in this study, we evaluated the influence of short-term ...the proximal and distal effects of blood...
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Paper 91 The Effect of a Single Freeze-Thaw Cycle on Matrix Metalloproteases in Different Human Platelet-Rich Plasma Formulations: A Prospective Cohort Study Kaitlyn E. Whitney1, Mitchell Kennedy2, Grant Dornan1, Jorge Chahla, MD, PhD3, Thos A. Evans, MD4, Marc J. Philippon, MD5, Robert F. LaPrade, MD, PhD4, Johnny Huard, PhD1 1Steadman Philippon Research Institute, Vail, CO, 2Steadman Philippon Research Institute, Yakima, WA, 3Steadman Philippon Research Institute, Chicago, IL, 4The Steadman Clinic, Vail, CO, 5Steadman Clinic, Vail, CO Objectives: The possibility of preserving platelet-rich plasma (PRP) from young, healthy individuals for future use is a compelling approach to reduce or delay degenerative processes, presuming that the retention of the biological properties are maintained. The purpose of this study was to measure and compare matrix metalloproteinases (MMP) isoform concentrations between whole blood (WB), leukocyte-rich PRP (LR-PRP) inactivated (LR-I) and activated (LR-A), leukocyte-poor PRP (LP-PRP) inactivated (LP-I) and activated (LP-A). Methods: Following institutional review board approval (2017-36), 24 donors that were physically and mentally healthy were prospectively enrolled in the study. Approximately 60 mL of WB was drawn from each donor to produce inactivated and activated LP-PRP and LR-PRP using manual processing methodology, as previously described. A complete blood count for WB and inactivated PRP products was obtained to verify that concentration of platelets was achieved. WB, LP-I, and LR-I samples were set aside for immunoassay and analysis. The LP-I and LR-I products were activated with 10% calcium chloride and recombinant thrombin in a red-top 10 mL vacutainer tube. Blood fractions were either immediately assayed and analyzed (fresh) or stored at -80℃ for 24 hours, 72 hours, and 160 hours. Commercial kits (EMD Millipore) were used according to manufacturer’s instructions for protein content: MMP-1, MMP-3, MMP-9, MMP-10, and MMP-12. A standard methodology for the Luminex 200® system was used as previously published. A pairwise Wilcoxin rank test was performed for statistical calculation. Results: Twenty-two healthy donors (n = 12 females, n = 10 males) with a mean age of 37.7 (range: 21 to 60), and average BMI of 23.7 kg/m2, were used in the final analysis. MMP-1 significantly increased between fresh and 160 hours in WB (p<0.05) (Figure 1), and significantly increased between fresh and 24 hours and 160 hours in LR-A (p<0.05) (Figure 4). MMP-3 significantly decreased between fresh and 24 hours, 72 hours, and 160 hours in LR-A (p<0.05) (Figure 4). MMP-9 significantly increased between fresh and 160 hours in WB, LR-A, and LR-I (p<0.05) (Figures 1, 2 & 4). MMP-12 significantly decreased between fresh and 24 hours in LR-A (Figure 4), while MMP-12 significantly decreased between fresh and 24 hours, 72 hours, and 160 hours in WB, LR-I, and LP-I (p<0.05) (Figures 1, 2 & 3). MMP-10 was not statistically different amongst fresh and freezing time points in all WB and PRP preparations. Interestingly, there was no statistical difference between MMP concentrations and freezing timepoints in LP-A. There were no significant correlations between MMPS and age, BMI or sex.
Conclusion: In this study, we evaluated the influence of short-term freezing (-80℃) on MMP concentrations in WB, inactivated PRP, and activated PRP formulations. Our results suggest that certain MMP isoforms, can either increase or decrease in response to freezing in WB, inactivated PRP, and activated PRP formulations. The development of PRP preservation approaches through minimal manipulation, without attenuating its biological properties, represents an important step in PRP mediated tissue regeneration and repair.
