Episódios
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Failure of shoulder stabilization surgery continues to plague contact athletes. Football players are thus at high risk of a repeat shoulder dislocation even after a well-done surgery to stabilize that joint. Such is the nature of a sport with violent and unpredictable collisions. Dr. Andrew Pennock, MD and his team at Rady Children’s in San Diego investigated the outcomes for high school football players who underwent arthroscopic stabilization surgery. They anticipated finding that the younger the player at the time of surgery, the higher risk of recurrence throughout his high school career. What they didn’t anticipate finding was that a high percentage of players who opted not to return to football did so because of fear. While we have seen this fear factor impact athletes after ACL reconstruction, the magnitude of this effect in this population was surprising.
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Second ACL injuries, whether it be a tear of the ipsilateral ACL graft or the native contralateral ACL, continue to be of great concern to patients and sports medicine practitioners particularly during the first 1-2 years after surgery. Sending a patient back too early to play is widely considered a major risk factor for this 2nd injury. As health care providers, we take pride in the joy and confidence a patient expresses as he/she advances through a rehab process towards his/her goals. However, when it comes to ACL reconstruction rehab, overconfidence may put the patient at risk, and perhaps slow and steady wins the race. We welcome Dr. Takehiko Matsushita, MD, PhD from Kobe University in Japan to discuss his study investigating the relationship between psychological readiness to return to sport and the risk of a 2nd ACL injury. His findings show that the biggest favor we can do for a patient who accelerates through the ACL recovery period quickly and confidently may be to slow him/her down.
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The right surgery for recurrent patellofemoral instability remains a topic of controversy. While medial patellofemoral ligament reconstruction (MPFLr) is the standby surgical procedure for this condition, many adjuncts including tibial tubercle osteotomy (TTO) are performed concurrently with the hope of improving the chances of success. Historically, a tibial tubercle-trochlear groove (TT-TG) distance greater than 20 mm has triggered surgeons to perform TTO, however recent evidence suggests this may be unnecessarily aggressive. We welcome Dr. Mininder Kocher, MD, MPH from Boston Children’s and Harvard Medical School to discuss his study evaluating the outcomes of MPFLr alone versus MPFLr + TTO in patients with recurrent patellofemoral instability with a tibial tubercle-trochlear groove (TT-TG) distance greater than 20 mm.
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Despite our technological advances in ACL surgery, the rehabilitation period remains challenging, particularly when it comes to lingering quadriceps weakness. Blood Flow Restriction (BFR) Therapy has been introduced as a potential means to speed up the return of quad function. We welcome Dr. Kelechi Okoroha from the Mayo Clinic to discuss his high-level study, “Effects of Perioperative Blood Flow Restriction Therapy Program on Early Quadriceps Strength and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction.” By utilizing BFR in both the pre- and post-operative periods following ACL reconstruction, Dr. Okoroha and his team did demonstrate a benefit in strength and patient reported outcomes.
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Proper treatment of Type III AC Joint Separations has been a topic of ongoing debate. In OJSM’s August edition, Drs. Mark Tauber, Phillipp Moroder and their team from the German Shoulder Center in Munich, Germany, published, “Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment of Acute Rockwood Type 3 Acromioclavicular Injury,” a high-level study that showed no difference in outcomes between surgical and nonsurgical management of this injury. We are joined by two of the finest surgeons in California’s Central Valley, Shoulder/Elbow Specialist Dr. Julia Lee, MD from Sierra Pacific Orthopedics and Traumatologist Dr. JT Christensen, MD from Kaiser Permanente to discuss this study and share their insights and practices.
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Once an exotic procedure, hip arthroscopy is now a commonplace surgery with an expanding footprint in Sports Medicine. One of the basic steps of hip arthroscopy is a capsulotomy to allow adequate access to the hip joint. Closure of the capsule, however, has been a point of controversy. While expert opinion has long touted the benefits of capsular closure, the technical difficulty of this step and the fact that it comes at the end of a time-sensitive surgery may explain why it is not performed universally. We welcome Dr. Jorge Chahla, MD, PhD from Rush University to discuss his team’s systematic review and meta-analysis comparing outcomes of repaired versus unrepaired capsules during hip arthroscopy. Dr. Chahla presents compelling evidence that capsular closure leads to better outcomes and is the way to go.
