does give you much more bone, but if you ask Joe DeBeer about his original description of the inferior surface, the arc, he actually took down about 30% of the entire length of it. So although you could probably get 10, 11, 12, 14 millimeters of surface of the glenoid, which is a lot with a congruent arc, he would almost always take 30% down so he didn't have too much of a lever arm. So here you go showing some of the difference of the classic versus the congruent arc, and why the congruent arc? Well, Joe DeBeer and Steve Burkhart said it just fit better, and they're exactly right in that concavity compression of the glenoid is very well restored, and you can also burr this down or use the CA ligament for the traditional to make that fit much better. So then you have to decide on the glenoid capsule, and there's a lot of things you have to think about ahead here. Jill Walsh will tell you I don't really worry much about the capsule. I take it all down to the subscapularis, put it in. It takes me 27 minutes, but he's a world's expert. It takes me a little bit longer, and I also manage the capsule. I usually take the capsule down in an L shape. I cut it superiorly off, and I put a suture right at that top corner at the superior medial border of that capsule on the glenoid, and I am able to take that down and then hold that up, and then it really nicely exposes it. It also lengthens the capsule so that you don't get over-constraint, and you can really get nice 45 degrees of external rotation to the side without having any capsular distress. And so now we next is looking at preparation. It's very important to do this. I like an oval type of burr, and there are many types of these on the market. And you can see we're preparing this. Use a little bit of irrigation, and then just gentle retraction, especially anteriorly and inferiorly to protect that axillary nerve. And again, we're looking for that subcortical area. When we're fixing this, we generally like to put the graft between 3 and 5 o'clock. You can put this in with commercial holders. You can also use K-wires to put it in. You can use your finger. You can use a cob. And generally, I use two screws about 1 centimeter apart, and you want the drill angle to be about less than 10 degrees to the glenoid surface. I use solid screws. I do not like cannulated screws. I've taken out too many bent cannulated screws in my revision latter-day practice. And so we have to be really careful with that. I do like small washers, but you have to be careful the washer doesn't impede over that glenoid edge. And this is a suture washer. It actually has a suture integrated into the washer, which can actually help you manage the capsular closure on top of anchors if you want to use that as well. Post-operatively, I usually use acrylic skin glue for all my open shoulders. We keep that armpit dry with an ABD pad. But I do start immediate passive wrist-shoulder-elbow range of motion. We immediately start these low contractions and scapular rows. So I like these folks to come out of the sling. If you look at LaFosse's work on the arthroscopic latter-day, I think it's a little bit crazy, but he's had some of these people out at full activities at two to four weeks from surgery. I think that's a little aggressive. I don't do that, but I am pretty aggressive about getting them out of the sling around three weeks or so. And I've amped this up a little bit for my usual six weeks in the sling and been very happy with the healing that I've seen on our x-rays as well as CT scan. But the nice thing about the latter-day is return to full activity at four months for most patients, maybe a little bit longer, and the super high-end contact athlete, maybe the riskier athlete, or those that might need a little bit more scapular work, scapular control, et cetera. But I think this is really where we can make an impact in return to play for our patients is this rehabilitation protocol. And this is probably one of my biggest changes, on top of looking at this from an arthroscopic manner. Just talking a little bit more about bone loss, the DTA procedure. We want to make sure we have adequate imaging. We've talked about this quite a bit at all of our talks, but here's a prior postage stamp fracture, as you can see. We have the 3D scapular reformats. And I generally use a padded Mayo stand. You can use a commercial arm holder. But I like the padded Mayo stand because this allows me to freely move the shoulder. It nicely relaxes the deltoid. We're going to do the same approach on this and then expose this area. A lot of times that bone is insufficient in the front of the glenoid, and we basically go down through the subscapularis split, and we're going to go and identify that bone. I just make that a mark with a needle-tip bovie. We keep about 2 1⁄2 to 3 centimeters at the top, 2 centimeters at the bottom. We use a deep gelpy to expose it. Then you can see nicely there I have the calypso. I'm using my finger to expose the calypso. I'm speeding this up in real time for you but we're actually pulling the capsule off anteriorly and doing that L-shaped capsulotomy to expose the glenoid. There is a commercial holder for this on the distal tibia but a lot of times I just do this freehand and this is a widely available graft. I can usually get these in a week or so. I do not do size match. I do male to male and female to female but we found through our studies that this fits very well. My first case was in about 15 years ago now and we now have some we're just collecting our 10 year data just like on one of the very nice papers that was presented here today in terms of our follow-up and overall graft integration and healing. We do like a little bit of an angle to the glenoid because we do know it's concave both superior inferior and anterior posterior. I want to make that nice concavity. You can do a pre-drill here if you want. It does show you very nicely where to put those drill tunnels and then you're able to harvest this and get certain sizes. I usually template this all out on my CT scan ahead of time. I also 3d printed these. I have a basic 3d printer almost on my desktop in the office which is pretty cool to print these out from a 3d and we're able to put these together pretty easily and figure out what our exact size is. Here I'm just showing putting this in basically by hand. Similar screw construct. These are two 4.0 millimeter solid screws with a washer and we do like that screw trajectory relatively flat to the glenoid surface. And the last thing I'll talk about is some of the innovations on the humeral head side. This is a reverse Hill Sachs. The problem the reverse Hill Sachs is it's not a Hill Sachs. It's a reverse Hill Sachs. It's all cartilage. It's a huge problem for patients especially if it's big enough. We see this posterior shoulder dislocations happen to be a 37 year old female mountain biker. She actually came to me in a sling in internal rotation still dislocated. It is the number one closed claim in the emergency department from a legal standpoint because they're very comfortable in a sling and internal rotation. So be careful of that. So if the tibia fits the glenoid the talus we found up to a certain level about 38 millimeters in length fits very nicely the humerus. And so basically this is Woodshop class 401. Nothing too fancy here. I have to go back and forth to the back table a few times. I put tiny K wires into it. Basically we're using the lateral edge of this and doing some angled cuts. We know this is in the shape of orange slice or a lemon wedge depending on the flavor of your drink of choice. But basically you put this in it's all cartilage and it's very good nice dense hard bone and we get a very nice healing outcome with that. So good luck on your glenoid and humeral bone loss journey. Some of the new things we've been working on and I think over the next few years we're gonna see some much improved techniques in our all arthroscopic game. So good luck. Thank you for that. We'd like to open this up for questions now at the mic. Okay and I'm happy to get started. For Dr. Lobo, I was curious I just wanted to confirm with your paper when you're talking about the number of anchors that you put in, were they all at the traditional Bankart area like below three o'clock or did you extend any up? The highest anchor we put in was 2.30 o'clock. 2.30 okay. So they range from 2.30 to 5.30. We didn't do any six o'clock anchors or pole shear anchors on that study. All right and can you clarify as well it was a little confusing where you had the core sutures actually made it stronger but there was a decreased load to failure? When you when you have with the three millimeter anchors they are the bio suture tech ones so they have like a rigid core. So those anchors they increase the strength of the glenoid rim which means that it required more energy or more force to create a postage stem fracture but when we measured the size of the fragment resulting from the fracture it was bigger than with the all suture anchors. Great thank you. Ben great paper on the 10-year follow-up of posterior instability. So it's interesting your ASES scores went down yet about yet a couple hundred in this cohort 186 and then you followed up with 55. So not a ton of follow-up at 10 years which obviously could be a bias. However what's interesting is your ASES score started to deteriorate. Christian Gerber talks about posterior instability being a precursor to early wear and tear of the shoulder, early arthritis, early issues. I mean ASES score 77 is not you know my shoulders about ready to fall off but it's it's not that great either when you look at an ASES score 77 in terms of their function because you get dinged pretty quickly on this. What are your thoughts on that and you know obviously that the durability is there but you know not necessarily the return and some of the ASES scores. Right yeah I mean I think you know our in general I mean and Dr. Bradley's published pretty extensively on this cohort or related cohorts for whatever reason our ASES scores tend to be a little bit lower than the national or international average. I mean typically we're in the 80s for post-operative ASES scores but preoperative are in the 40s so I don't know if it's just a poor disposition of the people in Pittsburgh or we have a lot of cloudy days but things tend to be a little bit lower but nevertheless we're a little bit lower than our previous cohort. Their return to sport rates are a little bit lower too. We did not really explore in this study the reasons for that and like I said we were unfortunately unable to kind of look at these specific patients at earlier time points to see if they have had actually a decline in their shoulder function or just for some reason we've been selecting among those 183 or 183 previous shoulders if we've selected some of the poor the poor outcomes. We have a question from the audience. This is for Dr. Provencher. Technical question about that. It's not not allowed only paper. When you're trying to position the glenoid yeah what exactly are you where are you placing that those towels are you trying to protract or retract the glenoid because that can make it incredibly difficult to place those screws and secondly what's your radiographic kind of follow-up of these patients and then when you say bye. Yeah no good question. So the the towels are two towels under the medial board of the scapula and you got to make sure that the beach chair positioner that you use or whatever you know whatever you're putting up with or you're just bringing the patient up that you've got that ability to have the medial board of the scapula up against the ribcage. So that's that's the key it allows you to open up the shoulder joint and deliver it out to you to so you're not basically if you don't do that the drill your instruments are in the patient's face and it's very challenging and you're in a struggle with their tube and the anesthesiologist and just the trajectory to get everything done. Second question was the yeah radiographic follow-up thank you was yeah so in general just you know standard maybe two six-week follow-up. I usually get x-rays around four-ish months I had a lot of these patients enrolled in some study protocols who were getting CTs on a lot of them but even without the study protocol I would say part of our standard of care especially in the military was getting a CT scan and before return to play. I don't know if that helped with the Latter Jay per se because you look at DeGiacomo's work 57% of the coracoid undergoes osteolysis and they still did okay. So I think it's more about us learning doing this procedure better rather than me feeling safe for them to go back. I think you're gonna learn a lot from the radiographs but CT scan is the hallmark if you're at all worried or worried about returning someone back to play. Question for Robin you know your return to sport criteria is interesting is there any thought of looking at patients earlier in the period I mean you didn't really show a significant difference because they were at six months but you know maybe at four months five months where you could get people back sooner. Yeah absolutely that's a great idea I mean it's funny because the premise of the the study was to see can we return to people can we get people back to sport by using these criteria yet we administer that return to sport test at the time frame when we would normally allow them to go back. So that's that's a great idea and I'll incorporate that when we were doing a follow-up study to this. So thank you very much. All right thank you for your attention we'll move on to the next session. I'm Lee Kaplan from the University of Miami. I have a pleasure to have Dr. DeCampos from Andrews Institute with me today. We're doing throwing injuries. The first talk is by Edward Chang at Inova Health System. The biomechanical comparison of the anatomic restoration of the ulnar footprint versus traditional ulnar tunnels in UCL reconstruction. Dr. Chang. Good afternoon. I'd like to thank the OSSM for giving us the opportunity to speak. Our disclosures can be found on the Academy website. I'd also like to acknowledge my co-authors for their help on this study. So UCL reconstruction has undergone many changes since it was first described. From an approach standpoint the flexor-protonator mass evolved from a detachment to a muscle sparing technique either by a muscle splitting approach or by a muscle elevation approach. The ulnar nerve initially was transposed in a submuscular fashion and now most patients are having an ulnar nerve transposition subcutaneously if they have preoperative ulnar nerve symptoms. On a humoral side, the tunnels were originally created through the posterior cortex and this has been modified to exit anteriorly. And the docking technique was also developed to address concerns over grab tensioning as well as the large drill hole sizes. But the ulnar tunnels have largely remained unchanged. But we've learned a great deal about the anatomy of the UCL footprint over the last 15 years. Anatomic studies by Jeff Dugas and Zulfaro demonstrated that the distal UCL inserts in an elongated and tapered fashion along the medial UCL ridge. And this most recent anatomic study using 3D CT scans demonstrated it has a large surface area as well. So our current ulnar tunnels don't restore or recreate the native UCL footprint and this has led some to question can we improve on our ulnar tunnels techniques to better restore the footprint. So in 2019 Chris Kemp demonstrated a UCL anatomic reconstruction technique where the ulnar footprint was fixed approximately by two all suture anchors and the tails were then distally fixed with a unicortical button. They demonstrated ultimate load to failure greater than the traditional docking technique. And so our study purpose is to describe a novel UCL reconstruction technique utilizing proximal distal ulnar tunnels to recreate the anatomic footprint and compare its biomechanical profile to the docking technique. We hypothesized that the biomechanical profile of the anatomic technique would be similar to the docking technique. So we had ten matched pairs and the arms in each pair were randomly selected to either undergo the anatomic technique or the traditional docking technique. Prior to reconstruction we analyzed the native UCL and loaded it to failure and then for the anatomic technique we placed two 3.5 millimeter drill holes along the medial ulnar ridge. The potential advantage of this technique includes a greater surface area for tendon to bone healing, improved stability and graft isometry. We get to maintain the inlay technique and there's a potential less risk of an ulnar nerve injury. The specimens were then loaded onto an MTS machine with the elbow fixed at 90 degrees. They underwent cyclical loading from 0.5 to 5 newton meters for 1,000 cycles and then subsequently was loaded to failure. Our main outcome of interest was maximum valgus moment and valgus angle at failure. So these are a few slides of our technique here. This one here demonstrates the or outlines the medial footprint. And then here's where the tunnels were drilled. And then the graft was then loaded into the ulnar tunnels with one of the limbs into the humeral tunnel. The second limb was then docked into the humeral tunnel and then it was tensioned in a traditional docking fashion. So our results we found no significant difference in the maximum moment or valgus angle at failure. The mode of failure was majority of the failures were on the humeral side. Our study did have some limitations. This was a cadaveric study which demonstrates time zero performance and does not take into account any bone tendon healing. The specimen age also is a little bit older than a typical patient that would undergo this procedure. And there's also some concern about this technique causing a sharp turn of the graft. And we tried our best to minimize that by drilling the tunnels obliquely and chamfering the edges of the proximal tunnel entrances. And we also did not notice any evidence of graft tearing or attrition at that site. So in conclusion, utilization of the anatomic tunnel location has similar biomechanical properties compared to the traditional method at time of initial fixation. Further studies are warranted to determine if the technique results in improved or different outcomes compared to the traditional reconstruction techniques. Thank you. The next paper will be from the Andrew Sports Medicine Orthopedic Center, Marcus Rothermich. Clinical outcomes on UCL surgery in non-baseball throwing athletes and non-throwing athletes. Thank you. Good afternoon everybody. I'm Mark Rothermich from Andrew Sports Medicine in Birmingham. Thank you for the opportunity to present our study looking at clinical outcomes following ulnar collateral ligament surgery in two different groups of athletes, both non-throwing athletes and throwing athletes from sports other than baseball. We have nothing to disclose related to this study. As the literature has consistently shown in recent decades, baseball players continue to demonstrate excellent clinical outcomes with a high return to play following UCL surgery. The recent development of the novel UCL repair procedure has not changed these excellent outcomes, with outcomes remaining similar between the two procedures as we continue to build on our cohort of UCL repair patients over time. In comparison, there has not been a high quality study with adequate follow-up that we've seen from a large registry of non-throwing athletes and also non-baseball throwing athletes. So the purpose of this study was to conduct the first large-scale study to evaluate the clinical outcomes, complications, including return to the OR and return to play rates for these athletes following UCL surgery. We hypothesized that in comparison to baseball players, the non-baseball throwers and non-throwing athletes would demonstrate similar outcomes. We have a large elbow registry at Andrew Sports Medicine and Orthopedic Center in Birmingham, Alabama, and we conducted a retrospective analysis going all the way back to June of 2001. We wanted a two-year follow-up, so we closed the enrollment for patients who have been operated on after October of 2019. All patients were operated on at our facility in Birmingham. We included all active non-throwing athletes and non-baseball throwing athletes who had surgery for UCL pathology with a minimum two-year follow-up. We excluded baseball players, non-athletes at the time of surgery, and injuries to the non-dominant upper extremity. We have an