platelet-rich plasma: does it decrease meniscus repair ... · platelet-rich plasma: does it...
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Paper 01 Platelet-Rich Plasma: Does It Decrease Meniscus Repair Failure Risk? Joshua Scott Everhart, MD, MPH, David C. Flanigan, MD, Robert A. Magnussen, MD, MPH, Christopher C. Kaeding, MD The Ohio State University, Columbus, OH Objectives: To determine whether intraoperative PRP affects meniscus repair failure risk. (2) To determine whether the effect of PRP on meniscus failure risk is influenced by ACL reconstruction status or by PRP preparation. Methods: 550 patients (mean age 28.8 years SD 11.3) who underwent meniscus repair surgery with PRP (n=203 total, n=148 prepared with GPS III system, n=55 Angel system) or without PRP (n=347) and with (n=399) or without (n=151) concurrent ACL reconstruction were assessed for meniscus repair failure within 3 years. The independent effect of PRP on meniscus repair failure risk was determined by multivariate Cox proportional hazards modeling with adjustment for age, sex, body mass index (BMI), ACL status, tear pattern, tear vascularity, repair technique, side (medial or lateral) and number of sutures or implants utilized. Results: Failures within 3 years occurred in 17.0% of patients without PRP and 14.7% of patients with PRP (p=0.52) (Angel PRP: 14.6%; GPS III PRP: 12.0%; p=0.59). Increased patient age was protective against meniscus failure regardless of ACL or PRP status (per 5-year increase in age: adjusted Hazard Ratio [aHR] 0.90, 95% confidence interval [CI] 0.81, 1.0; p=0.047). The effect of PRP on meniscus failure risk was dependent upon concomitant ACL injury status (Figure). Among isolated meniscus repairs (20.3% failures at 3 years), PRP was independently associated with lower risk of failure (aHR 0.18, 95% confidence interval (CI) 0.03, 0.59; p=0.002) with no difference between PRP vendors (p=0.84). Among meniscus repairs with concomitant ACLR (14.1% failures at 3 years), PRP was not independently associated with risk of failure (aHR 1.39 CI 0.81, 2.36; p=0.23) with no difference between PRP venders (p=0.78). Conclusion: Both PRP preparations utilized in the current study had a substantial protective effect on isolated meniscus repair failure risk over 3 years. In the setting of concomitant ACL reconstruction, intraoperative PRP does not reduce meniscus repair failure risk.
Paper 02 Outcomes of Arthroscopic Repair versus Observation in Older Patients Jason L. Dragoo, MD Stanford Medicine, Redwood City, CA Objectives: Meniscal root tears occur in a bimodal distribution, affecting both young healthy athletes and older patients with early degenerative knees. Root tears lead to de-tensioning of the meniscus and have been associated with increased contact forces and cartilage damage. Management of older patients with root tears is controversial and the efficacy of different treatment options is unclear. The primary aim of this study is to compare the clinical outcomes of patients undergoing an all-inside arthroscopic repair technique versus non-operative management for posterior meniscal root tears. Methods: 48 patients diagnosed with a posterior meniscal root tear between 2006 and 2015 were identified and divided into 2 groups, the arthroscopic repair group (AR, 30 knees), and the observation group (O: 18 knees). The AR group underwent a meniscal root repair technique where two all-inside sutures were used to reduce the root back to its remnant (reduction sutures) thereby re-tensioning the meniscus. One mattress suture was then added to strengthen the repair and repair the construct to the posterior capsule. KOOS subscores (Symptoms, Pain, Activities of Daily Living (ADL), Sports and Rec, Quality of Life), Lysholm, Tegner, and VR12 PCS questionnaires were used as the primary outcome measures at a minimum 2 years follow-up. Differences in baseline patient characteristics between the surgical and non-surgical group were examined using Fisher’s exact tests for categorical variables and Mann-Whitney U tests for continuous variables. For changes from baseline