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Meniscal root tears are a problem. They can occur without trauma, they can only be diagnosed on MRI but occur commonly in a patient population where MRI is not routinely utilized, they don’t respond reliably to partial menisectomy, and they result in rapid degeneration of the knee joint. What we don’t know is how rapid is that arthritic progression. Dr. Caitlin Chambers from the University of Minnesota and her team address this question with their study, “Association of Medial Meniscus Root Tears and Nonroot Tears with Worsening of Radiographic Knee Osteoarthritis.” She joins us to discuss her results and gives advice on managing patients with this problematic meniscal tear pattern.
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Platelet-Rich Plasma (PRP) remains a topic of controversy in Sports Medicine. One of the limitations surrounding this therapy is the paucity of high-quality data to support or refute its efficacy. We welcome Dr. Dean Wang, MD from UC Irvine to discuss his study looking at the fragility of the highest quality data we have on PRP. A fragile study is one in which the study’s conclusion would change with the reversal of only a few outcomes. Our medical community holds randomized-controlled trials in high regard, however if these studies are fragile, how much can we rely on them to be true?
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The correct surgical approach for a skeletally immature athlete with an ACL tear remains controversial. Transphyseal ACL reconstruction with a soft tissue autograft is a popular choice that most resembles the technique performed in adults. However, crossing an open growth plate comes with risk of growth arrest, though the frequency and magnitude of that risk is not well known. We thank Drs. Alexander Seeto, MD and Ivan Astori, MBBS for their discussing their findings with us.
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We welcome Drs. Adam Daniel, MD and Patrick Smith, MD from Columbia Orthopaedic Group to discuss their study “Reduced Incidence of Revision Anterior Cruciate Ligament Reconstruction with Internal Brace Augmentation." Though a proprietary orthopaedic implant, the term “Internal Brace” has become a household name in Sports Medicine and Orthopaedic Surgery in general. It’s application in the realm of ACL reconstruction has been theorized, however due to poor performance of prior augmentation efforts with ACLR, Internal Bracing for ACLR has been met with some degree of skepticism. Dr. Smith has decades of experience searching for ways to improve upon ACLR, a surgery that is still far from perfect. He reports on his experience with ACLR with autograft plus Internal Bracing. His results speak for themselves.
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2023 OJSM William A. Grana Award for Best Research Paper spotlight - Dr. Olufemi Ayeni from McMaster University Medical Centre in Ontario joins us to discuss his award-winning study “Effect of Osteochondroplasty on Time to Reoperation After Arthroscopic Management of Femoroacetabular Impingement: Analysis of a Randomized Controlled Trial." As hip arthroscopy continues to grow as a beneficial treatment option in Sports Medicine, high level evidence is needed to support its efficacy. Dr. Ayeni and his group provide high quality data supporting the long term benefits of osteochondroplasty versus soft tissue work alone.
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We welcome Dr. Gregory Maletis, MD sports medicine surgeon at Kaiser Permanante Baldwin Park and head of the Kaiser Permanente ACL Registry. The KP ACL Registry has generated 55 high-quality, peer-reviewed publications, with huge sample sizes. Dr. Maletis discusses the registry’s inception, history, inner workings, strengths, and weaknesses. We close by looking at this current study, selected as an AOSSM Specialty Day Abstract 2023 and featured in OJSM, as an example of what the registry can do.
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We welcome Dr. Daniel Whelan, Head of University of Toronto Sports Medicine, to discuss his team’s recent publication “Assessment of 30 Years of Randomized Controlled Trials in The American Journal of Sports Medicine: 1990-2020.” This critical look at how our very best clinical studies have changed over a 30-year period is a fascinating reflection of our own evolution as orthopaedic sports medicine specialists. The past informs the present and can teach us lessons on how to be better in the future.
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We welcome Dr. Patrick McCulloch, co-program director of The Houston Methodist Sports Medicine Fellowship, and his current fellow, Dr. Matthew Kraeutler to discuss their study “Effects of Running on the Development of Knee Osteoarthritis: An Updated Systematic Review at Short-Term Follow-up” published in OJSM in March. The connection between running and osteoarthritic progression in the knee has been a topic of controversy for years. Common sense would say running must be bad for your knees, however could the health benefits of running actually play a protective role? We thank Drs. McCulloch and Kraeutler and their team for tackling this hot topic and sharing their discoveries with us.