automated self-reported patient outcome data system called OBIRD that captured most of this data and also called patients to try to contact all players eligible for inclusion. The patient reported outcomes that we were interested in included the American Shoulder and Elbow Surgeons elbow score, the Kurland-Jobe Orthopedic Clinic shoulder and elbow score, the ASMI return to play questionnaire, and complication rates including revision procedures. In addition, we compared outcomes of UCL reconstruction versus UCL repair. We used student t-tests and the Fisher exact test with standard statistical significance of 0.05. Our elbow registry included 4,606 patients for this time period, and after applying our inclusion and exclusion criteria, we had 40 non-throwing athletes and 28 non-baseball throwing athletes who underwent UCL reconstruction or repair. From the 40 non-throwers, we found 37 for a follow-up of 93 percent. Of the 28 non-baseball throwers, 23 were contacted for a follow-up of 82 percent. We then collected all of the demographic and outcome data for these patients and compared their clinical outcomes. This is the demographic data for the 37 non-throwers, showing 28 patients who had UCL repair and 9 who had UCL reconstruction. The most common sports represented were football, gymnastics, and cheerleading. A majority of these patients were high school athletes representing 70 percent of the non-thrower cohort. The clinical outcomes for the non-throwing athletes demonstrated excellent outcomes with 35 out of 37 or 95 percent returning to competition at an average time of 7.4 months for UCL repair and 10.0 months for UCL reconstruction patients. The demographic data for the 23 non-baseball throwers demonstrates 11 athletes who had UCL repair and 12 who had UCL reconstruction. The most common sports for this group included softball, javelin, and football quarterbacks. Again, this is mostly high schoolers who represented 61 percent of this cohort. The clinical outcomes for this group were also satisfactory with 91 percent returning to competition at an average time of 8.4 months for UCL repair and 10.4 months for the UCL reconstruction patients. We feel that this study is very important as it adds information that was previously not at all known regarding clinical outcomes in non-throwers and non-baseball throwers following UCL reconstruction or repair. Due to the long time window for collection in this study there are inevitably recall and selection biases as limitations. Also, all of our data is from subjective patient reported outcomes which could limit the accuracy of the findings. But in conclusion, we were pleased with the excellent post-operative outcomes and the high return to play rate in non-throwing athletes as well as non-baseball throwing athletes following UCL reconstruction or repair. Again, there were no significant differences between UCL repair or reconstruction patients in either group of athletes. Also, this data is not statistically different from the outcome data for baseball players. We hope that this study serves as a foundation for future studies in both non-throwing and non-baseball throwing athletes. Thank you to our team in Birmingham for the exceptional registry of patients as well as the infrastructure to analyze this data in a meaningful way. And thank you for your attention. The next presentation will be Ian Engler from Tufts Medical School. The excision of hook of handmade fractures in elite baseball players surgical technique and return to play. Thank you Dr. Kaplan. Good afternoon everybody. My name is Ian Engler from the University of Pittsburgh Tufts Medical Center and Newton Wellesley Hospital and I'll be speaking today about excision of hook of handmade fractures. I have no disclosures. So I have some goals since a lot of us don't manage the hand surgically. I want you all to get a little review on hook of handmade fractures since we do take care of these patients. I want to touch on the surgical technique and why it matters and I'll go over some outcomes in elite baseball players but we do think this will extrapolate to hockey players, golfers and other athletes would take care of. So hook of handmade fractures are relatively common among elite baseball players but also present in other sports with clubs and sticks such as tennis, golf, hockey. They're often missed or have a delayed presentation and treatment has evolved over the years from non-operative management to ORIF to excision. We favor excision in athletes. Literature has shown good outcomes but has tended to have mixed populations, different sports and different levels of sports and techniques on the topic have been relatively extensile more so than we prefer. So our purpose was to review outcomes of hook of handmade fracture excision in elite baseball players and describe our surgical technique that's tailored to athletes. Our hypothesis is that we would have high rates of return to play with few complications. So this was a retrospective review at a single academic hand surgery practice of all hook of handmade excisions over a 15-year period in both professional and collegiate baseball players. We reviewed the following data including time from surgery to return to play and complications. To touch briefly on the surgical technique we make this incision over Guion's canal. You can see with the dotted circle the callus present from the butt of the baseball bat over time. Following dissection through the palmaris brevis you find the ulnar artery and the superficial sensory branch of the ulnar nerve just superficial to and ulnar to the hook of the handmade. So you can see how intimately related these neurovascular structures are to the hook. Following retraction of these you see the deep motor branch of the ulnar nerve. It's crucial to identify that the ulnar nerve bifurcates just proximal to the hook of the handmade so you need to identify both the superficial and the deep branches of the ulnar nerve. The deep motor branch passes closest to the hook of the handmade so the surgeon must take great care to mobilize that ulnarly. The hook is defined with subperiosteal dissection and removed as can be seen in each of these pictures. Post-operatively following a week of splinting we progress through a relatively quick return to play protocol beginning with throwing no catching initially and light swings into soft toss batting off a tee and eventually full play with a goal to return to sport by six weeks. Our results are 42 patients about half of whom were professional. Mean time from injury to surgery was seven weeks. Median time was two weeks. We try to treat these acutely but five of our patients had over 20 weeks of symptoms before presenting to us and undergoing surgery which is relatively common in this injury. All players returned to their prior level of sport 93% of whom were by six weeks. We had two patients return to the OR. Both had returned to sport within six weeks but one had scar tissue and another had a residual fragment at five and six months respectively that had ulnar nerve pain and had to return to the OR. They too returned to play within six weeks again and had no subsequent issues. So hook of handmade excision in our cohort leads to fast reliable return to sport and elite baseball players. We think it's preferred over non-operative management which has shown some unacceptably high rates of return to sport and open reduction internal fixation. Some studies have shown good outcomes with ORF but that can delay patient return to the field due to the need for bone healing. Also presents the risk of non-union as well as irritation from the hook or the hardware. There have been good outcomes reported with excision in the elite baseball population prior. An MLB database showed 81% return to play at a mean seven weeks and another study showed no change in statistics post-operatively. Surgical technique is really important. You need to balance visualization of these crucial neurovascular structures with minimizing invasiveness and prior described techniques have not been tailored to the athlete. They're more extensile either consistently spanning the wrist crease or dissecting through the carpal tunnel and we don't think these that's necessary in this population. We think we can minimize the invasiveness to a degree while still seeing the neurovascular structures adequately. So in conclusion for us sports surgeons, important to recognize hook of the handmade fractures. We can have good outcomes with excision especially if you use a surgical technique tailored to athletes. Thank you. Our next talk is return to play after biceps tenodesis for isolated slap tears and overhead athletes. Dr. Egan Hurley presenting. Hi my name is Owen Hurley. I'm from Ireland. I did two years research at NYU and I'm going to Duke in July. So I'm presenting on overhead athletes and biceps tenodesis, something not controversial at all. Unfortunately I have no disclosures. Biceps tenodesis has been gaining popularity as a primary surgical option for symptomatic type 2 slap tears since Below's original paper. Systematic review from our group found that it led to lower rates of revision surgery compared to a primary slap repair in primarily older patients and we looked at it in younger athletes and found that again lower rates of revision under 30s. However there's a concern the overhead athletes that it may not allow patients get back to their previous levels of activity. In terms of the literature, a recent systematic review found only 99 overhead athletes in the literature who underwent a biceps tenodesis. So there really is a lack of evidence out there. So the purpose of our current study was to investigate overhead athletes undergoing biceps tenodesis for the treatment of symptomatic isolated slap tears involving the biceps labral complex. A retrospective review was performed from January 2011 to April 2019 for patients who underwent biceps tenodesis for a slap tear. They were older than 16 and did not have any concomitant pathologies such as anterior posterior instability or rotator cuff tears or required any concomitant procedures and we defined overhead sports in our populations tennis, softball, swimming, rock climbing, handball, CrossFit, baseball, boxing, volleyball. A standard mini open subpectral tenodesis was performed with a unicortical button. The outcome measures we focused on were focused on return to play metrics which we defined as an ability to return to the same sport pre-injury with the return to same or higher level being a patient's ability to perform at the same higher level as they did prior to their initial injury. Additionally we used the slap RSI score which is a modification of the ACL RSI score for this population to assess psychological readiness to participate in sports. Standard statistical analysis was performed. Overall there were 53 overhead athletes that underwent biceps tenodesis as treatment for symptomatic slap tear with 44 or 83 percent available for follow-up. This included eight competitive athletes and 36 recreational athletes. Overall we found 82 percent of patients returned to play with 60 percent returning to the same or higher pre-injury level and 70 percent of patients were still participating in sports at the time of follow-up and of the eight competitive athletes seven or 88 percent were able to return to play and took an average of eight months to return however this might be slightly skewed by patients returning the following season or other reasons for delayed. And the mean slap RSI score was 70 with 70 percent passing the slap RSI threshold of 56 which is psychologically ready to return to play. In terms of other functional outcome scores, there's a high ASES score with the majority of patients satisfied and willing to undergo surgery again. None of the patients in our population did have a revision surgery at this time point. And finally, of those who didn't return, the mean age was 34, which was similar overall demographics to our mean population. The most common reason for not returning was residual pain in three patients. And then in those who returned but not at the same level, the primary reason was due to lifestyle change. There are some limitations to our study. There's no control group or comparative group included. It would be of interest to look at this compared to isolated SLAMP repairs. Additionally, it would be interesting to compare patients of different sports and see if it affected baseball players more than other athletes, but it wasn't possible due to small numbers. So in conclusion, the study found that athletes undergoing bisubstantiasis had a high rate of return to play, good functional outcomes, low rate of revision surgery. Thank you for allowing me to present my study. It will be published in the American Journal of Sports Medicine. Marcus Rothermatch is going to do the next study. Dr. Ryan is not here. This is a paper on clinical outcomes and return to play in softball players following biceps tenodesis or SLAMP repair. Okay. I'm going to cover for Dr. Ryan today. Good afternoon again. Thank you again for the opportunity now to present our study looking at clinical outcomes and return to play statistics in softball players following either a SLAMP repair or the biceps tenodesis procedure for shoulder pain. And again, we have nothing to disclose related to this study. Several years ago at ASMI in Birmingham, we began to think about tracking the outcomes from our registry of softball players. Specifically, we noticed a high number of softball athletes over the years who were suffering from shoulder pain. The most common sources of this shoulder pain, including tears in the superior aspect of the glenoid labrum and also pathology related to the biceps tendon anchor in the same location. The surgical options that we have traditionally pursued for these injuries include labor repair and more recently biceps tenodesis in this cohort of patients. There have been studies in the past that have analyzed comparative outcomes in patients between these two procedures, but we have not seen a high quality study with adequate follow-up that specifically looked at clinical outcomes and return to play in the softball population. So the purpose of this study was to fill that knowledge gap and evaluate clinical outcomes and return to play in softball players who have been treated with either a SLAMP repair or a biceps tenodesis. In our preparations for this study, we hypothesized that the clinical patient reported outcomes would be similar and thought that the return to play time might be faster in patients who have undergone a biceps tenodesis. This was a retrospective analysis from our large shoulder registry going all the way back again to June of 2001. We wanted a two-year follow-up, so again we closed the enrollment for patients who have been operated on after October of 2019. And again, all patients were operated on at our facility in Birmingham. We included all patients who played softball and underwent either of these procedures with a minimum two-year follow-up. We excluded all non-softball athletes and also softball players with less than two-year follow-up and patients who had undergone any other procedures on the ipsilateral shoulder. Again, we have an automated self-reported patient outcome data system called OBIRD that captured most of this data. And we also called patients to try to contact all softball players eligible for inclusion. The patient reported outcomes that we were interested in for this study included the American Shoulder and Elbow Surgeons shoulder score, the Andrews Carson score, the Kerlan Jobe Orthopedic Clinic shoulder and elbow score, the numeric rating scale for pain, and the ASMI return to play questionnaire. And then for our data analysis we compared those who underwent biceps tenodesis with those who underwent a slap repair. And we also looked for fast-pitch softball at pitchers versus position players. We used student T-tests and again the Fisher exact test with the standard statistical significance at 0.05. Our shoulder registry included a total of 16,500 patients and from this large group we had 111 patients who met our inclusion criteria. From this number 35 were excluded which made 76 softball players eligible for analysis in this study. Of these 76 patients, 63 were successfully contacted and the data was collected for a follow-up rate of 83%. For these 63 softball players we compared demographic, surgical, and outcome data for our two different surgical cohorts. And we also broke down this data by fast-pitch pitchers and fast-pitch position players. This is a magnified look at our flow chart of patients included and excluded which demonstrates that of the 63 softball players included in the analysis, 53 were fast-pitch and 10 were slow-pitched softball athletes. Of those 53 fast-pitch softball players, 18 were pitchers and 35 were position players. This flow chart also includes that of the 63 total players, 34 underwent biceps tenodesis alone and 21 underwent a slap repair alone. For all of these patients combined, the average age at the time of surgery was 20.6 years and the cumulative average post-operative follow-up time was 5.3 years. For the 21 slap repair players, the mean age was 20.9 and the average follow-up was 8.2 years. These patients generally had excellent outcomes with an average AC score of 87, KJAK score of 81, ASES score of 93, and NRS score for pain of 1.2. For the 34 tenodesis players, the mean age was 20.0, but the follow-up time was significantly shorter on average at 3.7 years. These patients had very similar clinical outcomes with an AC score of 82, KJAK score of 74, ASES score of 92, and NRS score for pain of 1.4. The only statistical difference between these cohorts was the follow-up time, reflecting a change in the standard treatment technique at our practice. This is a graphical look at the data showing statistically similar outcomes and return to play rates. The slap repair patients returned to play at an average of 7.5 months post-operatively compared with 7.1 months in the biceps tenodesis group, an average return to play difference of just 12 days. We also looked at the 53 fast pitch softball players and, again, there were no statistical differences between pitchers and position players. This is a detailed look at those numbers, which shows nearly identical patient-reported outcomes between fast pitch pitchers and fast pitch position players. We feel that this study is very important, as it adds information that was previously not known regarding clinical outcomes in softball players with shoulder pain. Due to the long time window for collection in this study as well, there are inevitably, again, recall and selection biases as limitations. Also, all of our data is, again, from subjective patient-reported outcomes, which could limit the accuracy of our findings. But in conclusion, we were pleased with the excellent post-operative outcomes and the high return to play rate in softball players after having either a slap repair or biceps tenodesis. Again, the difference in the average follow-up was the only data point that reached statistical significance between the two surgical cohorts and also when comparing fast pitch pitchers versus position players. We hope that this study serves as a foundation for future studies in softball players moving forward to optimize outcomes in young athletes with shoulder pain. Again, thank you to our team in Birmingham for this exceptional registry for the shoulder, as well as, again, the infrastructure to analyze this data in a meaningful way. And thank you again for your attention. Thank you very much to all the presenters. Do we have any questions from the audience on any of these papers? Please come up to the microphones. Dr. Chang, very good paper on the biomechanics. I guess my question is, are you thinking about doing a clinical study using these landmarks? I think that's the hardest thing is to translate your biomechanical findings where we know that at time zero, it does provide a similar biomechanical profile as the traditional owner tunnels. That's something that we're going to discuss about and with some of my colleagues. But right now, I guess we're thinking about it. Do you know how they decided to do the initial tunnels? Do you know what Dr. Jobe's thinking was when he decided to make them AP? I don't either. I'm just wondering if that showed up in your research. Doing the literature search, it seemed like a lot of the original anatomic studies about the owner footprint was more centered over the sublateral, which does have the majority of the