to follow up between the surgical and non-surgical group, independent sample t-tests or Mann-Whitney U tests were conducted depending on normality. A Fisher’s exact test was also utilized to analyze the rates of conversation to total knee arthroplasty (TKA) between the surgical and non-surgical group. Results: There were significant changes in all baseline to follow up mean KOOS subscores (all subscores: p < 0.001), Lysholm (p < 0.001), Tegner (p = 0.0002), and VR12 PCS (p < 0.001) scores for the AR group, while the O group had a significant difference in only mean KOOS pain (p = 0.003), KOOS ADL (p = 0.006), and VR12 PCS (p = 0.038) scores from baseline to follow-up. The AR group had a significantly larger increase from baseline to follow up in mean KOOS pain scores (32.0) compared to the O group (15.7) (p = 0.009), KOOS symptom scores (AR: 24.2, O: 9.3, p = 0.029) as well as in Lysholm scores (AR: 27.3 and O: 7.1; p = 0.016). During the follow-up period, 3.3% of patients in the AR group underwent a TKA, which was significantly lower than the 33.3% of patients in the O group (p = 0.008). The hazard of TKA conversion is estimated to be 93.2% lower for patients in the AR group compared to the O group (p = 0.013). Conclusion: Our study found a significant improvement in all clinical outcome scores in the AR group at 2-year follow-up. There was a significantly larger increase in KOOS pain, KOOS symptom, and Lysholm
scores in the AR group compared to the O group. The AR group also had a significantly lower conversion to TKA and significantly lower hazard of TKA conversion as compared to the O group. Surgical management showed higher functional outcomes and decreased TKA conversion rates as compared to observation and should be considered as a treatment option for the treatment of meniscal root tears in the older population.
Paper 10 Opioid Use is Reduced in Patients Treated with NSAIDS After Arthroscopic Shoulder Instability Repair: A Randomized Study Kamali A. Thompson, BS, MBA, David S. Klein, DO, Guillem Gonzalez-Lomas, MD, Michael Joseph Alaia, MD, Eric Jason Strauss, MD, Laith M. Jazrawi, MD, Kirk A. Campbell, MD NYU Hospital for Joint Diseases, New York, NY Objectives: The current opioid epidemic necessitates physicians to seek ways to decrease patients’ requirements of narcotic medications without sacrificing their postoperative comfort level. This study evaluated patients’ pain following arthroscopic shoulder instability repair and compared the use of narcotic medications between patients prescribed NSAIDs with rescue opioid prescription to those prescribed opioids alone. We hypothesized there would not be a significant difference in postoperative pain and addition of NSAIDs would result in decreased opioid use. Methods: Forty patients scheduled to undergo an arthroscopic shoulder instability repair were randomized to receive Ibuprofen 600mg and a 10-pill rescue prescription of Percocet 5/325mg (n=20) or Percocet 5/325mg (n=20). Primary outcomes were the amount of Percocet tablets used in the first week and VAS on postoperative day (POD) 1, 4, and 7. Statistical analysis was done using independent t-tests and bivariate analysis for correlation. Findings were considered significant at p<0.05. Results: Forty patients with a mean age of 35.08 (± 8.48)were enrolled between December 2017 and May 2018. The total amount of opioid consumption was statistically significantly lower in the multimodal group compared to the opioid group (p <0.04) as well as Percocet consumption between POD 0-4 (p <0.04). There were no significant differences in VAS at any point between the two groups. One patient in the Ibuprofen cohort experienced dizziness on POD 1. Two patients in the Percocet cohort experienced nausea and vomiting on POD 1 and POD 4. Conclusion: Multimodal analgesia using NSAIDs with an opioid rescue prescription has resulted in significant reduction in postoperative narcotic consumption. As both cohorts showed similar pain levels, it is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed. The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution.
