Part 2: Upper extremity and rehabilitation/return to play
The 2016 AAOS Annual Meeting featured innovative and thought-provoking research in all fields of orthopaedics. Summarized here are some highlights from presentations in sports medicine and arthroscopy. In the April issue, we looked at studies on lower extremity, basic science, and cost-effectiveness. Here we cover selected research on upper extremity and rehabilitation and return to play.

Upper extremity
In Paper 328, CPT Drew W. Nute, MD, CPT Nicholas A. Kusnezov, MD, et al analyzed a large sample of active-duty military patients who underwent pectoralis major repairs. Of 257 patients, 242 patients (94 percent) were able to return to their preoperative level of military duty at an average follow-up of 49 months. Higher body mass index (BMI) and active psychiatric conditions were predictive of failure to return to activity. Senior author MAJ Brian R. Waterman, MD, reported that "primary pectoralis major tendon repairs generate reproducible functional outcomes with near complete restoration of strength and resolution of pain, irrespective of tear location, chronicity, or method of fixation."

In Paper 322, which presents research on management of glenohumeral osteoarthritis from the Steadman Philippon Research Institute, Peter J. Millett, MD, MSc, and colleagues presented the clinical outcomes on 44 shoulders in 42 patients undergoing a comprehensive arthroscopic management (CAM) procedure at a minimum of 5 years after surgery. The CAM procedure consists of glenohumeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis, and is one of only a few nonarthroplasty alternatives for these historically difficult-to-treat patient populations.

The authors demonstrated an overall survivorship of 92 percent at 1 year, and 73 percent at 5 years, and identified several positive prognostic factors, including glenohumeral joint space greater than 2 mm, glenoids with A1, A2, or B1 morphologies, and critical shoulder angle greater than zero degrees.

Justin Yang, MD, and colleagues at the University of Connecticut reported on the clinical outcomes of 40 patients undergoing Latarjet reconstruction for combined glenoid and humeral head bone loss, in Paper 706. The authors identified 40 patients with recurrent instability with anterior glenoid bone loss less than 25 percent (average 15 percent) and engaging Hill-Sachs lesions at an average 3.5 years follow-up.

In addition, a comparison group of 12 patients with greater than 25 percent bone loss (average 34 percent) with or without engaging Hill-Sachs lesions undergoing Latarjet was also analyzed.

The authors found the overall recurrence rate to be 15 percent, with no difference in recurrence rates between the two groups. The number of previous surgeries and the preoperative Beighton scores were directly correlated with postoperative Western Ontario Shoulder Instability scores. Certainly, a variety of risk factors have been identified for recurrence following shoulder stabilization, and Paper 706 provides additional insight into the importance of the risk factors of previous ipsilateral shoulder surgery, as well as baseline hyperlaxity.

In a study from Duke exploring an alternative to traditional treatment of massive cuff tears, lead author Julie A. Neumann, MD, reported on the use of porcine dermal matrix grafts as interposition grafts during repair of massive rotator cuff tears. This prospective observational study of 61 shoulders with massive rotator cuff tears repaired with interposition xenografts demonstrated that at a mean follow-up of more than 4 years, patients had improved subjective outcomes, pain, active range of motion, and muscle strength.

In addition, more than 90 percent of grafts were intact at final follow-up, as assessed by ultrasound imaging. This survivorship rate is better than previously published rates for primary rotator cuff repair. This paper (713) was one of six selected as a "2016 AAOS Game Changer."

Rehabilitation and return-to-play
A study from Rush University Medical Center titled "Quality and Variability of Physical Therapy Protocols for anterior cruciate ligament (ACL) Reconstruction" examined the standardization, or lack thereof, of online postoperative rehabilitation protocols for ACL reconstruction.

The authors reviewed the websites of 155 academic orthopaedic programs and were able to obtain online postoperative protocols for 33 of these programs. Lead author Eric C. Makhni, MD, MBA, summarized the key findings: "In total joint replacement, it is well documented that standardization of processes and care pathways leads to improved clinical outcomes. These concepts have yet to be proven in sports medicine. The goal of the study was to document the baseline level of variability in physical therapy protocols for ACL reconstruction. We identified significant variability with regards to both the types of exercises included in these protocols, as well as when patients were allowed to attempt these exercises postoperatively. Future research should focus on whether increased standardization might lead to improved clinical outcomes in these patients," Dr. Makhni said.

Regarding the lack of uniformity or standardization in postoperative rehabilitation and return to play (RTP) protocols, Mary Lloyd Ireland, MD, of the University of Kentucky, promoted development of more objective RTP measures, stating that "patients progress at different speeds. Work with your rehabilitation team. Functional assessment tests should include timed hop tests, strength, step downs, and sport-specific movements." Furthermore, Ireland said a benefit of objective functional tests is to help patients "understand that they are not yet ready to return to the same sport in which they tore their ACL."

Other offerings
In addition to the presentations highlighted here, dozens of video presentations and scientific exhibits complemented and augmented the findings discussed in all of the original research podium and poster presentations. Hot topics this year included advances in hip arthroscopy, techniques in advanced shoulder reconstruction, and the growing use of biologic therapy across all areas of sports medicine and arthroscopy.

Rachel M. Frank, MD, is a PGY-5 resident at Rush University Medical Center. She will be doing a sports medicine fellowship at Rush. Jeremy M. Burnham, MD, is a PGY-5 resident at the University of Kentucky. He will be doing a sports medicine fellowship at the University of Pittsburgh Medical Center.

References:

1. Nute DW, Kusnezov NA, Dunn J, Waterman BR: Complication and Re-operation Rates Following Pectoralis Major Tendon Repair in the Young Active Population.2016 AAOS Annual Meeting, Paper 328.
2. Millett PJ, Greenspoon JA, Horan MP: Survivorship after Arthroscopic Management of Glenohumeral Osteoarthritis with a Minimum 5- year Follow-up. 2016 AAOS Annual Meeting, Paper 322.
3. Yang J, Mazzocca AD, Cote M, Edgar C, Arciero RA: Recurrent Anterior Shoulder Instability with Combined Bone Loss: Results with the Modified Latarjet Procedure. 2016 AAOS Annual Meeting, Paper 706.
4. Neumann JA, Reay KD, Zgonis MH, Mayer SW, Boggess B, Toth AP: Interposition Porcine Dermal Matrix Xenografts: An Alternative to Traditional Treatment of Massive Cuff Tears. 2016 AAOS Annual Meeting, Paper 713.