surface area. But it's only, I guess, over the last 15 years that we're learning that it does have that kind of tapered insertion down the UCL ridge. Thank you very much. Dr. Engler, one of the interesting points of your presentation in the paper was that players were back to play at around six weeks. But the protocol that you had for the physical therapy, they were really picking up a bat at around six weeks, somewhere in there. Were they getting back to that level at that time, or were they getting back to just full activity? They were getting back to full play by six weeks. The protocol has them actually beginning to pick up a bat around week two, taking some light swings, no contact, before progressing into T around four, week four, and then soft toss at week five. So you showed a protective device. Were they using that initially when they picked up a bat, or they were clear? Not consistently. Yeah, that was really patient preference because these athletes are so particular about what they like to wear. We certainly encourage it, but it was up to them. I really liked your paper. Made me glad I wasn't a hand surgeon. But my question for you is, this is a baseball-only article with baseball-specific rehab and return to play. How about the hockey players and the other athletes, other sport athletes? How do you determine their rehab and return to play? Yeah, that's a great question. The nice thing about excision, you're not waiting for bone-to-bone healing like an ORF. So you can return them to play relatively quickly. It's mostly a soft tissue issue with healing of the skin and soft tissues. So I think other sports can match this protocol relatively quickly. You're certainly, depending on the athlete, hockey players might try to push it and get back a little bit sooner. So with them, we might need to be a little more cautious. But I think the protocol can hold across sports. Go ahead. Hi, my name is Tom Metallica. I'm from Grand Rapids, Michigan. For the presenters regarding the slap repair versus tenodesis, I'm a little bit older and we were always taught that the biceps tendon was an important part of shoulder stability, especially in the overhand athlete. And I always struggle with my overhand athletes what to do with the biceps tendon, especially when there's a slap repair. What do you guys think? Are you guys telling us now that the biceps is not important in the overhand throwing athlete and we can remove it from the superior glenoid tubercle and attach it to the front of the humerus and it would still be fine? I think that's one of the important things about our study, and you can comment as well. But this is kind of the beginning of comparing that data to what historically was known regarding slap repair. And I think that's what's the most important thing about our study, and I think yours as well, is that we haven't found any differences. Yeah, so we also looked at it in a separate study in kind of our under 30-year-olds, and what we found there was similar. They're doing well, they're getting less revisions. I think we're still really at the start in saying, should we be just doing this forever? And it's kind of starting to figure out into that niche. I know Dr. Strauss, who was one of my senior authors on this, looked at it in terms of stability in overhead athletes when he was a fellow and found that actually the biceps tenodesis did just as well for superior stability as well as slap repair. Mark, I know you had two talks. I want to ask you about the UCL and non-baseball throwing athletes. The paper showed that your catchment was from 2011 to 2019. Has your repair changed? Obviously you have one of our leaders, Dr. Dugas, here at your institution. Were you doing the repairs later in the thought process, or did they happen along that whole aspect of time? Certainly later in the collection cohort, and that's been now certainly the majority of what we do in our young athletes. The majority of these patients are younger, are high schoolers with partial tears that are ripe for repair now. So that's changed the data set. If we looked at it from the first half of the data set and the second half, they would look different demographically. And that could be a couple different studies, a couple different papers to look at it over time. Certainly the last eight years or so, it looks a lot different in our demographic data for our patients. Thank you very much. I think we're out of time. Congratulate the authors. Good afternoon. I'm Jeff Dugas. Juliette and I are going to have a legend discussion, case presentation with two of the most prolific UCL surgeons that have graced the planet in Drs. Andrews and Elitrosh. So we've prepared a few cases for discussion, and we're going to start with Juliette on case one. This first player is a minor league pitcher for us that went to an SEC school, and he was a starting left-hand pitcher who started his first pro season at AA because of the COVID problem. So there was a very limited experience of instructional level ball for a while. In his first pro season, he had a 1.77 ERA, a lot of strikeouts, and he went to the futures all-star game. The first incident happened in college. He had just some medial soreness following a throwing session in fall 2018. He didn't really have an injury. We didn't see him at that time. So his team doctor, which was at an SEC school, obviously, had no MRI that did not show a tear, some bone marrow edema only around the proximal UCL insertion. So they shut him down for six weeks, had one of their local doctors do a PRP, and then because he was still having a little bit of soreness, got a second opinion, and they recommended more conservative treatment, and he did well. And then there was a two-year interval before he had problems. So he pitched well for two years. This is his original MRI. Dr. Andrews, what do you think of it? It looks like he's got a signal that sometimes will be read as normal, but probably represents a little signal in the upper proximal part of his ligament. It's black, two-thirds distal, but then you get toward the top, you see it has a little signal in it. It's probably one of those minor partial tears that he had. These are his original x-rays, also taken at the time of the second opinion. And just to be clear, this player had stress fused tubes, which were negative. So the second incident occurred two and a half years later when he was in pro ball. So he was pitching, and in a game, after 70 pitches, he said he was sore the next day. So no problems pitching. Maybe his performance was off. They do a lot of metrics now at every game. They measure every pitch, they check every pitch, and they were able to see that he was a little lower than his baseline. But he woke up the next day with a little bit of soreness, and the trainer saw him, and he was seen in the training room. Everything was normal. He might have had a little bit of tenderness. And so based on that, what imaging would you get? Oops. Too fast, Jeff. This is the imaging we got, Neil. Do you agree? I'm not that big on valve stress fused, but no harm. But I would have definitely gotten x-rays and a new MRI scan. Okay. Well, one thing you didn't tell us was what kind of velocity. That's really important with this guy. Is he a power pitcher? What kind of velocity? His normal velocity is 93 to 94. And he was down in the 91 average. Just that one day. So his performance was down just a touch from the previous performance. My primary care sports medicine doctors that see patients with me like this, when I get through, they all say, well, why don't we do an ultrasound? So we've been doing it right there in the office. I'm still not convinced, but it's not a bad thing to do as an addition to your MRI. I don't think it takes the place of an MRI, though. Your wish is our command. Here's an MRI. So on the left is just a static MRI. And on the right, I'm sorry, ultrasound is an ultrasound stress view. And they showed 0.3 millimeters of difference. I'm going to suggest to you that the organization did not want to get an MRI. So what's questions for the panel now? I think you might have answered them. Dr. Ellitrage, your recommendation? MRI. Okay. Not an MRI. I like to get an MRI on this because the periligament of sedima that you'll sometimes see with gradually incompetent ligament is important. And sometimes you lose the ability to see that kind of contrast with a contrast MRI scan. So based on the data that you have, we did not get an MRI. So this is all the information you have to make a recommendation. Well, I'm not going to do anything other than recommendation based on that. You're not going to do anything other than conservative management. They're not going to let you get a scan. You're usually not going to get away with a professional player by not doing an MRI at this point, I can tell you. That's just automatic. Well, this is the third organization that we've had. And this is a different recommendation. But they pay the bills. So that was their recommendation. So we agreed that they would have rehab with the trainer. And he did a return interval program pretty quick and went back. Okay. So then this is literally two weeks later he pitched in a game. And again, his velocity did, they say, return to normal in practice, according to their metrics. And he was starting in a game, good control, and all of a sudden he had some tightness. So they pulled him out of that game in the fourth inning and they told us also that his velocity was down below normal in that game. So he was sore then and his symptoms resolved overnight and he was seen the next day with no tenderness, but he said, I feel something. And that was the first time he had felt something different. So, Dr. Ellitraj, here it is. There's a periligamentous edema. I think the distal ligament now, you have to be a little bit concerned, maybe peeling off the sublime tubercle. But where Jimmy pointed out, the proximal signal, too, I think that that is also thickened and a little bit disorganized at the top. So his whole ligament is starting to suffer here. If you look at that second MRI from your left, it looks like he's got a T sign there. And the other one, the first one from the left, it's just inconclusive. It looks like he's probably been injured right at the joint line. By the way, what part of the season? Is this early spring training or is this late? We had a late start to the season last year in minor league ball. So we started in, I think, June. So this was two months in. Three months in. So he's into June now? No, no. We started in June. This is August. He's in August. So he's almost done with his minor league season. The problem with this is if you continue to go conservative and you can't come to grips with fixing it, you're going to wind up getting into two seasons. And two seasons in professional baseball usually doesn't work. So you got to think about what the timing of this and when he's hurt and how long are you going to go conservative before you give up on this particular player and fix it. Okay. So at this point, your recommendation is, oh, the readout was high grade partial distal tear, but I agree with you that it was, we were concerned approximately two. So this patient, the organization asked for a second opinion. The second opinion doctor, by the time he saw him, it was five days later, and now the patient didn't have any findings on the physical exam. This is, for me, this is August. He's a minor league player, correct? Minor league player August. The only chance he's got to be ready for spring training is successive conservative treatment. But you got to have a really heart to heart talk with this guy that successive conservative treatment with what you're seeing with the gradual wearing away of his ligament is not at a high level of a percentage to get him well. And if he wants to try conservative treatment and see if he can get well, I'd probably do a PRP, shut him down for three or four months and hope he can come back in spring training. And that would be the end of, if he had trouble in spring training, you got to start getting it fixed. If he's in a mode of saying I want it fixed now, my buddy had this, he had a PRP, it didn't work, I don't want a PRP, and he wants it fixed, I'd fix it at this point. Well, let me tell you what they're going to ask you, they probably have, because this kind of player and his representative is going to be asking me, what about fixing, what about doing a repair and this technique I hear that Dugas does down there called internal brace. And this is exactly the scenario, about August, they're looking at spring training and beginning of the following season. And so that's going to be an option they're going to ask about. With this guy and where he is in his career and how that ligament looks with problems approximately mid substance and now distally, this would be the one that I would be answering them saying I wouldn't repair this, I wouldn't do an internal brace on this guy, he's too young and still on the development curve, I'd give him a good, if he gets an operation in my hands with this thing, he's going to get a reconstruction. So I know Jeff has had some great results with doing just the repair and the internal brace. The way I would, if I had to fix this one, I would actually repair his ligament and do the reconstruction. So I'd do a biologically anchored repair internal brace, but in the ligament tissue, not external to it. So maybe we can even ask Jeff his opinion on this. I would agree with Neil exactly what he said. And what I've been doing is I would send this kid up over to see Jeff and see if Jeff thought he was a candidate for an internal brace. I probably wouldn't make that decision personally. But he's had the experience maybe to tell us yes or no relative to, and if it was going to be done, I'd probably ask him to do it. But this kind of diffused thing on a young guy that you want to get him the best chance of coming back long term, I would be less worried about him being ready for the upcoming season than I would be about making sure that he, so I could be wrong and I think the future results may show that maybe that's too aggressive as far as reconstruction. But this kind of ligament, I agree. And it's interesting, we didn't tell you guys who this patient was, but you guys were the second opinions and the reconstructing surgeons. So Dr. Andrews recommended PRP, but also told him that if he wanted to have it fixed, he could. He went out and saw Neil and Neil said the same thing. He was from the west coast and he had it fixed and you did a reconstruction with the repair distally. So this is a problem without having Conway or I'll check here, you're going to have us agreeing on every single thing. This is not going to be too much fun. So anyway, you guys, we didn't tell you, but you actually did, very consistent. All right, next case. This is a junior, high school junior committed to an SEC school as a pitcher. No pain prior to the injury, was pitching just fine. This injury actually happened a couple weeks ago. No prior elbow shoulder pain, normal shoulder range of motion, positive milking, positive everything, x-rays look good. And this is his MRI. And I'm going to show you a couple of slices of this, but that's his MRI. Never had an elbow problem before. And now he's got this mid substance and that's about as mid substance as it gets. Some of these mid substance ones you look at, maybe they're a little closer to one end or the other, but that one to me looks like it's in the 50 yard line. And so. Go back to your x-ray, Jeff. What about the olecranon tip? Yeah, he didn't have any symptoms there. That always comes up as it's there and you got to show it to him. Sometimes that is not bothering him. Sometimes you'll have to tell him that it may get bigger and if you're there fixing the ligament, do you clean that up? That's a big question. Yes or no. Sometimes I'll do it. Sometimes I won't touch it. But anyway, it's there. It didn't show up on the MRI, though. That's what I thought was interesting. So he has one view of the MRI, olecranon tip, Just a little bit abnormal. But he was asymptomatic there. So got a mid substance rupture and SEC commit. Big old boy, 6'3", 205, throws at 93, 94 as a junior in high school from Huntsville, Alabama. So what are we doing with this? Is there any role for conservative management in this? Is there any chance of a biologic arrest? I mean what are our chances of this kid getting back to throwing like that? I haven't seen biologics work in this. I haven't either. You have? No, I have not. Miracles do happen. This sounds like he's a real legit prospect judging from what you're telling me about his size. And I think we would all say that this is not a candidate for repair. Typically. I would say this kid needs a full reconstruction. Would anybody consider a hybrid? Put a weave in the tape or something. That's why I put this case in there. What would be the hybrid option? I know you've been doing some of those, Neil. What do you think about that for this case? It's a good point. When I do the hybrid part, I don't put the suture in that is going to supposedly be load sharing external to the tissue. I put the suture into the ligament tissue so that it's truly incorporated in it. And then if it's a more proximal tear, I'll pull those stitches up approximately into my drill holes with the graft or opposite if it's distal. One that's in the mid substance like this, typically I won't do that. I just longitudinally fillet it open, lay the graft in there. Before I put the graft in, I put my stitches in that native tissue first and then don't tie them. Just lay the stitches open, lay the graft in, and then tie the stitches around the bundles of the graft. And that's exactly what we did. So I used a gracilis. He didn't have a palmaris. And I chose reconstruction because of the mid substance. And my thoughts were the same on the hybrid. I didn't think it was a great one for that. Okay. Next 17-year-old high school travel team pitcher with a history of right shoulder internal rotation deficit who had a previous outside posterior capsule release two years earlier. Previous intermittent elbow symptoms in the game through a curve ball, felt a pop, wild pitch, unable to continue. Positive everything on exam. His shoulder total arc of motion was 20 degrees shy of his non-throwing arm and reports that his shoulder motion was no better than before his prior capsular release. These are his x-rays, which are fairly unremarkable. We got an MRI with intraarticular contrast, which shows this. And so to Neil's point, this is an acute injury, so it's sometimes, you know, more difficult to see the periligamentous edema. But what are your thoughts on this and where do we go from there? You get a little blush down at the bottom that I don't think is contrast. I think that is some edema in the deep muscle bed adjacent to the distal ligament. And you don't really see a good or well organized ligament, do you? You don't. His ligament doesn't look very good. This kind of a kid at this age, this one, hold on to your hat because these are hard because his shoulder is an issue. His mechanics are an issue. He's nowhere near, he doesn't know how to pitch yet. And he probably has the ability to throw it in the mid-90s. I see kids like this come in all the time and I tell their parents, I said, look, you know, your kid has a Ferrari motor and a Pinto suspension. And I'm going to fix him. He can throw it in the mid-90s as a sophomore in high school. But his shoulder is a mess and everything. So it takes a lot of work on this nonoperative work before or after a surgery like this, you know. So, you know, standard fare list of options here. In the interest of getting to more cases, I'll tell you that we did take him, we did think that was a tear and he did turn out to have a complete distal tear. You can see in the middle slide I've got an elevator up under that flap on the sublime tubercle. So we did a repair. You can see the repair on the far right picture. We did the repair with the internal brace. My thoughts on this, and I put this up because I wanted to highlight the nature of the shoulder thing. And I think anybody that does UCL surgery or looks at throwers, you must look at the shoulder. And that internal rotation deficit like Neil and Dr. Andrews, I see this and the fellows will tell you, I would bet half of the people that come in with elbow injuries have some kind of a shoulder rotational deficit. Dr. Andrews, do you think we're seeing more of that? Is that a weight room phenomenon? Is it not paying enough attention to