Paper 15 The Importance of Staging Arthroscopy for Chondral Defects of the Knee Hytham S. Salem1, Zaira Chaudhry2, Ludovico Lucenti, MD3, Bradford S. Tucker, MD4, Kevin B. Freedman, MD5. 1Rothman Institute, La Jolla, CA 2Geisinger Commonwealth School of Medicine, Philadelphia, PA, 3Rothman Institute, Philadelphia, PA 4The Rothman Institute, Egg Harbor Twp, NJ, 5Rothman Institute at Thomas Jefferson University Hospital, Bryn Mawr, PA Objectives: Chondral injures of the knee are a common source of pain in athletes. The specificity and sensitivity of MRI in evaluating chondral defects of the knee have been found to be as low as 73% and 42%, respectively. Staging arthroscopy is a more accurate method of evaluating the articular surfaces of the knee prior to cartilage restoration surgery or meniscal allograft transplantation (MAT). Addressing all concomitant pathology can be important for the success of cartilage restoration surgery, and treatment plan may change based on the extent and location of cartilage damage. The purpose of this study is to evaluate the role of staging arthroscopy in the diagnosis of chondral defects prior to autologous chondrocyte implantation (ACI), osteochondral allograft transplantation (OCA) and MAT, and to elucidate its utility in surgical planning prior to these procedures. Methods: All patients who have undergone ACI, OCA or MAT of the knee with prior staging arthroscopy at our institution between January 2005 and May 2015 were included in our review. Cases in which defects were evaluated during another procedure, such as anterior cruciate ligament reconstruction or treatment of meniscal pathology, were excluded. Any patients who did not have a documented staging arthroscopy procedure were also excluded. Medical records were reviewed to document the diagnosis and treatment plan based on symptoms, MRI findings and previous operative records. Operative records of the subsequent staging arthroscopy procedure were then reviewed to document the number of chondral defects with corresponding size and grade, any concomitant meniscal pathology, and the proposed treatment plan after arthroscopic visualization of the knee. All changes in treatment plan following staging arthroscopy were recorded. Results: A total of 98 patients were included in our review with 52 females and 46 males. The mean age of our patient population was 32.3 (range 15.3-57.9), and the mean BMI was 27.58 (range 15.8-41.6). The primary diagnosis was articular cartilage pathology in 86 cases (87.8%) and meniscal deficiency in 12 cases (12.2%). A total of 46 patients (47%) had a change in plan following staging arthroscopy. Fourteen patients (14.3%) were found to have additional defects that warranted cartilage restoration surgery. Thirteen patients (13.3%) were found to have defects that did not warrant cartilage restoration surgery, and instead were managed with debridement chondroplasty. Surgical plan was changed from ACI to OCA in 4 cases (4.1%) and OCA to ACI in 1 case (1%). A previously proposed plan of MAT was deemed unwarranted in 1 case (1%), and an initial plan of meniscal repair was changed to MAT in another (1%). In 19 cases (19.4%), staging arthroscopy was used to determine whether OCA or ACI was most
appropriate. Of these, 8 (42.1%) were treated with OCA, 8 (42.1%) underwent ACI, 1 (5.3%) received minced juvenile cartilage allograft transplant, and 2 (10.5%) had debridement chondroplasty alone. Conclusion: To our knowledge, this is the first study to provide empirical evidence on the clinical value of staging arthroscopy prior to ACI, OCA and MAT. Based on our review, a change in treatment plan was made in 47% of cases in which staging arthroscopy was used to evaluate articular cartilage surfaces. Therefore, the results of our study indicate that staging arthroscopy is an important step in determining the most appropriate treatment plan for chondral defects prior to OCA, ACI and MAT.
Conclusion: Our results demonstrate that subacromial bursa represents a viable source of mesenchymal stem cells. We developed a reliable protocol for isolation of BDSCs from patient bursa samples. We show that BDSCs in the presence of BMP-12 and ascorbic acid can differentiate toward a tenogenic lineage. Our work provides strong evidence that BDSCs may be a potent tool for cellular therapy and may benefit future patients who undergo surgical repair of chronic rotator cuff tears.