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We welcome back Foot & Ankle Specialist and Residency Director of Loyola University Medical Center, Dr. Adam Schiff, MD to discuss surgical versus nonsurgical management of Achilles tendon ruptures. We review the study “Operative versus nonoperative treatment of acute Achilles tendon rupture: a propensity score-matched analysis of a large national dataset“ published in OJSM in February coming to us from Duke University. In the study, Dr. Brian Lau and his team found an increased risk of complications with surgical versus nonsurgical care, no difference in reoperation rates, and increased costs with surgical care initially but an equalization of costs at 5 years post-injury. The authors also report that over the study period from 2007-2015, there was little change in the rate of surgical repair, despite the widely published success of modern nonsurgical care. Dr. Schiff lends his expertise on this topic, lays out the pros and cons of each approach, the historical perspective, what situations might be best suited for each treatment pathway, and the psychology he sees in his patients as they decide whether to have surgical repair of their Achilles tendon rupture.
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We welcome Foot & Ankle Specialist and Residency Director of Loyola University Medical Center, Dr. Adam Schiff, MD to discuss suture button versus screw fixation for ankle syndesmotic injuries. We review the study “Comparison of Suture Button and Syndesmotic Screw for Ankle Syndesmotic Injuries: A Meta-Analysis of Randomized Controlled Trials“ published in OJSM in January coming to us from Southwest Hospital of Army Medical University in Chongqing, China. In the study, Dr. Kang-Lai Tang and his team found no difference in terms of malreduction, however the suture button group had significantly lower rates of local irritation and unplanned reoperation. Dr. Schiff lends his expertise on this topic, lays out the pros and cons of each approach, the historical perspective, and what situations might be best suited for each treatment construct.
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Historically, results of direct ACL repair are poor. As such, it has been viewed as a substandard surgical option in comparison to ACL reconstruction, the modern gold-standard approach. However, ACL reconstruction is not without its flaws, and as technology and techniques have advanced, the idea of ACL repair has reemerged. Coming to us from Tripler Army Medical Center, Drs. Christian Cruz and Craig Bottoni share their results with ACL repair in their military population. Like studies from the past, the failure rate was high at 26%. However, those that succeeded had good to excellent results in an average return to full duty time that beats what is expected with ACL reconstruction. Drs. Cruz and Bottoni share their experience with this active population and why ACL repair may make sense in certain situations as well as when to avoid it.
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The correct graft choice for ACL reconstruction remains a topic of debate. Dr. Shelbourne and his group have published extensively on the merits of the contralateral patellar tendon autograft. They presented their impressive results in this large-scale study published in OJSM in November and join us in this podcast to discuss their rationale, protocol, experience, and keys for success.
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The right surgery for an unstable shoulder remains a topic of controversy. What is the right approach? If performing a soft tissue stabilization, is Bankart repair alone sufficient? What is the amount of critical bone loss that would tip the scales towards a Laterjet? World-renowned shoulder specialist Dr. Patrick Denard of the Oregon Shoulder Institute joins us to discuss his recent study, “Arthroscopic Bankart Repair with Remplissage as an Alternative to Laterjet for Anterior Glenohumeral Instability with More Than 15% Glenoid Bone Loss,” published in OJSM in December. 15% glenoid bone loss has commonly been referred to as the threshold beyond which a soft tissue only procedure should not be performed. Dr. Denard shares his wisdom with us and why the addition of Remplissage may change the decision-making when dealing with bone loss above this limit.
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Sports Specialization is the focus on a single sport year-round oftentimes at the exclusion of other sports. It is a practice seen increasingly in our youth athlete population that aims to improve an athlete’s competitive advantage but sacrifices rest and has been associated with physical and psychological stress that can lead to attritional musculoskeletal injuries and burnout. We welcome Dr. Nirav Pandya, Pediatric Sports Medicine Surgeon from UCSF, local Sports Medicine authority for the San Francisco Bay Area, and trusted social media presence. In November’s OJSM, Dr. Pandya’s group published “Youth Sports Specialization and its Effect on Professional, Elite, and Olympic Athlete Performance, Career Longevity, and Injury Rates: A Systematic Review” which examines simply whether Sports Specialization works in terms of accomplishing its goal to better prepare an athlete to get to the next level, and at what cost.
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