flexibility? Why are we seeing so much shoulder stuff with this? We know the causes. We know what that does to the elbow. I think that there's so much emphasis now on internal rotation deficit that most of the ones I see have already been working on getting their motion back in their shoulder. But by the time I see them for something. So I don't think it's, I think it's probably better than it used to be. But I don't know that for a fact. The kind of motion loss you're talking about, though, Jeff, is dangerous. Because that's a total arc loss. And those kids have an external rotation loss, too. They do. Typically you'll look at their MRI scan and it's what Jimmy first noted with these, we got the epidemic of these young Tommy Johns about ten years ago that the chickens were coming home to roost from year-round baseball when you're 11, 12 years old. And that's in the growth years. And so it not only affects the elbow, but you get poster glenoid dysplasia, you get thickening of the chondrocaps labral junction posteriorly. So you get this big non-ossified, what you might want to call a Bennett's lesion in the back. And so you get a deficiency of bone, a bony glenoid, but you get the big wedge of hard, fibrous stuff. And so they can't rotate. The capsule becomes very thick. And it's a constellation of syndrome that they're taking up motion with their scapular thoracic joint. And it's just, it's a real problem to manage before and after surgery like this. But it can be done. I know a lot of guys that get through it. But it takes real thoughtful approach to the therapy. So do you recommend, so as part of their rehab for their UCL, are you recommending that they do shoulder rehab too? Is this the reason where people say, oh, if I get a UCL surgery done, I'm going to be a better pitcher? Most of the time when you rehab the elbow, you're rehabbing the shoulder. I'm more worried about this kid's shoulder coming back than I am about his elbow. And what he's talking about is what Kevin Wilk showed us. If you had a five degree or more loss of total range of motion, you had an increased chance of having elbow problems. So it's the total arc that you're worried about. By the way, if you have a kid in high school has his shoulder and his elbow both having to be operated on in high school, I looked those statistics up. The success of having two operations, both shoulder and elbow in high school, is dismal. Believe me, I can't remember the exact percentages, but that's too much surgery, too much whatever, not a good enough player, not meant to be a baseball player. And that's just a kiss of death. All right. This actually came into my office on Wednesday. So I created this one yesterday because I want input. So this is a college freshman, pitcher only, never had real elbow problems. And he came in with that. And so, you know, he comes in and he's got an MRI in his hand. And this is the MRI. So he has this fracture of this gigantic enthesophyte. Is he symptomatic? He is now. It was a one pitch injury, right? It was a one pitch injury. He popped it. He's bruised. He's a 20 year old freshman in college. Pitcher only. Never had elbow problems. So I mean, I know historically what we've done for this is take out the piece and do a hamstring, do a larger piece of tissue. Is there any role for putting a piece of thin tissue as a capsule? Because he's not even going to have a joint capsule once we take that out. You're just going to have graft intraticularly, I would think. What is the role for doing a multilayer procedure here, using some small anchors and creating a capsule versus just putting a big piece of tendon graft when you take that out? I don't know that ORIF is great, but. I think Neil would agree with me that the percentage of success with that particular problem surgically is not as high as you would expect. But what I've been able to do is to carefully peel the periosteum off of that fragment, peel it back in two layers, take the bone out, and then lay that back down over the joint itself. And then you at least get a little coverage. I've never used any kind of capsular. Yeah, I haven't either. I haven't been able to do that. Yeah. First of all, that's not normal bone. So you never want to try to fix it. You're going to open it. Like Jimmy said, that's not going to be a void above that piece. The few millimeters you have above the osteophyte and the humerus, there's going to be tissue there. And there's going to be dense periosteum covering that fragment. So what I would do is exactly what Jimmy said, and then you're going to have the part that's still there, the part that's coming off of the normal sublime tubercle, that's going to be hypertrophic. And so what I would do with that is I wouldn't trim that down any further, because then you don't want to get into the situation that you were talking about where you have a big void. What I've done is I take a ronjour and I chew a little trough from the anterior band of the reconstructive graft to sit in, and a little trough for the posterior band so that it's not so non-anatomic. It sits right in line how you want it. Create a track for it. Yeah, create a track for it right there. And then you have that periosteum that you preserved that Jimmy was saying, and you sort of make a graft sandwich with the tissue that's there in your graft. Yeah, would you add a piece of tape to that? Well, you know, what I would do is I would do a three-stranded graft, either with a palmaris or a hamstring, and so pull up the anterior band as one free limb, and then the other limb, pull up the folded end of the other limb and pull that up into the epicondyle, and then that third limb, bring it back down. So you'd have a lot of tissue. Yeah, yeah. I don't think I would. Definitely use a hamstring, though. Definitely. By the way, Neil knows the case, too. Sometimes you'll see bone like this where it almost touches. They haven't fractured through it, and you can treat them non-operative. We've got a kid that's, what, 10 years in the majors and two big contracts. You and I both saw him in Las Vegas together. That's right. And he's still playing. We haven't touched him yet. You should see his x-ray. It's amazing. So you don't just necessarily see that and start operating on it, believe me. Did that player have a problem, or was he just had a bad accident? He got sore a little bit, and they were all worried about him because they had just given him a big contract. Mainly Neil and I reassured him, and I'm still following him on a yearly basis. He hasn't had any more trouble. Well, I'm going to say thanks, as always. It's great to see you guys. Thank you for the time. Thank you very much. Appreciate it, everybody. Thanks, guys. Great job, Jim. Thanks. To conclude the session is Scott Rodia, who's going to talk to us about biologics in the UCL. Thank you. So, quick review on biologics. Here's your role in the management of the UCL in the elbow here. So your disclosures here. So any discussion in this area of biologics, you start by asking yourself, you know, what are the biologic targets? What is it that we are really trying to treat here? Do we want to just treat pain, or do we want to, in fact, truly stimulate tissue healing and maybe lead to some type of tissue regeneration? So, in thinking through what I want to do with the biologics for that, cells, PRP, some other autologous blood-based formulation, there's a number of targets we can consider. And this is relevant because this may help us choose the right treatment for that particular pathology. So do we want to simply stimulate new matrix formation? Perhaps we want to accelerate matrix remodeling, improve vascularity, increase cellularity, cell migration. Maybe we want to decrease inflammation. Perhaps just decrease pain mediators. These are all important goals, but they're all different. And until we identify what we're trying to treat, it's hard to really choose the ideal or optimal treatment for a given pathology. Now, in this setting, for the LBO8 UCL, if you're doing a surgical reconstruction, do you want to augment graft healing in the tunnel or the graft-mid substance? I think the desired biologic target will also certainly differ if you're doing UCL repair versus reconstruction versus, of course, non-operative treatment. So where are we in this whole field? So we'll talk a bit about PRP and other autologous blood-based products. You know, the general consensus at this time is that all these treatments can be symptom-modifying, but really very little data to suggest that they are in any way structure-modifying, that is, as far as regenerating any functional tissue. Different options, of course, that are available to us today. Obviously, PRP and different formulations are available. One point I would make here, too, is that this dichotomy of leukocyte-rich versus leukocyte-poor, it's important, but it's only a place to start. We need a much more refined, nuanced evaluation of PRP. What's more important is probably the type of white cells, the ratio of platelets to white cells, the absolute number of platelets. So, again, you could have one other lecture just on the details related to PRP. There are other autologous blood-based products, though, as well. Obviously, the ACP, which is a leukocyte-reduced formulation. Autologous Condition Serum, ACS, the so-called orthokine or regenokine in this country, not FDA-approved, but is being used. Alpha-2-macroglobulin, this is a particular peptide that is a broad-spectrum MMP inhibitor. It can also be concentrated from peripheral blood. So all of these products are out there. They're available, and there's something being developed now, Autologous Protein Solution, another two-stage technique on autologous blood. It essentially concentrates IL-1 receptor antagonists. So, again, these are all potential options available for us. And the current data suggests that all of these different formulations have anti-inflammatory and probably immune-modulating activity, and as such, they may help pain. So back to your athletes you're treating, you're just seeing those last cases there, maybe these things do help pain. Does PRP lead to true tissue healing? Start with inflammation. That is such a fundamental process in any connective tissue repair, and modulation or manipulation of the inflammatory process will certainly have an important role in the injured ligament. However, inflammation is also very, very complex. It's an evolving process in the injured joint or the post-surgical joint, with different cell types that are present at different points during the healing process. And we really have very little data to suggest functional tissue regeneration following PRP injection. So what is the evidence? What is the clinical evidence in this area? One of the earliest studies is this group, this is by Lou Yochum's series of patients about nine years ago, 34 patients, partial thickness, UCLA tears. He used a leukocyte-rich formulation, and they used ultrasound to measure opening the medial joint to try to get a sense of valgus loading and opening. So they find positive outcomes based on standard outcome measures here, and these were significant differences. They found the medial elbow joint space opening with valgus stress did decrease in the treated players, interestingly, with their ultrasound. Average time to return to play, about three months, 12 weeks here. So overall, positive data here. Moving forward a couple years later, this is Buddy Savoie's group. Also partial, only cladoligament injuries. These are all case series here. These athletes were kind of standard rehab, bracing rehab therapy, and he used two injections of a leukocyte-rich PRP. And the majority of these patients demonstrated stability of the ligament and returned to play at the same or even higher level. So positive outcomes here. In fact, in this series, they thought MRI demonstrated reconstitutional ligament in all of their patients. This is some pictures from their, one particular figure from their article where they thought the post-treatment MR demonstrated some reconstitution or healing, if you will, of the ligament. They did report this was less effective in patients who had previous repair or reconstruction, as we might expect. But overall, again, positive data here. This is a group from Japan, 30 players, five of these were professional. And what they did here is they trephinated, you know, needled the ligament, and then they used a leukocyte-reduced formulation, different than the prior two studies. They also used ultrasound to look at, with valgus stress, to look at opening the medial joint there. And they reported improvements in the standard outcome scores, graphically seen there. And the majority of these athletes returned to sport at their pre-injury level. Average time, 12 weeks here, kind of similar to the other ones. Average joint space opening did decrease from 3.8 to 3.5 millimeters, and they found that was significant here. Better results for proximal tears, and some of the other theories have kind of shown that as a principle you'll see throughout here. An important limitation here, there's no group with just a trephination, so that needling may certainly turn on the biology. So hard to make any real conclusions here. Clearly positive effects, but we're not sure if it's the PRP, trephination, maybe both. And more recently, just last year, this is Jimmy Andrews' group here, 50 patients, and these were treated with, so he had low grade and higher grade partials and completes, so kind of all comers here. A leukocyte-rich PRP formulation was used in these athletes, and here's what they found. So the first line there, about 60 percent with partials. Type one and type two are partials, and you see kind of smaller numbers in the complete tears. Some of those complete tears, in fact, interestingly, did get back to play. Ten patients required a second injection, and of those, only 30 percent got back. So if you, you know, if you fail that first injection, you do a repeat, you're probably in a tougher group there. But they concluded that PRP treatment probably does not appear to be appropriate for complete tears, that type four of those completes, but may enhance recovery, improve outcomes with partials. So some positive data here, again, for partial injuries. If you look at larger databases, this is some work from Michael Ciccotti, who's a co-author, and Jan Afronik from Major League Baseball here. So this is their injury tracking system. 544 players with elbow UCL injuries. 133 had PRP, 411 did not. Mixed group. Overall, PRP did not improve return to play outcomes or ligament survivorship, and if you actually look at their Kaplan-Meier curve here, the blue is your PRP group, but they found players who received PRP had a longer delay in return to throwing. It's actually a little worse, interestingly, in the PRP group. MRI grade and tear location did not really affect return to play outcomes or progression to surgery. This is just a picture from their paper demonstrating, you know, looking at location of the tear, whether it's proximal or distal. Real limitations of these big databases. There's obviously tremendous variability with respect to the PRP formulations used, different injection protocols, dosing, timing. Rehab obviously is not standardized, and this can be said for a lot of this PRP and other biologic literature, we clearly need better reporting. But overall here, not really in favor. And lastly, a literature review here, where based on their criteria, they can only include three studies that really met their criteria here, and all were just kind of lower level evidence, level four evidence here. But they concluded, quote here, athletes whose treatment included PRP showed higher return to competition rates and shorter recovery times compared with athletes treated just with rehab alone. But again, low level data. This is unfortunately the status of our literature here. So again, it does make it a bit difficult to draw real firm conclusions from some of these, what are limited analyses right now. Similar to studies of PRP in many tissues, there is obviously tremendous heterogeneity in these outcomes, as seen here. We need better studies. We need in vivo studies. Maybe animal studies can help, but we clearly need our clinical studies. We need to collect the appropriate clinical data. We need to identify what is the appropriate dose? What's the appropriate timing? What type of PRP formulation? How do we rehab these patients? And that's why, back to that earlier idea of identifying the biologic targets, only then can we decide what's the optimal formulation, how much, when, all those important questions. So a lot of outstanding questions in this whole area. Again, back to the issue, can we actually heal tissue? Can we regenerate tissue? There's obviously nothing in the UCL in the elbow. This is one study I put in. It's a nicely done study from Bob LaPrade. It's a rabbit MCL model. So it's an MCL, but in the knee. It's the Cabot Award from the American Journal of Sports Medicine. But it's relevant, I think. And he went ahead and made these MCL injuries in knees in the rabbits and traded them with either a platelet-poor plasma, so no platelets, or PRP at two different doses. And essentially, they found one single dose of either platelet-poor or PRP did not improve ligament healing, did not have a positive effect. In fact, at the higher dose, the 4X PRP negatively affected ligament strength and histology. It's at six weeks post-injury, just some of their histology scores they quantified. So both platelet-poor and the higher dose PRP had lower sub-scores histologically. And importantly, failure load and stiffness was also lower in that group treated with the higher dose. What they conclude here is that high doses of PRP actually decreases the mechanical properties and quality of repair tissue. So again, a lot of outstanding questions in this area. Lastly, a little bit on cell therapy. We can use cells from obviously a number of different sources that are available to us. And kind of where is the field today? So a couple of summary thoughts for you. First, I would submit to you that the minimally manipulated preparations that are currently used in our country clearly need to be distinguished from sorted, culture-expanded cells produced in the laboratory. Those are very, very different populations. So these are regulated under this section 361. And the relevant factor there for us is that these formulations can only undergo minimal manipulation. So we can't take our lipo-aspirate or bone-aspirate out and do cell sorting or culture expansion. That's very different than laboratory-produced cells, which are selected with cell sorting, culture-expanded for the ideal population that you want. So understand that the cell populations that you and I use clinically are really poorly characterized and tremendously heterogeneous. And in fact, by any criteria, the number of stem cells is frankly vanishingly small. In fact, the term stem cell should not even be used when discussing current techniques related to cell therapy. Understand that adult tissues contain essentially zero stem cells by any cellular or molecular criteria. I would submit to you the use of the term stem cell in our literature related to these type of things is misleading scientifically and therapeutically. A better term would be connective tissue progenitor cell. These are cells that are resident in many tissues. It can, in fact, proliferate and generate progeny with some capacity to differentiate into various cell types, but it's a more restricted differentiation potential. And this is the agreed-upon term to kind of refer to these cells that we can harvest from adipose or bone marrow or other sources. And you can measure these connective tissue progenitors by culturing it and measuring colony forming units and cultures. These are standard ways that ideally we start to use these techniques to measure what it is we're putting in our patients. We can ultimately correlate what I put in the patient with their clinical or their imaging outcome. So what options are available to us as clinicians today? Well, obviously we can derive, we can use bone marrow for mesenchymal stromal cells. The S is stromal, not stem. Adipose tissue, we can essentially use so-called microfragmented tissue. That's like the lipogems. And I have no relationship with any of these companies at all here. Distinguish this microfat, this microfragmented fat that is used. Distinguish that from both stromal vascular fraction and adipose-derived cells. And not to get into too much detail, but since all