Paper 34 Lateral Extra-Articular Tenodesis Reduces Failure of Hamstring Tendon Autograft ACL Reconstruction -Two Year Outcomes from the STABILITY Study Randomized Clinical Trial Alan M. Getgood, MD, FRCS (Tr&Orth)1, Dianne Bryant, PhD2, Robert B. Litchfield, MD, FRSC2, Robert Gordon McCormack, MD3, Mark Heard, MD, FRCS4, Peter B. MacDonald, MD, FRCS5, Tim Spalding6, Peter CM Verdonk, MD, PHD7, Devin Peterson8, Davide Bardana9, Alex J. Rezansoff, MD10, Stability Study Group11 1Fowler Kennedy Sport Medicine Clinic, London, ON, Canada, 2University of Western Ontario, London, ON, Canada, 3University of British ColumbiaOrthopaedics, New Westminster, BC, Canada, 4Banff Sport Medicine, Banff, AB, Canada, 5Pan Am Clinic, Winnipeg, MB, Canada, 6University Hospirtals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom, 7ANTWERP ORTHOPAEDIC CENTER, Gent, Belgium, 8McMaster University, Hamilton, ON, Canada, 9Queens University, Kingston, ON, Canada, 10University of Calgary Sport Medicine Centre, Calgary, AB, Canada, 11Fowler Kennedy Sport Medicne Clinic, London, ON, Canada. Objectives: Persistent anterolateral rotatory laxity following anterior cruciate ligament reconstruction (ACLR) has been correlated with poor outcome and graft failure. We hypothesized that anterolateral complex reconstruction by way of a Lateral Extra-articular Tenodesis (LET) in combination with single bundle ACLR would reduce the risk of persistent rotatory laxity in young individuals who are deemed as being at high risk of failure. Methods: This is a pragmatic, multicenter, randomized clinical trial comparing standard hamstring tendon ACLR with combined ACLR and LET, utilizing a strip of iliotibial band (Modified Lemaire). Patients aged 25 years or less with an ACL deficient knee were included. They also had to have two of the following three criteria: 1) Grade 2 pivot shift or greater; 2) Returning to high risk/pivoting sports; 3) Generalized ligamentous laxity. The primary outcome was graft failure defined as either the need for revision ACLR or symptomatic instability associated with a positive asymmetric pivot shift, indicating persistent rotational laxity. Secondary outcome measures included the P4 pain scale, KOOS, IKDC. Patients were followed for two years with visits at 3, 6, 12 and 24 months postoperatively. A sample size of 300 per group was calculated based on a relative reduction in graft failure by 40%, with type 1 error of 5%, 80% power and 15% loss to follow-up rate. Results: 624 patients were randomized with a mean age of 18.9 (range: 14-25), 293 male. 436 (87.9%) patients presented pre-operatively with high-grade rotatory laxity (grade 2 pivot or greater) and 215 (42.1%) were diagnosed as having generalized ligamentous laxity (Beighton Score of 4 or greater). 523 of the 624 patients are at least 2 years postoperative; 29 lost to follow-up (~5%). In the ACLR group 104/252 (41%) of patients suffered the primary outcome compared to 61/242 (25%) of the ACLR+LET patients (RR=0.61, 95%CI 0.47 to 0.79), p<0.0001. 39 patients suffered graft rupture, 28/252 (11%) in the ACLR group compared to 11/242 (4.5%) in the ACL+LET group (RR=0.41, 95%CI 0.21 to 0.80, p<0.001). At
3 months postoperative, patients in the ACLR group had less pain (p=0.004); at 3 and 6 months all KOOS subdomains, the IKDC favored the ACLR alone group (p=0.03). At 12 and 24 months, no important between-group differences were observed in any patient reported outcome. Conclusion: The addition of LET to a hamstring autograft ACLR in young active patients significantly reduces graft failure and persistent anterolateral rotatory laxity at 2 years post operatively.