these terms are out there, the stromal vascular fraction requires enzymatic digestion. We can't do that. FDA doesn't allow it. And that results into a heterogeneous mix of cells. But this is not something you and I can do routinely right now without an IND. Similarly, adipose-derived cells, that's a cultured cell. Also not used in this country. So if using adipose right now, it's going to be at most mechanical emulsification. Cells derived from various perinatal tissues have, of course, been used. Derived from umbilical cord bloods, amniotic fluid, amniotic membrane, placenta, all these different tissues. A number of studies, independent studies, demonstrate that, in fact, the majority of these perinatal preparations that are commercially available have very few or no viable cells, in fact. Now, they do contain various anti-inflammatory mediators, immune modulating cytokines. What happens, these are all marketed, though, on the presumption that their activity was due to cell activity and viable cells. And so as of May 31st of last year, all of these perinatal products can only be used in a clinical trial under an investigation of a new drug, an IND. So if you've used these in the past, you can't use them now unless the patient is in the clinical trial and the FDA is starting to really scrutinize practices around the country. If we use cells, can that lead to true tissue healing? We talked about PRP, what about cells? Does that induce healing? Probably similar to PRP and other autologous blood products, the current data suggests that cells clearly produce signaling molecules that clearly have an anti-inflammatory and, again, immune modulating effect, but really very little data to suggest any structure-modifying effect. That is, true tissue healing or regeneration, very little data to support that that can occur, and certainly very little or none related to the L-bone and the UCL. There's little data to suggest that these cells, in fact, even engraft. Cells we inject probably work via a paraquin manner by stimulating either other local or maybe distant cells. Implanted cells may well improve tissue healing, but probably by modifying the local biologic environment via signaling molecules that are produced by implanted cells. So lastly, what should we use today for the ulnar clavicle ligament in the elbow? For Jeff's case, the data showed you there. I think the data and the clinical experience suggests that PRP seems reasonable to improve pain in the conservative treatment. Partial tears make the most sense. Maybe you can combine it with trephination. I think the goal of any of these things is to sort of make a chronic process acute for the non-operative treatment. You're going to turn on the biology. Needling may do that. It appears that a leukocyte-rich preparation will be most appropriate. PRP seems more predictable for proximal tears. Inconclusive whether PRP or cell injection will lead to true tissue regeneration or improvement in structural healing. Very little data on cell therapy approaches and ligament at this time. Just practically speaking, bone marrow and liporaspiration, you know, there's real challenges to doing that in the clinic. So non-operative treatment, those aren't trivial to do in your office or clinic. And lastly, there is a lot of work going on in this area. Identifying purified cytokines, gene-modified cells, novel small peptides that really do hold promise for improving connective tissue healing and biology. Thank you. Are there any questions for Scott? I love being around smart people. You didn't fool anybody. That's amazing. Any questions for Scott before we move on? I feel like I have more questions than answers. No, I think that's great. All right. We'll thank you, Scott. Good afternoon. I'm Brett Owens. I'm very proud to be here with Eric Carson. We have 30 minutes to quickly go through the meniscus. We have two meniscal papers and then we have Rob Brophy who's going to give us his approach to root repair and transplantation. The first paper up is Optimal Tibial Tunnel Placement for Medial and Lateral Meniscal Root Repair in the Setting of Multi-Leg Reconstruction of the Knee. Safa Gursi from Rush. Thank you. Good afternoon. Sorry for the delay. I'm going to present our study in which we define the optimal tunnel placement. Great. For medial and lateral meniscal root repair in the setting of ACL and PCR reconstructions. Water disclosures can be found online. So the root tears are quite common among all meniscus tears. And we need to repair those tears to restore the knee mechanics. Otherwise root repair is almost equal to a meniscectomy. So lateral root tears are commonly associated with ACL tears while the medial ones are commonly seen in nature but also they can be seen with multiple injuries and the particle with the PCL as well. Although there are anatomical landmarks on the tibial plateau have already been described, there is no definition regarding to their entry points on the anteromedial tibia when creating a tunnel for a trans-tibial pull-out technique. Due to the limited bone mass in the proximal tibia and the instance of combined injuries can be seen with the root tears lead to increases called tunnel conversions. So in the study our purpose was to define the optimal tunnel placement for root tears in the setting of ACL and PCR reconstructions. Actually the study idea came from a clinical problem. We were initially creating our root tunnels above the ACL tunnel. Then we observed some tunnel conversion between the ACL and root tunnels. Then we hypothesized that if we create our root tunnels as they will be parallel to ACL tunnel in sagittal plane, we may avoid conversions. But the knee reorientation may bring the root tunnels closer to PCL entry. So we included the PCL in the study as well. So in this study we used the CT scans of 20 knee cadaveric knees. We segmented them on mimics software to create a three dimensional tibia shape. Then the entry and exit points were defined on geomagic software and the final tunnels were created and reoriented on MATLAB by writing some codes. So we determined the exit points on the tibial plateau based on their anatomical landmarks have already been described in previous four lab parts paper. So here are the attachments of the medial and lateral roots. Here is the ACL, PCL, PCL again from a posterior view as it should be 5.5 millimeter above the champagne glass drop off line. So regarding to their entry points on the intermedial tibia, only the PCL entry point has been described previously in the literature as it should be 6 centimeter distal to joint line to reach the 5.5 millimeter above the champagne glass drop off line without penetrating the posterior wall. ACL entry was determined by the senior author as he usually creates in his clinical setting. So for the root tunnels, the single tunnel and double tunnel techniques were created and analyzed separately for single and double tunnel techniques. For the single tunnel, each tunnel was 3.5 millimeter. For the double tunnel technique, each tunnel was 2.8 millimeter with a 5 millimeter distance between each other. But there was no definition regarding those two tunnels should be vertical, horizontal or oblique. So we assumed that those two tunnels should be in a circle of 10.6 millimeter in diameter in total. Then the root tunnels that had been initially created above the ACL were reoriented as they will be parallel to ACL in sagittal plane. Less than 2 millimeter distance defined as a tunnel convergence and the prior power analysis demonstrated adequate power in the study. In the initial tunnel configuration in which the root entries and root tunnel entries were above the ACL, we observed tunnel convergence between the ACL and lateral root tunnels in 20 out of 20 specimen. It was similar in double tunnel technique while the differences between the tunnels were slightly lower. In the reoriented tunnel configuration where we make the tunnels, the root and the ACL tunnels parallel to each other, all those tunnel convergence between the ACL and root tunnels that we observed in the initial configuration were solved. However, in the reorientation since we moved our root tunnels closer to PCL entry, there was another convergence occurred between the PCL and medial root tunnels in double tunnel technique in two out of 20 specimen. Here you can also see our tunnel configuration in an axial view. So in this study, the entry points of the root tunnels appear somewhere between the ACL and PCL entry points. This table is also ranking and summarizing the favorable tunnel configuration with repair techniques based on the greater distance between tunnels. Also the orange highlights are indicating the ones we observed at least one tunnel convergence. So in this study, there was no convergence occurred between the ACL and root tunnels when we make them parallel in sagittal plane. Since the reorientation brings the root tunnels closer to PCL entry, double tunnel technique may require some extra caution. There are two musts to make the study work. First, you should follow the anatomical landmarks on the tibial plateau. The second, you may need to create your ACL starting point just a bit slightly closer to tibial crest instead of going too much posterior medial to provide less than 65 degree angle in sagittal plane for ACL tunnel. Once you have done those, since the exit points on the tibial plateau are different, the entry points on the intermedial tibia will be at different locations without any tunnel convergence. Thank you for your patience. All right. If we could bring up the next talk, please. Kevin Plancher talking on the treatment of lateral meniscal tears influences OA rates following ACL reconstruction at nine-year follow-up. Good afternoon. I'm Kevin Plancher. I want to thank President Spindler and Rick Wright and everyone for allowing us in the program committee to share our thoughts on lateral meniscus tears in osteoarthritis. I have nothing to disclose or ownership here. As we know, meniscal injuries are common. You heard in acute ACLs more often than not, it's the lateral meniscus that's frequently torn and it's on the medial side for a chronic ACL. But clearly there is a strong predictor we know of osteoarthritis development with patients with meniscal tears more so than just ACLs. And 50%, as it says, develop osteoarthritis unfortunately 10 to 20 years after these ACL combination meniscal diagnoses. Meniscal repair and ACL repairs improve meniscal healing has been seen in many studies. And we can show improved knee functional outcomes with higher IKDCs and Tegner scores. But the unanswered question is does the risk of OA occur and differ with ACL plus meniscectomy or ACL and a repair and especially on the lateral side. So we wanted to look at the incidence and the risk of osteoarthritis long term in patients after ACL reconstruction and to determine whether the influence of the lateral meniscus repair versus a partial lateral meniscectomy would alter outcomes. 107 patients with acute ACL reconstruction at that time looking with medial or lateral meniscus tears, a consecutive series was done where there was autograph or allograph of a bone we excluded as it says revision ACLs or multi-leg injuries. Preoperatively you saw standard AP weight bearing views. We looked at the alignment that was seen in the tibial femoral angle measurement. We looked at the operative reports back in the arthroscopic examination. We looked specifically at the videos. Everyone had a video. And besides the operative report to look at the partial lateral meniscectomy or a lateral meniscus tear, some all inside, some with an inside out technique. We classified postoperatively the radiographic evaluation with a KLOA classification system looking specifically at grade 3s seen here with the space and the sclerosis or a grade 4 for severe arthritis and categorized the joint space as normal 2 to 4 or less than 2 millimeters. We did our statistical analysis as seen here for the analysis of variance and the chi squared and looked again. 107 patients, 55 males, 52 females, the average age slightly older. This is not a group of 17 and 18-year-olds. At 36 no significant difference was seen in the evidence of how many partial meniscectomies versus repair nor the presence of osteoarthritis versus no osteoarthritis which allowed us to get rid of the fact that as you get older you get more arthritis and that was able to be excluded. The average follow-up was about 12 years as you know with a mean of 9 and no significant difference at that follow-up but an older age group at follow-up of 47 years of age. Here you can see the variation in preoperative alignment from about 5 degrees of varus to 5 degrees of valgus and the pathology here, the lateral tears with 60% of the patients having it and 50% of the patients having a medial tear. Specifically postoperatively in osteoarthritis and meniscal tears in the lateral compartment we saw overall 15% of the patients did develop osteoarthritis in that KL3 and 4. With a lateral meniscus tear we saw and without a lateral meniscus tear only 4.7%. We did see in the lateral meniscus tear 4.7 as it says times more likely to develop OA than if you don't have a lateral meniscus tear and two times more likely to develop OA than if you have a medial meniscus tear. Specifically for repair versus partial meniscectomy you can see small series in numbers. 13 patients had a lateral meniscus repair and none developed osteoarthritis, 11 all inside, 2 inside out and the 51 patients that did have meniscectomy at a high rate of 27% developed osteoarthritis at that mean 9 years. Significantly decreased incidence of OA with lateral meniscus repair compared to partial lateral meniscectomy seen here. So in conclusion saying ACL tears with meniscus injuries are common. Over 50% of patients have it. Lateral meniscus tears, greater postoperative osteoarthritis 4.7 times more likely than a lateral meniscus tear seen than without it. And in partial meniscectomy an increased incidence of osteoarthritis versus meniscus repair. None in the repairs. 27 or so percent with the partial lateral meniscectomies. I don't have good answers but I will say today that we're learning in the lateral side. Please save and attempt to repair a lateral meniscus. Thank you. presentation will be done by Rob Rothi. He'll be looking at root versus transplant. Thanks for the invitation to speak today. I'm not aware of any conflicts of interest. Meniscus root tears are defined as tears occurring at the posterior horn attachment of the meniscus to the tibial plateau. We can think of these as bony or soft tissue avulsion injuries at the meniscal attachment itself or radial tears of the meniscus typically within a centimeter of the insertion. As we heard earlier, these tears result in a loss of hoop stresses which causes biomechanical effects that approach that of a total meniscectomy with 25% increase in peak contact pressures as compared to these with intact menisci. We do think of these typically as being different injuries on the medial meniscus which tend to occur in older patients. They're usually degenerative injuries, usually lower energy injuries or no history of an injury whereas lateral root tears as we heard earlier tend to occur in younger patients. They're traumatic and almost always in conjunction with ACL tears. Resection of these tears may have reasonable clinical outcomes but it does not do the knee a favor in the long term as there's significant progression of OA and need for knee replacement following resection of root tears. So there is growing interest in fixing these tears. There are factors associated with outcomes in particular advanced degeneration in the compartment of the tear is not associated with good outcomes nor is malalignment. There's some conflicting data regarding patient age and elevated BMIs associated with worse outcomes as well. Nevertheless a recent meta-analysis showed that these tears do have the potential to reduce the rate of osteoarthritis in the knee and are a cost effective treatment. Repair technique has been well described. Both using sutures as well as trans-tibial pull out repairs as we saw earlier may use one or two tunnels and a variety of suture configurations to reattach the meniscus to the tibia. Typically you'll need to identify the tear and confirm that the compartment looks to be in reasonable shape. You will then drill your one or two tunnels often using some sort of retro drill to take down some of the cartilage and bone at the top of the tunnel. You'll then want to use one of a variety of instruments to pass sutures and get control of that posterior root. It may be a little challenging in terms of placing the suture and making sure you have a good bite of meniscus that will not pull out without moving too far away from the root itself. Once you have the sutures then you'll typically retrieve the sutures through the tunnel and secure them over the front of the tibia in order to secure the meniscus back onto the tibia. In terms of outcomes there's been multiple studies that show there are improved outcomes when you repair these tears compared to resection. There is growing evidence that there's less osteoarthritis over time. A very nice recent study in ADSM showed a significant drop off in progression of OA and the need for future knee replacement with repair compared to non-operative treatment or resection. So clearly there's growing evidence that they have some benefit in the short term. We did a recent review of midterm outcomes that was published in ADSM with almost 1,000 patients, most of which were female with a mean age approaching 60 with reasonable clinical and radiographic follow-up using a variety of outcome measures. All of the studies showed clinical improvement at final midterm follow-up. About half of patients did have at least one grade of radiographic progression at a mean follow-up of four years. About one in four had progression of cartilage damage on MRI at about two and a half year follow-up. And only 5% of patients had progressed to total knee arthroplasty, which if you remember was at about six year follow-up. There was another recent systematic review in OJSM looking at outcomes of lateral meniscus root repair. This group was shifted more towards male patients, had a much younger mean age of under 30. There was both side-to-side repairs and pull-out repairs in this group, all of which occurred with concomitant ACL reconstruction. And there was a mean follow-up of almost three years. All of these studies again showed clinical improvement. There was no radiographic narrowing in this cohort. No change in chondral damage or extrusion on patients with MRI follow-up and very good healing in those with arthroscopic follow-up. Another very good study compared medial and lateral root tears and this nicely summarizes the difference. The medial tears occur in older patients in their 50s typically compared to 20s. They're heavier. They tend to involve more females than males. They tend to have knees that are already starting to degenerate and they do have a higher rate of meniscal extrusion compared to the lateral side. Whereas the lateral tears are much more likely to be associated with ligamentous injuries and they're much more likely to be repaired at the time of surgery. This study did show better outcomes with repairs on the lateral side, but those may be due to differences in patient characteristics as well as the tear pattern and the treatment because of these differences between the types of patients that have these tears. So in summary, we're seeing these root tears more commonly. We're studying them. There are distinct differences between those on the medial and lateral side of the knee. We do want to consider repair on appropriately indicated patients as repair has better midterm outcomes and there's more to come in terms of long-term outcomes about how these patients do. Now I have a little bit of time to briefly just update meniscus transplant. Again, an optimal treatment for patients with meniscal deficiency and pain. There are well-described techniques using a bone trough or keyhole, bone plugs or soft tissue suture fixation only. I'm just going to briefly have time to touch on a few updates in terms of who are the ideal patients, how these techniques perform, rehabilitation, return to activity and survivorship. So the proper patient really should have a nonfunctional meniscus after previous surgical treatment. Typically younger patients do better. They need a correctable or intact alignment, ligaments and articular cartilage. On the younger side of