Paper 36 ACL Reconstruction In High School and College-aged Athletes: Does Autograft Choice Affect Recurrent ACL Revision Rates? Christopher C. Kaeding, MD1, Kurt P. Spindler, MD2, Laura J. Huston, MS3, Alex Zajichek, MS4, MOON Knee Group3. 1The Ohio State University, Columbus, OH, 2Cleveland Clinic Sports Health Center, Garfield Hts, OH, 3Vanderbilt Orthopaedic Institute, Nashville, TN, 4Cleveland Clinic, Cleveland, OH Objectives: Physicians’ and patients’ decision-making process between bone-patellar tendon-bone (BTB) versus hamstring autografts for ACL reconstruction (ACLR) may be influenced by a patient’s gender, laxity level, sport played, and/or competition level in the young, active athlete. The purpose of this study was to determine the incidence of subsequent ligament disruption for high school and college-aged athletes between autograft BTB versus hamstring grafts for ACLRs. Our hypothesis is there would be no recurrent ligament failure differences between autograft types at 6-year follow-up. Methods: Our inclusion criteria were patients aged 14-22 who were injured in sport (basketball, football, soccer, other), had a contralateral normal knee, and were due to have a unilateral primary ACLR with either a BTB or hamstring autograft. All patients were prospectively followed at two and six years and contacted by phone and/or email to determine whether any subsequent surgery had occurred to either knee since their initial ACLR. If so, operative reports were obtained, whenever possible, in order to document pathology and treatment. Multivariable regression modeling controlled for age, gender, ethnicity/race, body mass index, sport and competition level, activity level, knee laxity, and graft type. The six-year outcomes of interest were the incidence of subsequent ACL reconstruction to either knee. Results: Eight hundred thirty-nine (839) patients were eligible, of which 770 (92%) had 6-year follow-up for subsequent surgery outcomes. The median age was 17, with 48% females, and the distribution of BTB to hamstring was 492 (64%) and 278 (36%) respectively. Thirty-three percent (33%) of the cohort was classified as having “high grade” knee laxity preoperatively. The overall ACL revision rate was 9.2% in the ipsilateral knee, 11.2% in the contralateral normal ACL, and 19.7% had one or the other within 6 years of the index ACLR surgery. High-grade laxity (OR: 2.4; 95% CI: 1.4, 3.9; p=0.001), autograft type (OR: 2.1; 95% CI: 1.3, 3.5; p=0.004), and age (OR: 0.8; 95% CI: 0.7, 0.96; p=0.009) were the 3 most influential predictors of a recurrent ACL graft revision on the ipsilateral knee, respectively, whereas the sport of the index injury (OR: 0.3; 95% CI: 0.2, 0.7; p=0.002) was the most influential predictor of a subsequent primary ACL reconstruction on the contralateral knee. The odds of a recurrent ACL graft revision on the ipsilateral knee for patients receiving a hamstring autograft were 2.1 times the odds of a patient receiving a BTB autograft (95% CI: 1.3, 3.5). For low-risk patients (5% incidence of graft failure), a hamstring graft can increase the risk of recurrent ACL graft revision by 5 percentage points, from 5% to 10%. For high-risk patients (35% incidence of graft failure), a hamstring graft can increase the risk of
recurrent ACL graft revision by 15 percentage points, from 35% to ~ 50%. An individual prediction risk calculator for a subsequent ACL graft revision can be determined by the nomogram in Figure 1. Conclusion: There is a high rate of subsequent ACL tears in both the ipsilateral and contralateral knees in this young athletic cohort, with evidence suggesting that incidence of ACL graft revisions at 6 years following index surgery is significantly higher in hamstring autograft compared to BTB autograft.