things, it's preferable to have patients with closed feces and the patients need to be able and willing to participate in rehab. Evidence of frank arthritis, elevated BMI and inflammatory arthritis are contraindications. A recent meta-analysis of fixation technique for transplants showed good clinical outcomes as well as relatively low tear and failure rates at mean five-year follow-up. There were no significant differences between soft tissue suture fixation and bone fixation in these studies. So tear rates, failure rates, clinical outcomes and extrusion were all fairly similar whether either of these techniques were being used. In terms of rehabilitation, there was a recent review that was focused on return to sport but reported what were the rehabilitation approaches in these studies. Most studies, 70 percent started range of motion within the first week of surgery. Again, at least 40 percent allowed full range of motion by eight weeks, some allowed earlier and a few later. Partial weight bearing was most commonly allowed by the fourth week with two-thirds of studies allowing full weight bearing by six weeks after a meniscus allograft transplantation. In terms of return to activity, there have been a couple of recent good studies. Both of these studies showed return to sport at close to 80 percent with close to 70 percent at the same level or better as prior to a meniscus transplant. It was usually around nine months after surgery. Soccer, swimming and running were the most common activities in one of these studies. Another recent review of almost 2,000 patients again showed a 75 percent return to sport. This was a little later, about a year out after surgery, although only half got back to baseline and almost 90 percent discontinued at least one activity and over 90 percent were restricted to just recreational activity. Another study looking at the active military showed only 20 percent had returned to full duty at two years after meniscal allograft. Another recent study showed a much more variable return to sport after surgery with a delayed return and a wide range in terms of getting back to pre-injury level. Recent studies have shown good ten-year survivorship in the 70 to 80 percent. One recent study showed slightly better survival and clinical outcomes with allografts on the lateral side compared to the medial side. And there was a nice recent systematic review of almost 2,000 patients looking at factors associated with survivorship. Severe cartilage damage was strongly associated with poor survivorship. Number of patient and concomitant procedures did not show a big impact on survivorship. And there was conflicting evidence, but at least some evidence that older patients and patients with kissing cartilage lesions do not have as good survivorship after meniscus allograft. So meniscus transplants are a good option in properly indicated patients. There are a number of widely accepted and described techniques. There's emerging data on return to activity and survivorship. And I think, as we heard a little bit earlier, it's ideal to preserve, repair, or replace the meniscus when possible and appropriate, because it does matter. Thank you. Nice job. Thank you, Rob. We do have a few questions, time for some questions, so please come to the podium if you'd like. Jeff. Thank you, Kevin. I thought your study was great. Did you look at all lateral meniscus tears that you just left alone, that you didn't do a meniscectomy or repair? So I admit that we didn't leave. They either were meniscectomy with a partial to some extent, and we did classify them all types and all cumbersome lateral, but none were left alone. Thank you. Kevin, I'll follow up. That was a series of 100 patients over around 20 years. Would you say that there was an evolution in your practice at all, either with the ACL reconstruction or with your approach to lateral meniscus tears? And would you say as your results, you're more aggressive now? You kind of alluded to that at the end. I think it's a very fair statement. I started out in life, my training was from Colorado, so it was the repair technique, but I think I am much more cognizant that I started to see as they came back, my patients, I wasn't so pleased with the narrowing of the joint line in younger patients, and these are not that young. These are 35 years going on to 46 years. And so I've become very much more aggressive to try, and I do explain that it may fail, and you may have to come back to take things out, but we've been pretty successful with the lateral meniscus tear. I think it takes a little time and practice, at least in my hands it did, to become more facile on the lateral side, whether it's in front of the popliteus or behind it. And I think, yes, and I think I say it, my ACL probably 20 years ago was not nearly as good as my ACL is today. That's why we learned. Dr. Garasso, a question for you. This is a 3D kind of modeling study. Has this been kind of translated anatomically to look at it? Because my question is the size of the tibia approximately, and those types of patients going to be doing like a smaller tibia, or do they run out of real estate? Yeah, definitely. We tried that in our, we changed this, tried and changed our previous initial tunnel configuration in our clinical setting, and personally I can say that it works. But also the one previous study has been just published on ASMR, and they tried, they put their root tunnel entries between the ACL and PCL, but without defining any angular base configuration or definition. They also showed that if you place your tunnels between the ACL and PCL, and they did this study on the cadaver models, like the real human specimens, and they also showed that there's no convergence if you put between the ACL and PCL. Excellent. Thank you. And for Rob, you know, obviously with root repairs as we've gone along, I mean, this is changing on a day-to-day basis with our indications initially starting off with like really young patients. What, where do you think we're migrating towards now as we're going forward now, where it seems like a lot of us are pushing the indications? And I think that is the biggest challenge. There's no doubt that repairing these in the right setting has great benefit, but there is a slippery slope in terms of where there may not be much benefit. I think that's where a lot more needs to be followed in terms of what factors really should guide you away from being aggressive. I mean, we know the advanced degeneration. I think the question is age and BMI, where are the cutoffs and where does that really, you know, say you may be trying, you may be throwing more of a hail Mary than a predictable treatment. So do you have a cutoff now for either age or BMI or do you want to plead the fifth? No, no, no. I mean, I think BMI clearly is, you know, very, I mean, the interesting thing for us, remember from our series, so the patients above 35 did poorly, yet we had one patient who lost 150 pounds after surgery, had the best clinical outcome and did great, who was over 35. So, you know, you do have to use selection, but I do think heavier patients are going to be a much less likely to do well. I do think the chondrosis is you get advanced chondrosis, just forget it. The age I think is more relative. You know, there is, there can be a very active, somebody in their 50s who's running and has an intact normal knee and a great healthy BMI may want to get a repair to try to keep doing what they're doing. And last but not least, the excursion of the excreted meniscus. What's your thought process on that? Well, and I think that's one of the big areas of evolution in terms of some of the thought about, you know, the tibial meniscal ligament and some things that go along with that. So I think that's an area that we do need to learn more about and figure out how to address that properly. So as everyone comes on in, come on in and take a seat. We're going to get started with our second knee session here. We'll start with introducing our speakers. I'm Latul Farrell from the Cleveland Clinic. And again, it starts at knee session number two. And our first speaker up, we have Elizabeth Dennis, who's going to give us a talk on outcomes of MPFL reconstruction with concomitant tibial supercosteotomy, both in primary as well as failed prior to patellar femoral stabilization. Thank you. Good afternoon. On behalf of my co-authors, I would like to present our research on outcomes of MPFL reconstruction with concomitant tibial tubercle osteotomy for failed patellar stabilization versus primary MPFL reconstruction with concomitant TTO. Our disclosures are listed here. Patellar instability is a complex problem, as there are many factors that play a role in the risk of recurrence, such as age, skeletal maturity, family history, contralateral instability, patellar alta, trochlear dysplasia, and rotational malalignment. Current recommendations regarding the scope of surgical intervention for patients with recurrent patellar instability are evolving. It's not well understood which subset of patients with recurrent patellar femoral instability require concomitant bony realignment procedures in addition to soft tissue stabilization. If the patient's complete pathology is not addressed at their index procedure, there can be a high risk of recurrent instability and or persistent pain necessitating revision surgery. To date, it's not known if the outcome of MPFL reconstruction with TTO performed in a revision setting after a failed patellar stabilization equate the outcomes of an MPFL with a TTO performed as a primary procedure. The purpose of this study was to assess the demographics, radiographic findings, patient reported outcomes, return to sport rate, and recurrent instability events in a series of patients who underwent MPFL plus TTO versus those who underwent the same procedure after experiencing recurrent instability post-operatively. Patients who underwent MPFL plus TTO from March 2014 to December 2018 were identified from an institutional patellar femoral registry and separated into two groups listed here. Baseline demographics, knee-specific patient reported outcome measures were collected prior to surgery and at one and two years post-operatively following surgical intervention. Return to sport rates and episodes of recurrent instability were also obtained and the radiographic measurements listed here were collected. Our study cohort included 91 knees in 83 patients, 58 patients in the primary group, and 53 excuse me 33 in the revision group. Groups were similar with respect to average age and number of female patients. The percentage of concomitant cartilage procedures was also similar between groups. This table lists the prior procedures that patients in the revision group underwent before their MPFL plus TTO. Notably, 10 patients who required revision had an isolated MPFL reconstruction while 11 had an isolated lateral release. With respect to the radiographic measurements, the mean TTTG, Katanda-Chomps index, patellar trochlear index, and presence of patella alto was similar between groups. Trochlear dysplasia as defined as a trochlear depth index less than three millimeters was present in 76 percent of primary patients and 73 percent of revision patients. Each group had a large percentage of patients with a PTLTR, a measurement of lateral patellar tracking which may be predictive of patellar instability, greater than 5.5 millimeters with no statistically significant difference between them. The mean PTLTR in the primary group was statistically significantly higher than that in the revision group. The time to final follow-up was 3.1 years in the primary group and 3.7 years in the revision group. There were four cases of recurrent instability in the primary group and none in the revision group. Of these four cases, there was one dislocation event and three subluxation events. The dislocation occurred a year and a half after surgery during a collision in a lacrosse game. Two of the subluxations occurred during traumatic falls and one occurred during routine daily activity. No patients in the revision group had a subluxation or dislocation event. There was no statistically significant difference between these findings. The radiographic measurements for the patients who experienced recurrent instability are listed here. Notably, all four knees had a TTTG greater than 17 millimeters and a TDI less than three millimeters. A total of 66 patients were involved in sports prior to surgery. The primary group had an 88% return to sport rate and compared to 83% in the revision group. 90% of patients in the primary group and 88% of patients in the revision group had a minimum of two years of follow-up. At baseline, the primary group had a higher IKDC. At two-year follow-up, both groups had significant improvements from baseline scores in all PROs except for PD-FABs which had no change. To control for concurrent cartilage injury and subjective outcome scores, we stratified the primary and revision groups by the presence of a concomitant cartilage procedure. Initial stratified analysis of this subset of patients found no effect on outcome scores in either group over time. In conclusion, management of patellofemoral instability is complex. The optimal timing of surgical intervention and whether a concomitant bony realignment procedure is indicated has yet to be elucidated. This study demonstrates that MPFL plus TTO is reliable and reproducible procedure whether it's performed in the primary or the revision setting. Significant improvements were seen in both patient populations from baseline to one-year follow-up with outcome scores sustained at two-year follow-up. Patients in both the primary and revision groups were able to benefit from improved subjective outcomes with very low recurrent instability rates. Additionally, revision patients returned to sport at the level seen for patients after primary surgery. Our study contributes evidence to this growing body of literature and provides support for counseling patients that safe and reliable outcomes can be achieved for MPFL plus TTO whether it's performed at an index procedure or in a revision setting. Continued data collection is currently underway to determine if these results will be sustained at long term. These are our references. Thank you very much. Thank you. So next up we have Michael Alaya who's going to give a talk about the clinical outcomes and return to sport in patients undergoing osteochondral allograft. Thank you. All right. So I'm Michael Alaya from NYU. Thanks to AOSSM for allowing us to present this data. Thanks to our co-authors. Disclosures are found in the manual. As we all know, osteochondral allograft transplants are consistently shown to have a positive impact on functional outcomes, good reliable survivorship, and even large defects. However, return to play is often a common question that we have not established an excellent answer for. Hurley et al. recently showed that rates from return to play can be anywhere from 60 percent to about 100 percent, but the majority of these papers are small series. And there's only one study showing over 100 patients. So the purpose of our study is to evaluate the clinical outcomes and the rates of return to play in patients who underwent an OC graft for a symptomatic osteochondral defect in the knee. Our hypothesis being that patients undergoing these procedures would have a high rate of return to play. This is a retrospective review performed from January 11 to April 2019 for patients who underwent any sort of osteochondral allograft for any compartment. The inclusion criteria included patients over 18 years of age with a preoperative diagnosis of a grade 3 to 4 OC lesion in the knee, with a minimum of 12 months of follow-up, associated malalignment, meniscus deficiency, ligamentous laxity, etc. were all included to simulate a real world environment. The exclusion criteria included diagnosis of tricompartmental knee OA, inflammatory disorders. Our primary outcome was return to play, which was defined as any ability to return to the same pre-injury sport, with return to play at the same or a higher level being defined as that of a patient's ability to perform at the same or a higher level than what they started with. Secondary outcomes include VAS for pain, CUSCOR, Tegner, and reasons for not returning to play. Descriptive statistics were used, and any comparisons were made using p-values set to 0.05. So moving into the results, you can see we have 103 patients in this cohort, with the majority being male at about 64%. The mean age was roughly 32 years old, with a BMI in the slightly overweight region of 27. Follow-up in terms of years was 2.7 years on average. Prior ipsilateral knee surgery was about 40% of patients. Moving into lesion location, this was a relative smattering of cases, but as you would expect, the majority of the lesions were located on the medial femoral condyle, as well as the lateral femoral condyle, which encompassed about 70 to 75% of the cases. The graft sizes were relatively large at 20.9 millimeters in diameter, followed by graft lesion number two, which would have been in the patellofemoral compartment of 19.4. Concomitant procedures, again, to reflect real world practice, you can see there's a relative smattering of them, from ACL to high tubal osteotomy, tib-tubercle osteotomies, et cetera. Overall, our return to sport for the same sport was unfortunately a little lower than we had hoped. It was about 63%. Unfortunately, even worse, return to sport at the same or the higher level was only about 50% of cases. When we analyzed these further, we found that most of them were unable to return, secondary to persistent pain at about 17%, physical inability at about 8%, or fear of re-injury, which we all know is a common reason why a lot of our patients don't go back to sport after any kind of procedure that we do. Moving into VAS pre and post, the VAS certainly improved. VAS improved by about five points, as expected with the typical outcomes after osteochondral allograft implantation. Kuh scores post-operatively were 75, and the Tegner score decreased, again, as expected from pre-injury from 7.1 to post-operative at 5.3. In terms of complications, again, as what you would expect, the majority of our further surgeries were related to manipulation under anesthesia slash lysis of adhesions at 5%, with a low rate of other complications in revision surgeries. The limitations of this study, it's a retrospective analysis with a follow-up rate of only 70%, unfortunately. It was a long period to study these patients, and only about 70% of them were able to be contacted. There was no assessment of range of motion, minimum of 12 months of follow-up, and older ages for athletes, not the elite level. So in conclusions, we had moderate return to play after osteochondral allograft at 65%, but unfortunately only 50% of our patients were able to return to the same level of pre-injury status. This has important pre-op, this has important counseling implications for all of our patients, for anybody that does these procedures in practice routinely. They're going to want to know about return to sport, and I think this is an important number that we can give them. So thank you very much for your time. Thank you. My name is Dr. Flanagan from The Ohio State University, and it's my honor to announce our next two speakers. Joseph Tramer is going to be talking about blood flow restriction therapy. I love that. Improves early patient reported outcomes following ACL reconstruction from the Henry Ford Hospital. Thanks so much. As he said, I'm Joe Tramer, up at the resident Henry Ford Hospital, soon to be starting a sports fellowship at Stanford, and I'm very excited and honored to be here today talking to you guys about blood flow restriction in the setting of ACL reconstruction. So Dr. Bowman gave a great talk this morning about BFR, but to reiterate, blood flow restriction involves placing an occlusive device around a limb during exercise, which occludes venous outflow. Many studies have attempted to elucidate the exact mechanisms of action of what this might do, with most showing lactic acid accumulation, leading to anabolic hormone release, as well as changes in muscle protein synthesis that mimic an environment of high intensity exercise. The benefit of BFR is that this can be done with low or no loads, which is potentially attractive in the perioperative patient. This has been studied in healthy patients and found to lead to increases in muscle strength, activation, and volume. And as all of our patients undergo a degree of quadriceps atrophy following ACL tear and reconstruction, it's a potentially attractive modality to help them accelerate their quadriceps recovery. At the time of us thinking about initiating this study, the systematic review had recently come out of level one and two studies looking at BFR in the setting of ACL patients, and there were only six studies included, with a mix in terms of what their protocols were and whether or not this worked. And despite this, many of our physical therapy clinics were already offering this to our patients, so we felt it prudent to look into it further. So the purpose of our study was to perform a randomized controlled trial using our usual physical therapy protocols, comparing to integrating those usual protocols with BFR, and this was performed both before and after ACL reconstruction. We evaluated 130 patients and ended up randomizing 46 patients. We analyzed 16 BFR patients in the end and 22 in the control group. Of note, there were three patients who had a discontinued BFR use early in their post-operative period due to pain and discomfort during cuff use. We saw these patients at the initial clinic visit, as well as the day of surgery, multiple time points after surgery, up to six months. There we collected biometric data as well as patient reported outcomes. Our main primary outcome measure was isometric quadriceps strength, which was tested using a handheld diatomometer using protocols that have been previously validated against traditional Biodex machine testing. For the two weeks prior to surgery, all patients underwent prehabilitation, which consisted of these four exercises and the following rep scheme. The BFR group performed these exercises with the cuff inflated to 80% of their personalized limb occlusion pressure, ensuring there was at least two minutes of cuff deflation between exercise sets. Patients underwent surgery and then underwent identical rehabilitation protocols after surgery with the addition of BFR during these exercises shown here. We, at three months following surgery, patients progressed to heavy resistance exercises and discontinued BFR, so this was mainly targeted towards when patients were doing low or no load exercise. There are no baseline demographic differences between our patients. Most were in their mid-20s and received a BTP autographed. Our main strength measure was quadriceps index, which we define as the average isometric quadriceps torque of the operative leg divided by the non-operative leg. And as you can see, at six weeks, there was a significantly higher quadriceps index in the BFR group compared to the control group. I'll also point out that the BFR group reached and slightly exceeded their baseline quadriceps index in the six-month study period, whereas the control group did not quite. Additionally, at six weeks, there were higher patient-reported outcomes in the PROMIS physical function, as well as IKDC scores in the BFR group compared to control. So some concluding thoughts. In our cohort, BFR performed at 80% of a personalized limb occlusion pressure. It was tolerated by most patients. However, I will note that those three patients dropped out early in the study period. We initiated this in the first two weeks after surgery, so they seemed not to quite tolerate it at that time. So there can be consideration to delaying this, to initiating this a little more for patients who have initial discomfort. Additionally, six weeks following ACL reconstruction, patients had improved patient reported outcomes and higher quad index. So there is some evidence here to support that this may accelerate quadriceps recovery, especially in that early period when patients are doing mostly body weight exercises. And our patients felt better about their knees, and this was reflected in the higher patient-reported outcomes at six weeks. Additionally, the BFR resulted in earlier return to their baseline quadriceps index, and we'll have to continue to follow these patients to see long-term outcomes and differences in return to play. Thank you very much. Next will be Michelle Zhao from Stanford University talking about increased lower extremity injury associated with player load and distance in collegiate women's soccer. Thank you so much for the opportunity to present our work this afternoon. My name is Michelle. I'm a second year medical student at Stanford. I'll be talking on our study, increased lower extremity injury risk associated with player load and distance in collegiate women's soccer. Our disclosures can be found in the app. And so women's soccer is gaining increasing popularity in the United States and worldwide across all levels, and prior literature has shown that female and male athletes have different injury risk profiles. For example, women's soccer players are at higher risk of ACL injury, whereas men's soccer players are at higher risk of groin and hamstring injuries. And one factor that may affect injury risk is an athlete's workload, which can be measured using wearable GPS units. Prior studies in men's soccer have shown that high total workloads and spikes in workloads are associated with an increased risk of injury, but there is limited research in this field specific for women's soccer. So the purpose of our study was to examine the relationship between injury risk and workload collected from wearable GPS units in NCAA Division I women's soccer players. For our methodology, we retrospectively reviewed lower extremity injury and GPS workload data collected over three seasons from one team, and 65 individual soccer seasons were included in our analysis. For our workload analysis, the GPS variables of interest were player load, which is a metric representing the sum of total accelerations, total distance, and high speed distance. And each player injury was matched to non-injured players of the same season and week. We then compared GPS data over a four-week period between groups, the injured and non-injured cohorts, and this was a measure of the cumulative load. We also calculated the acute to chronic workload ratio, which is the average load one week prior to injury relative to one month prior to injury, and this is a measure of relative load. So for our results over the three seasons, we found the total of 53 lower extremity injuries that caused athletes to miss at least one practice or game, and we had 34 non-contact and 19 contact injuries. We also found that the incidence of injuries in games was over three times higher than in practices. When looking at the cumulative load results, we found that the prior two-week, three-week, and four-week cumulative player load and total distances were significantly higher for injured players compared to non-injured players, and we found no significant differences in high speed distances in the four-week period prior to injury. When looking at relative load, no significant differences were seen for acute to chronic workload ratio with any variable player load, total distance, and high speed distance. Some of the limitations of our study included that we had both contact and non-contact injuries included. An argument could be made for that contact injuries may have less to do with load. The majority of injuries occur during games, so injury risk may be more related to game minutes played. And finally, our data was collected from only one team, so we didn't perform sub-analyses based on position, and results may not be generalizable to all of women's soccer. The key findings from our study were that higher player load and total distance but not relative workload are associated with injury in women's soccer players. We also found an incidence of lower extremity injury was over three times higher in games compared to practices. Oh, sorry. Back one more. And then results from our study show that GPS data can be used to identify modifiable risk factors for injuries in women's soccer. Thank you so much. We welcome anyone to come up to the microphone for questions as you're coming up, but maybe I'll start one with Michael. Yes, David. Yeah. So, you know, obviously, I think a pretty interesting paper in looking at the amount of, I would say, you know, unexpected, not as high return to sport. How did the concomitant procedures impact that? Did you look at that kind of sub-analysis? Yeah, we did. It was part of the actual new slides that I had uploaded, but they didn't get on there. It didn't actually. It's the same percentage kind of happened all the way throughout. Cool. So I'll take the next question. So for Liz, looking at your studies, I know in your primaries, the numbers are not such that you can do a subgroup analysis as to anatomy that may predispose to redislocation. But in your revision group, was there any trends looking at those patients? I know two-thirds did not have a formal NPFL done. Was that essentially the biggest reason for revision, or did you guys see any other big reasons? I think that's an excellent question. So one of the limitations of the study is the heterogeneous nature of the revision group. And this study, you know, in a much larger, you know, patient population, we could look at well-done NPFLs or well-done TTOs that failed and try and figure out why those failed. But we don't have that. That's future work. So the group here is, we know that an isolated lateral release is not a good procedure for patellar stabilization. We know that a medial embarkation is not. We know that if you see a loose body and you go in and take it out and you don't stabilize the patella in high-risk patients, that they go on to have recurrent instability. So those patients, it's easy to say that they did not have a patellar stabilization procedure done correctly the first time around. But obviously, you know, our group of patients was kind of one of each of those things. So hard to generalize anything from that. Liza? Also for Liz, I wanted to ask you, I maybe misunderstood the paper, but did you do the revision of the TTOs as well? Excellent question. And the title might have been misleading to that, but no, there was only one patient in the revision group that had a TTO done previously. So that TTO was revised. Okay. And then a question for Dr. Tramer. You know, I saw it actually was a picture that you had next to the systematic review done by Jorge. So I'm not sure if you actually do this, but I saw that you were doing blood flow restriction in a closed chain fashion. And this is a little bit debated. I'm not a blood flow restriction expert, but it is a little bit debated because it's felt that in an open chain exercise, you isolate out the quad, which is primarily the muscle we're doing. So in your routine, do you routinely do an open chain? Do you mix it up with open and closed chain? I just was a little bit confused by the picture. Yeah. So there was a, we don't do open chain loaded exercise. And so that's mostly integrated in the early phases of the therapy when they're doing body weight exercises. So the patients in both groups were doing that. And we basically just added the BFR to select exercises in our typical ACL protocol. So we didn't really change anything from what we were doing previously, but they were integrating into both types of chained exercises. Jeff. Yeah, for Dr. Zhao. On the load and distance study, how receptive were your coaches to looking at the data that you got from that as far as implementing that to try to cut that down? Because our coaches think it's important as long as it's showing the players are getting faster and moving more, but they have no interest when we start talking about injury for it and cutting back on how much to do in practice. Yeah, that's a great question. So the coaches at Stanford are very receptive. They have performance coaches who will analyze the data and then give them certain players who need to have modified workloads for the next training, and they will be very receptive to that. Michael, certainly when we look at chondral procedures, the patella femoral compartment has always been very challenging. And your results show that there's really no difference in terms of outcomes depending on locale. Were you surprised by those findings, and what do you make of that? I missed the last part. It said depending on what? The location. I was trying to be fancy and say locale, but the location. I did not do well in my verbal SATs. You should know that by knowing me by now. Yeah, I mean, that surprised us, too. I mean, there's a lot of surprising things from this paper, particularly the low level of return to play. And to offload or not offload, that's always the question for patella femoral. Where is the lesion, medial facet, lateral facet? Is there a role in offloading at all? And to be honest, I mean, I guess the biggest thing that surprised me on that paper was the very low return to play, and the rest of it, I guess, just fell in line with it. We'll end this session now and move on to the HIP session. Thank you, everybody. Congratulations. You guys all made it to the last and best session of the specialty day. My name is Robbie Westerman. I'm from the University of Iowa. And this is Lily Bagundovic. She's from Orthopedic Associates of Wisconsin. And we'll wrap up this meeting with HIP session two, looking at the last four papers of the program. So the first paper is titled Long-Term Outcomes After Arthroscopic Treatment of Femoral Acetabular Impingement for Patients with Borderline Dysplasia. The author is Ryan Selley from Hospital for Special Surgery. So come on up. Good afternoon, everyone. I'm Ryan Selley. I'm presenting on behalf of myself and my co-authors at HSS on our paper and our long-term outcomes of arthroscopic management of AI in borderline patients. I have nothing to disclose. As I'm sure most people in this room know, outcomes following isolated hip arthroscopy for dysplasia have been unfavorable. Results include iatrogenic instability and conversion to total hip at a young age. Conversely, patients with borderline dysplasia and primary diagnosis of FAI and not instability have portended more favorable results at short and medium-term follow-up. So this has been demonstrated in multiple studies. We published on this at our institution our three-year data in 2018. Dr. Philippon's published his research on this. Dr. Dohm as well as Dr. Noh have all published on this in the short-term, all indicating that appropriately selected borderline dysplasia patients can do well after a hypartheroscopy. And then Dr. Jastom and Ngo again published on this and their five-year outcome. Most recently, Dr. Philippon published his 10-year data looking at borderline dysplasia patients and they noted 87% survivorship at five years and then 79% at 10 years. Risk factors for failure in their cohort was patient age, tonus grade, micro fracture, and tonus angle greater than 15. So the purpose of our study was to assess our institution if durable outcomes can be expected after hypartheroscopy and borderline dysplasia patients. We defined this as a lateral center edge angle between 18 and 25 and then we compared it to a control cohort of nondysplastic patients with a lateral center edge of 25 to 40. So our methods here, the borderline dysplasia group consisted of 33 patients with 38 hips. This was 71% of the original three-year cohort. And then an age and sex match control group of 83 patients with 96 hips with normal coverage was also identified. Patient report outcome scores including modified Harris hip, HOS ADL, sport subscales, and IHOP33 were collected preoperatively and subsequently an average of 9.6 years postoperatively. So as for the most important slide in the talk in terms of picking these patients for surgery, the patients you want to operate on in the borderline group are those with the inchier going pain that's consistent with provocative flexion type positions or activities, pain reproduction with straight flexion or a fader maneuver, and imaging you want to see presence of a CAM lesion or diminished head-neck offset. Patients that we try to avoid operating on in terms of arthroscopy are those with lateral-sided symptoms, muscular fatigue-related sitting pain, or abductor fatigue with standing. And then on exam, watch out for absence of impingement signs and then pain with the inchier instability of testing. In terms of imaging, elevated tonus angle has been identified as a risk factor for failure for isolated hip arthroscopy and then excessive vestibular or femoral anteversion and inchier wall deficiency. So these patients underwent surgery in a standard fashion or institution, the supine position. A T-capsulitis performed to evaluate sores of impingement and dressed CAM lesions. Labor refixation was performed if this was minimally repaired. And a femoral osteochondroplasty was performed in nearly all patients. And lastly, a capsular closure. So these are our results. The patient demographics, there was no differences in age, sex, or procedures performed. Labor repair was performed in nearly three-quarters of patients in both groups. Ephemeroplasty in nearly all patients. The mean lateral center edge angle was 22.4 and the tonus angle was 6.2 in the borderline dysplasia group. It was significantly different than the control core that had a lateral center edge of 31.7 and tonus angle of 2.4. There was no difference in astiagular or femoral version parameters, though there was significantly larger alpha angles in the borderline dysplasia group, but we don't feel that this was clinically significant. In terms of differences between groups, we found no difference between any pre- or post-operative outcome scores between groups. The mean improvement in patient-reported outcomes for the modified Harris HIP was 22, HOS ADL was 21, sports subscale 31, and then IHAT 33 was 43. We found no significant differences between rates of achieving MCID, with rates varying depending on your outcome score between 73 and 93. In terms of, we also performed a linear model to assess for improvement by treatment effect by controlling for age, sex, bio-surgery, alpha angle, and found no difference. In terms of our failures, we had one conversion to THA, excuse me, to total HIP in the borderline dysplasia group and two in the control group, and there were no differences between this or rates of revision arthroscopy between groups. So in conclusion, durable outcomes greater than nine years with lower vision rates can be expected after isolated hip arthroscopy. It includes camera section, labor refixation, and capsular closure. In borderline dysplasia patients with equivalent outcomes to a FAI cohort with normal coverage parameters. And these results highlight the importance of appropriate diagnosis of patients with arthritis, without arthritis and instability or impingement categories and tailoring treatment appropriately. Thank you. All right, so the next paper is gonna be the natural course of recovery following health-related quality of life, applying hip arthroscopy for femorocetabular impingement presented by Thomas Alter from Rush University. All right, thank you for having me and I'd like to thank my co-authors. We have nothing to disclose related to this presentation. A major goal of orthopedic research is to improve patient selection through the identification of predictive factors that may influence outcomes following hip arthroscopy. Through identification of predictive variables, we can better select patients that are most likely to achieve favorable outcomes following surgery. The field has identified a multitude of factors associated with outcomes, including age, sex, BMI. We've shown that narcotic use and workers' compensation is associated with inferior outcomes. In terms of imaging, increased tonus grade and hip dysplasia, as well as chondral defects and MRI are associated with inferior outcomes. And then looking at interventions, response to interarticular injections are generally supported to confer more favorable outcomes following surgery. And then capsular closure and labral repair, when compared to capsular release and labral debridement, generally result in improved outcome. And then the last one there, interoperative findings. Chondral defects at the time of surgery have been associated with inferior outcomes. And so a tremendous value has been placed on evaluating the growth patterns and longitudinal data following surgery. Growth models are used to quantify trends or patterns in longitudinal data. So traditional growth patterns have really used these fixed effect models that are restrictive. They rely on the average intercept and the average slope to describe the longitudinal data over time. However, what we find is the reality