Paper 58 Non-traumatic Fatalities in Football: Over-conditioning Kills Barry P. Boden, MD1, Ilan Breit2, Scott Anderson, ATC3. 1The Orthopaedic Center, Rockville, MD, 2Baltimore, MD, 3Norman, OK Objectives: Football is associated with the highest number of fatalities of any high school (HS) or college sport. In contrast to the annual number of traumatic fatalities in football, which has declined 4-fold since the 1960’s, the annual number of non-traumatic fatalities has stayed constant with current rates that are 2 to 3 times higher than traumatic fatalities. The purpose of this study was to describe the epidemiology and causes of non-traumatic fatalities in HS and college football players, to determine the effectiveness of the NCAA policies to reduce heat and sickle cell trait (SCT) fatalities, and to provide prevention strategies. Methods: We retrospectively reviewed non-traumatic football fatalities identified over a 20 year period from July 1998 through June 2018. Information was obtained from extensive internet searches, as well as depositions, investigative, autopsy, media, and freedom of information reports. Heat and SCT fatality rates were compared pre and post implementation of the NCAA football acclimatization model (2003) and SCT screening (2010) policies, respectively. Results: There were 187 (150 H.S., 37 college) non-traumatic fatalities (avg. 9/yr.). The most common causes of fatalities were cardiac (98, 52%), heat (44, 24%), SCT (23, 12%), and asthma (10, 5%). The majority of fatalities (127, 68%) occurred outside of the regular season months of September through December with the most common month for fatalities being August (61, 33%). Most (163, 87%) of the fatalities occurred during a practice or conditioning session (heat=100%, SCT=100%, asthma=90%, cardiac=77%). Hallmarks of exertion-related fatalities were: 1. conditioning sessions supervised by the football coach or strength and conditioning coach, 2. irrationally intense workouts and/or punishment drills, and 3. an inadequate medical response. The average annual rate of heat-related fatalities remained unchanged at the collegiate level pre (0.4) and post (0.4) implementation of the NCAA football acclimatization model in 2003. The average annual number of SCT deaths in collegiate football declined 58% (0.83 to 0.25) after the 2010 NCAA SCT screening policies were implemented. At the HS level, where there are no SCT guidelines, the number of SCT fatalities increased 400% (0.25/yr. to 1.0/yr.) since 2010. Conclusion: Most non-traumatic fatalities in HS and college football athletes do not occur while playing the game of football, but rather during conditioning sessions which are often associated with overexertion and/or punishment drills by coaches, especially strength and conditioning coaches. The football acclimatization model implemented by the NCAA in 2003 has failed at reducing exertional heat-related fatalities at the collegiate level. SCT screening policies adopted by the NCAA in 2010 have been effective at reducing fatalities in college athletes and similar guidelines should be mandated at the HS level. Conditioning related fatalities are preventable by establishing standards in workout design,
holding coaches and strength and conditioning coaches accountable, ensuring compliance with current policies, and allowing athletic health care providers complete authority over medical decisions.
Paper 66 Outcomes of Non-Operatively Treated Elbow Ulnar Collateral Ligament Injuries in Professional Baseball Players by Magnetic Resonance Imaging Tear Grade and Location Aakash Chauhan, MD, MBA1, Peter Nissen Chalmers, MD2, Peter Douglas McQueen, MD3, Christopher L. Camp, MD4, Hollis G. Potter, MD5, Michael G. Ciccotti, MD6, John D'Angelo7, Heinz R. Hoenecke, MD8, Brandon J. Erickson, MD9, Stephen Fealy, MD5, Jan Fronek, MD10 1Dupage Medical Group, Naperville, IL, 2University of Utah Health, Salt Lake, UT, 3Romano Orthopedics, Chicago, IL, 4Hospital for Special Surgery, Rochester, MN, 5Hospital for Special Surgery, New York, NY, 6Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 7Major League Baseball, New York, NY, 8Scripps Clinic, La Jolla, CA, 9Rothman Institute, New York, NY, 10Scripps Clinic Medical Group, La Jolla, CA Objectives: Evaluate the relationship of 1) MRI tear grade and 2) injury location with outcomes for non-operatively treated elbow ulnar collateral ligament (UCL) injuries in professional baseball players. Methods: 544 professional baseball players were identified from the MLB Health and Injury Tracking System (HITS) that were treated non-operatively for their UCL injuries from 2011-2015. Of these players, 237 MRI’s were directly available for review by an independent, expert musculoskeletal radiologist who evaluated the grade (Grade I -edema, II-partial tear, III-complete tear) and location of the tears (humeral, ulnar, both-sided). Player demographics and outcomes including return to throwing (RTT), return to play (RTP), failed non-operative treatment leading to UCL reconstruction (UCLR), and Kaplan-Meier survivorship analysis of the native UCL to re-injury or surgery based on MRI grade and tear location was measured. A multivariate analysis adjusting for age, MRI grade, tear location, and level of play (Major = MLB; Minor = MiLB) was also performed. Results: The average age of all players was 22.5 years, 90% played at the MiLB level, and 84% were pitchers. The radiologist’s MRI injury grade was distributed as follows: Grade I (36%), Grade II (49%), and Grade III (15%) injuries. The tear locations were distributed as follows: humeral (65%), ulnar (13%), and both-sided (22%). There were no statistically significant differences in RTT, RTP, and UCLR by grade or tear location. However, objectively, ulnar-sided tears had the lowest RTT (81%) and RTP (42%). The ulnar (58%) and both-sided (60%) tears also had an objectively higher rate of UCLR compared to humeral sided tears (51%, p=0.441). The survivorship analysis showed a consistent decline over time with increasing MRI grade. By location, humeral tears had the highest survivorship (1 yr = 51%; 2 yr = 44%). However, there was no statistically significant differences in survivorship for either grade or location. Multivariate analysis measured the likelihood of not returning to play as 3 times higher [95% CI: 1-9.3; p=0.044] for older players (>25) compared to younger players. The likelihood of having re-injury or UCLR after non-operative treatment failed was almost 6 times higher [95% CI: 1.5-21.7; p=0.012] for MLB players as opposed to MiLB players. MRI grade and tear location were not significantly predictive of returning to play, re-injury, or surgery.
Conclusion: This is the largest study to evaluate the prognostic relationship of MRI injury grade and tear location with outcomes for non-operatively treated elbow UCL tears in professional baseball players. Lower MRI grade and humeral location were objectively associated with a higher RTT, higher RTP, lower UCLR, and higher survival compared to higher grade, and ulnar or both-sided tears. Older age (>25) had a significantly higher likelihood of not returning to play after non-operative treatment. Competing at the MLB level had a higher likelihood of re-injury or having UCLR. Based on this study, non-operative treatment of UCL injuries will likely be more successful in younger players, lower grade tears, and humeral-sided injuries.
Paper 84 Quadricep Femoris Strength at Return to Sport Identifies Limb at Increased Risk of Future ACL Injury after ACL Reconstruction in Young Athletes Mark V. Paterno, PhD, PT, ATC1, Mitchell J. Rauh, PhD, PT, MPH, FACSM2, Staci Thomas, MS3, Timothy E. Hewett, PhD, FACSM4, Laura C. Schmitt, PhD, PT5 1Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, OH, 2San Diego State University, San Diego, CA, 3Cincinnati Children's Hospital, Milford, OH, 4Mayo Clinic, Rochester, MN, 5The Ohio State University, Columbus, OH Objectives: The ability of current return to sport (RTS) criteria to identify young, active patients after ACL reconstruction (ACLR) independently, at high risk for future ipsilateral or contralateral ACL injury is limited. The purpose of this study was to determine if meeting current, standard RTS criteria collectively, or in part, would identify young athletes at risk for an ipsilateral or contralateral ACL injury after primary ACLR and RTS. The tested hypothesis was the likelihood of an ipsilateral or contralateral 2nd ACL injury in the first 2 years after RTS would be the same in groups that successfully met or failed to meet all RTS criteria prior to RTS. The second hypothesis was that quadriceps femoris strength at the time of RTS would identify which limb was at greatest risk for future ACL injury. Methods: One hundred eighty-one patients (116 female) with a mean age of 16.7±2.9 years old underwent ACLR and were released to return to pivoting/cutting sports. These patients were enrolled in a prospective, observational cohort study, completed a RTS assessment and were tracked for occurrence of an ipsilateral graft tear or contralateral ACL injury after ACLR for 24 months. The RTS assessment included 6 tests: isometric quadriceps strength, 4 functional hop tests and the International