is there's heterogeneity in the recovery following hip arthroscopy. Not all patients take the same course. So ideally, we'd like to see all patients recover initially between surgery and short-term outcomes, and then maintain those improvements through midterm outcomes. However, some patients progress more steadily, some patients fail to progress by short-term outcomes, but progress between short and midterm outcomes, and some patients do not progress at all. So how do we account for the heterogeneity in multiple subgroups seen in the post-operative course? And that's where random effect modeling comes in, specifically growth mixture modeling. It's less restrictive. It accounts for between-subject heterogeneity. It allows for random intercepts and random slopes, and a major advantage, it allows for identification of subgroups with variable numbers of classes. And so here's an example of a growth mixture model, including two subgroups, and each subgroup has its own unique recovery of longitudinal recovery. So the purpose of this study was to determine if subgroups of patients existed based on the recovery trajectories of patient-reported outcomes after hip arthroscopy for femoris, tebrary impingement syndrome, and if there were subgroups of patients, the next goal was to identify if clinical predictors of subgroup membership existed. We performed a retrospective study. We looked at patients undergoing hip arthroscopy for femoris, tebrary impingement syndrome with preoperative one-year and two-year IHOP, our standard exclusion criteria were applied. Variables we looked into were demographic variables, age, sex, BMI, social variables were workers' compensation, sports participation, psychiatric history. Pain variables that we looked at were back pain as a binary measure, chronic pain over two years in prior narcotic use, and radiographic variables included the Dunn alpha angle as well as tonus grade. Getting into our results, we had a total of 443 patients that met this criteria. The average age was 34, and 72% were female. Average BMI was 25. We then looked at the one through six class, so one through six subgroups of growth mixture models, and looking at the model fit statistics as well as unique trajectories and the proportion of patients in each group, we selected the three class model to be the best model to move forward with our analysis. And the proportion of patients in each group were 70, 22, and 7.7% respectively. And so this is a diagram of our three groups. Each is the average of the individual subgroups. So with that green one, you can see early progression by short-term outcomes that is maintained through midterm outcomes. If you look at, and we call that the early progressors, that would be our reference group. The next would be our orange group that does not progress between surgery and short-term outcomes, but then later progresses by midterm outcomes. And then that red group would be your late regressors who initially may have shown some improvement at short-term and then later regressed at midterm outcomes. And so here's a look at each of all the patients. So a total of 310 lines here representing the unique recovery of each patient. And then the red line is the average for that group. Here is our late progressors and our late regressors. And when we looked at each of these variables, what we found was that there were differences between groups in all these variables, BMI, workers' comps, course participation, back pain, psych history, chronic pain over two years and preoperative IHOT. And these differences were maintained between, on post hoc analysis, between the early progressors and late regressors. And we performed a univariate multinomial logistic regression. The following variables were indicative of favoring group membership in the late regressor group. That would be BMI, workers' compensation, back pain, psychiatric history, prior narcotic use and preoperative chronic pain. Predictive variables that did not favor involvement in the late regressor group were increased IHOT and then sports participation. And then these variables continued to be significant in the multivariate analysis. We then looked at early progressors and late progressors. No variables were significant. Sports participation had a p-value of .05. So sports participation did not, was not significant for membership in the late progressor group. And there is no significant variables in the multivariate analysis. And so limitations of this study is it's retrospective. It's limited to midterm outcomes. The late progressor group was relatively small and it was a single surgeon study so it may be limited by generalizability. In conclusion, we used growth mixture models to identify three unique trajectories of recovery following hypertheroscopy including early progression, late regression and late progression. And then we found that preoperative psychiatric conditions, chronic pain, workers' compensation status and lower IHOT scores were predictive inferior recovery trajectories. Thank you. All right, the next paper is the effect of osteochondroplasty on time to reoperation after arthroscopic management of FAI presented by Dan Cohen from McMaster University. Hi everyone, my name is Dan Cohen. I'm one of the orthopedic residents. I'll be presenting on the effect of osteochondroplasty on time to reoperation after arthroscopic management of femorastabular impingement on behalf of Dr. Ianni and the Max Sports Research Group from McMaster University in Hamilton, Ontario in Canada. So for disclosures, for this study specifically, there was no funding received but for the primary first trial of the studies based off of the research grants are listed below and none of the authors have any conflicts of interest to declare. So femorastabular impingement or FAI is a condition whereby mismatch in shape and size between femoral head and astabulum causes debilitating hip pain in young adults. It's becoming increasingly understood in recent years as both treatment and diagnosis are increasing as well. Our recently completed femorastabular impingement randomized control trial or FIRST is a multicenter international randomized control trial that looked at the effects of arthroscopic osteochondroplasty versus arthroscopic lavage in 220 adults between the ages of 18 to 50 diagnosed with FAI. The purpose of this paper in particular was using data from the first trial to assess and compare the effect of number one, arthroscopic osteochondroplasty versus number two, arthroscopic lavage on the time to re-operation in adults aged 18 to 50 with FAI over 27 months post-operative using a time to event analysis. So for the methods, the initial FIRST trial involved 10 centers across Canada, Denmark, and Finland between October 2012 and November 2017. There were two groups, the lavage group and the osteochondroplasty group. Both groups each started with 110 patients and the lavage group ended up with 104 patients at 27 months follow-up and the osteochondroplasty group had 105 patients at 27 months follow-up. And in the osteochondroplasty group, whether the patient had an FAI, whether the patient had a camera print or lesions, these lesions were resected, while in the lavage group, no osteochondroplasty was performed and only lavage of the joint was performed at three liters of normal saline. And any concurrent procedures such as label repair or cartilage lesions were addressed in both groups equally. So for data analysis, for the time to event analysis, Kaplan-Meier curves and Cox proportional hazard regression models were used. The independent variable was a procedure and age and impingement subtype were both explored as potential covariates. Tests for non-proportional hazards were used as well. And the effects from the Cox model were expressed as a hazard ratio with corresponding 95% confidence intervals and associated p-values with an alpha level significance of 0.05. So what did the study show? So in the osteochondroplasty group, a total of eight incident reoperations were identified within 27 months follow-up for a cumulative incidence of 7.4% and an unadjusted reoperation incidence of 3.4 per 100 person years. While in the lavage group, a total of 19 incident reoperations were identified within 27 months follow-up for a cumulative incidence of 17.9% and an unadjusted reoperation incidence rate of 8.7 per 100 person years. And these results are further demonstrated on the Kaplan-Meier curve on the right with the osteochondroplasty group labeled in red and the lavage group labeled in blue. So for patients with FAI, the hazard reoperation for patients undergoing osteochondroplasty was 40%. That of patients undergoing lavage for a hazard ratio of 0.4 and 95% confident interval of 0.17 to 0.91 with a significant p-value at 0.029. And all proportional hazard assumptions were met and there was no significant impact of censoring or covariates on the outcome of the model based on sensitivity testing. So in conclusion, this randomized time-to-event analysis of 27 months follow-up demonstrates that for adults between the ages of 18 and 50 with FAI, arthroscopic osteochondroplasty is associated with two and a half fold decrease in hazard of reoperation at any point in time compared to arthroscopic lavage with or without label repair. These are our references and thank you very much. All right, so the final paper will be defining clinically significant improvement on patient reported outcome measurement information system test for patients undergoing hip arthroscopy for the treatment of femorocetabular impingement system at one-year follow-up presented by Blake Bodendorff from Rush University. Thank you. These are our disclosures. So we know that patient reported outcome surveys have been developed as standardized outcomes for our patients. However, there are several drawbacks with the vast variety of PROs that are that are available and there's really no consensus for the best individual or group of patient reported outcomes specifically for hip arthroscopy. A lot of patients experience survey burnout, especially when you give them, you know, ten different surveys. It's going to take a lot of time. They may not complete them and that can be a problem when you're collecting outcomes for the purpose of research. So how can we gather all the information we need while minimizing the burden to patients? The patient reported outcomes measurement information system or PROMIS was developed in 2004 by the NIH in order to address this using both item response theory as well as computerized adaptive testing which essentially leads you down a string of prompts depending on your previous response in order to minimize the number of questions that you have to ask and or ask and answer in order to arrive at your final patient reported outcome measure. So this also attempts to negate the floor or ceiling effects with fewer individual questions when compared to the legacy patient reported outcome measures that we are most likely all of us are familiar with. So we saw that patients require less time when using the PROMIS system than legacy patient reported outcome measures and on average at, you know, the PROMIS surveys take about 40 seconds as compared to the HOS which is nearly four minutes and the IHOT which is slightly less than that at just over two minutes. The PROMIS system however has been shown to be less responsive than those legacy PROs that we are all familiar with. There are moderate to strong correlations with the legacy PROs and there are no floor or ceiling effects which are great as well as large effect size. However we found that the IHOT 12 score is more responsive than these both in the PROMIS pain interference threshold as well as the PROMIS physical function score. So we sought to define the minimum clinically important difference or MCID, the patient acceptable symptom state, as well as substantial clinical benefit thresholds for both PROMIS PF as well as the PROMIS pain interference instruments for patients that are undergoing hip arthroscopy for FAI. So we performed a retrospective review of patients who underwent primary hip arthroscopy for symptomatic FAI after they failed conservative measurement or conservative treatment and PROs were administered both preoperatively and at one-year time points post-operatively in a prospective fashion. We gave them PROMIS PF and PROMIS PI as well as the HOS ADL, HOS sport subscale, modified Harris hip score and the IHOT 12 and we calculated MCID based on the distribution method as well as PASS and SCB based on the anchor based method. We saw that patients achieving CSOs or we compared patients that achieved these clinically significant outcomes with those who did not achieve CSOs and performed a multivariate logistic regression to determine predictors of CSO achievement notably patients that were undergoing bilateral procedures, those that had dysplasia and any previous hip arthroscopies were excluded. So we ended up with 124 patients and our final analysis the mean age was just under 33 years, mean BMI was 26 and the majority of these patients almost three-quarters were female. All patients underwent primary labral repair, acetabuloplasty, debridement, synovectomy, femoral osteochondroplasty and capsular closure by the single surgeon. We saw statistically significant improvements in all PROs from preoperative to one-year post-operative when these patients were pooled together. So there were no significant differences in any demographic or clinical variables for patients achieving MCID. We saw that patients achieving MCID had a higher or worse preoperative pain promise, pain interference score and a lower percentage of patients had chronic pain preoperatively. So going on to our PASS results, patients who achieve PASS had significantly higher preoperative promise physical function scores. And we also saw that these patients tended to be younger on average at 31 versus nearly 36 years of age. And then looking at substantial clinical benefit, patients achieving this were significantly younger at 30 years versus nearly 36, had significantly lower BMIs and also had higher preoperative physical function promise scores. So patients who reached MCID via promise metrics had comparable rates, 89 versus 87%. However, patients that achieved PASS and SCB had significantly lower rates with promise. So this brings into question the previous study that I mentioned, whether or not promise is a less responsive instrument. We also see that this could have been a result of the minimum one-year follow-up, so a longer study could shed some light on that. Ben found that IHOT12 was more responsive than PROMIS-PI and PROMIS-PF. He also showed that a greater proportion of patients achieved CSOs at two years when using legacy PROs. So again, time may tell us a better answer to that. Childs and authors also demonstrated strong correlations between the PROMIS-PF and hip-specific legacy PROs three months after hip arthroscopy, but there were only modest correlations with the pain interference subscore. We also saw that chronic pain was correlated with a lower rate of achievement of clinically significant outcomes for the PROMIS-PI score. And then BASKES has demonstrated that patients with symptoms greater than two years before hip arthroscopy had worse outcomes and were less likely to achieve CSOs. So briefly in conclusion, our study defined the MCID, the PASS, and the substantial clinical benefit for PROMIS-PF and pain interference. Clinically significant outcomes were achieved for PROMIS at comparable but slightly lower rates than the legacy instruments. Patients with higher preoperative PROMIS scores, younger age, and lower BMIs were more likely to achieve CSOs. And preoperative chronic pain history or previous orthopedic surgery was a negative predictor for achievement of a clinically significant outcome. So I would say although the PROMIS may correlate with hip-specific metrics, it's not as responsive and that may limit its ability to replace legacy metrics in their present form. So I would just say caution using this until further follow-up studies are published. Thank you. First question for Ryan Selley. All arthroscopic hip surgeons know that every patient with borderline dysplasia should not be treated with a scope. Besides a large alpha angle, what other pearls in terms of radiographic measurements, femoral version, physical exam, can you tell us based on your study that would suggest somebody would be safely treated with a scope? We didn't identify any specific risk factors for failure to achieve MCID based on at least the data that we have here. Just anecdotally, some of the things that I mentioned, patients that present with symptoms that are more dysplastic like with static overload, lateral sided hip pain, anterior instability testing, the PART test is a prone apprehension relocation test. It's something that we use now. It hadn't been developed yet at the time with a lot of these patients. And then I think tonus angle is probably an important thing to pay attention to, anterior center edge angle, looking at your anterior wall index. A lot of patients have these out of way hips where they really have no anterior wall. It's easy for them to come out the front and probably do poorly with a hip scope. Something that might be helpful is looking at back in time at the time when Brian was doing these scopes on borderline dysplastic patients is to look at the patients you referred for PAO and compared their measurements and their physical exam parameters. That might be helpful for the general population in trying to decide who gets a scope and who gets a PAO in this cohort. Ernie Sink actually publishes borderline dysplasia patients, so it's out there. This question is for Dr. Alter. In your group of patients that they had that slow progression or delayed improvement from their hip arthroscopy, do you have any hypotheses as to why that might be and how you can kind of identify those patients pre-op? I think that study is limited because we only have 34 or so patients in that group. So I think if we had a larger study that was probably more appropriately powered, we'd hopefully find more factors that would influence why these patients progress at a slower rate. I think that the sport activity would be significant eventually if you had more patients. I think that makes sense. Patients who want to get back to sports, they're generally healthier patients, younger, lower BMI even though that was controlled for. I think their expectations are set a little higher to get back to sport. Question for Dan Cohen. Is there any role to leave femoral deformity or a femoral CAM lesion behind during an arthroscopic surgery for FAI to treat only on the acetabular side? Based on the results of this, should we just treat every CAM lesion we see during hip arthroscopy? Based on subgroup analysis, we did look at whether there was an influence of a CAM lesion or an FAI lesion on post-outcomes, and there wasn't. So I guess based on that, I'd argue to probably, just given the lower hazard ratio with lavage, to probably address every CAM lesion or every FAI-related lesion. Dr. Nepple. Jeff Nepple, LSU. Another question for Dr. Selley, somewhat related. Any sense of during the study period or now, how big that yes group is versus the no group? Ernie's published on results of PAO in this group that's about the same size of group. Any guesses on what the breakdown is for isolated arthroscopy versus hip scope PAO? No, I'd be really interested to look at, you know, you don't see the patients that don't get operated on a lot, which may be the best thing for some of these borderline people, but you know, it'd be nice to look at all the non-operative patients and then the ones that end up getting hip scopes and PAOs and get a sense, but no, I don't. Any other questions? All right. I'd like to thank Rick, Cassandra, Dr. Spindler. Do you guys have any closing remarks? Well, thanks to the few and the proud, but get your reservations and we'll see at the Broadmoor this summer for the 50th anniversary. And on behalf of Cassandra and Kurt, I just want to thank the AOSSM staff for all the assistance in helping us put this together and for you all for staying until the end. So safe travel if you're traveling today or tomorrow and then we'll see you in Colorado Springs in July.

orthopedic surgery

biceps tenodesis

overhead athletes

return to play

functional outcomes

revision surgery

meniscus transplant

knee function

pain relief

long-term studies

femoral acetabular impingement

hip arthroscopy

borderline dysplasia

growth mixture modeling

osteochondroplasty