Knee Documentation Committee (IKDC) patient reported outcome survey. Limb symmetry index (LSI) was calculated for strength and hop test assessments [(inv/uninv)*100]. Subjects were classified into groups that successfully passed all 6 RTS tests at a level of 90 compared to those that failed to meet all 6 criteria. Chi Square tests and Fisher Exact Tests were used to determine if successfully passing all 6 RTS measures resulted in a reduced risk of 2nd ACL injury in the first 24 months after RTS as well as to assess if ability to successfully pass individual RTS criteria resulted in reduced risk of 2nd ACL injury. Results: Thirty-nine (21.5%) patients suffered a 2nd ACL injury with 18 ipsilateral graft failures and 21 contralateral ACL tears in the first 24 months after RTS following ACLR. At the time of RTS, 57 patients (31.5%) achieved LSI values of 90% or greater on all testing as well as an IDKC value of 90 or greater. At this level, there was no difference in ipsilateral graft failures between patients who passed all RTS criteria (15.8%) and those who failed at least 1 criterion (7.3%; p=0.08). There was also no difference in contralateral ACL injuries between patients who passed all RTS criteria (7.0%) and those who failed at least 1 criterion (13.7%; p=0.22). When individual RTS criterion were evaluated, patients who failed to achieve 90% quadriceps strength LSI were 84% less likely to suffer an ipsilateral graft failure (OR=0.16; 95%CI: 0.04, 0.74;p=0.009), but 3 times more likely to suffer a contralateral ACL injury (OR=2.5; 95%CI:1.0, 6.5;p=0.05).
Conclusion: Current criteria to evaluate readiness to return young athletes to pivoting and cutting sports, may not identify young, active patients independently at high risk for a future ipsilateral graft tear or contralateral ACL injury. Inability to achieve 90% LSI on an isometric quadriceps strength assessment resulted in a reduced risk of ipsilateral graft failure, but an increased risk in contralateral ACL injury after ACLR and RTS. Further investigation is needed on the relationship between quad strength and side of future ACL injury and whether other factors may help contribute to a predictive model of future ACL injury specific to limb.
Paper 97 The Effectiveness of Mandated Headgear Use in High School Women’s Lacrosse at Reducing the Rate of Head and Face Injuries Samuel L. Baron, BS1, Shayla J. Veasley2, Matthew T. Kingery, BA1, Michael J. Alaia, MD1, Dennis A. Cardone, DO1 1NYU Langone Health, Department of Orthopedics, New York, NY, 2NY Department of Education, New York, NY Objectives: There has been continued controversy regarding whether or not headgear use in women’s lacrosse will increase or decrease the rate of head injuries. In 2017, the Public Schools Athletic of New York City became the first high school organization in the country to mandate ASTM standard F3137 headgear for all women’s lacrosse players. The purpose of this study is to investigate the effect of mandated headgear use on the rate of head and face injuries in high school women’s lacrosse. Methods: This was a prospective cohort study. The study group included eight varsity and junior varsity women’s lacrosse teams, as well as their game opponents, who were mandated to wear F3137 headgear for all practice and game events over the course of the 2017 and 2018 seasons. Certified athletic trainers assessed and documented all injuries that occurred as a result of participation on the lacrosse teams and athlete exposures were estimated based on the number of team practice and game events. Injury rates were compared with those from the High School RIO (Reporting Information Online) injury data reports from the 2009 to 2016 seasons. Results: Over the study period, 17 total injuries were reported during 22,397 exposures for an injury rate of 0.76 injuries per 1,000 athlete-exposures. Two head/face injuries, both of which were classified as concussions, were reported during the study for a head/face injury rate and concussion rate of 0.09 per 1,000 athlete-exposures. The headgear cohort demonstrated significant decreases in rates of in-game head/face injury (RR 0.141, 95% CI [0.004, 0.798]), in-game concussion (RR 0.152, 95% CI [0.004, 0.860) and practice non-head/face injury (RR 0.239, 95% CI [0.049, 0.703]) when compared to the control cohort. Conclusion: Mandated use of F3137 headgear was shown to be effective at lowering the rate of head or face injury and concussions in women’s lacrosse. Additionally, mandated headgear use was also shown to lower the rate of injury to body locations other than the head or face during practice.