Paper 92 The Proximal and Distal Effects of Blood Flow Restriction Therapy on Upper and Lower Extremity Strengthening: A Randomized Controlled Trial Eric N. Bowman, MD1, Rami El-shaar, MD2, Heather Milligan, PT3, Greg Jue, PT4, Karen Mohr, PT5, Patty Brown, PT6, Drew M. Watanabe, BS7, Orr Limpisvasti, MD5 1Vanderbilt University Medical Center, Nashville, TN, 2Kerlan-Jobe Orthopaedic Clinic Program, Los Angeles, CA, 3Elite OrthoSport PT, Los Angeles, CA, 4Select Physical Therapy, Los Angeles, CA, 5Kerlan-Jobe Orthopaedic Clinic, Los Angeles, CA, 6Patty Brown Physical Therapy, Los Angeles, CA, 7Kerlan-Jobe Institute, Los Angeles, CA Objectives: Blood flow restriction (BFR) therapy consists of low-intensity exercise performed under reduced venous return due to an inflatable tourniquet. This produces similar physiologic and clinical effects to high-intensity routines with less joint and tissue stress. Postoperative patients may benefit from more efficient rehabilitation. Proximal and distal effects of BFR have been evaluated, however, minimal literature exists on its use in orthopaedic conditions. The purpose of this study was to determine the effects of low-intensity BFR therapy both proximal and distal, in the upper and lower extremities. Methods: This was a prospective, randomized controlled trial of healthy subjects completing a standardized 6-week course of BFR therapy. Subjects were randomized to BFR therapy on one extremity or to a control group. Subjects were excluded for cardiac, pulmonary, or hematologic disease, pregnancy, or previous surgery in the extremity. Data collected at baseline and completion included: limb circumferences, isokinetic, and manual strength testing. Results: Forty subjects completed the protocol. Average age was 27.7 years; 54% were female. For both upper and lower extremity groups, a statistically significant increase was observed in manual and isokinetic strength both proximal and distal to the BFR tourniquet when compared to both the non-tourniquet extremity and the control group (p<0.05). Limb circumference significantly increased in the upper (p<0.01) and lower extremities (p=0.02). A significant increase in manual strength was noted in shoulder abduction and scaption, and hip extension and abduction even in the non-tourniquet BFR extremity compared to the control group (p<0.05). Conclusion: Low-intensity BFR therapy led to greater increases in muscle strength and hypertrophy. Similar strengthening effects were seen in proximal and distal muscle groups. Strength increases in the contralateral BFR extremity may corroborate a systemic effect. This study provides data to further evaluate the efficacy and safety of BFR therapy in operative and non-operative orthopaedic conditions.
Paper 93 Expanding the Potential of Nonoperative Therapies In Advanced Knee Osteoarthritis: Treatment Response to Repeat Administration Triamcinolone Acetonide Extended-Release Is Similar Across Kellgren-Lawrence Grades 2-4 Deryk G. Jones, MD1, Andreas H. Gomoll, MD2, John C. Richmond, MD3, Andrew I. Spitzer, MD4, Virginia B. Kraus, MD, PhD5, Kim Huffman, MD, PhD5, Amy Cinar, PhD6, Joelle Lufkin, MPH6, Scott Kelley, MD6. 1Ochsner Clinic Foundation, Jefferson, LA, 2Hospital for Special Surgery/Cornell Medical Center Program, New York, NY, 3New England Baptist Hospital, Dedham, MA, 4Cedars-Sinai Orthopaedic Center, Los Angeles, CA, 5Duke University School of Medicine, Durham, NC, 6Flexion Therapeutics, Inc., Burlington, MA Objectives: Triamcinolone acetonide extended-release (TA-ER) is approved in the US to treat pain associated with knee osteoarthritis (OA). Intra-articular corticosteroids (IACS) are often used to manage recurrence of pain and symptoms during the prolonged course of OA. Effectiveness of IACS in advanced knee OA is unknown, and lack of effective nonoperative treatments may accelerate consideration of total knee arthroplasty (TKA). This post hoc subgroup analysis of a Phase 3b, single-arm, open-label study (NCT03046446) evaluated the efficacy of initial and repeat administration TA-ER in knee OA with a range of radiographic severity classified by Kellgren-Lawrence (KL) grade. Methods: Patients aged ≥40 years with symptomatic knee OA for ≥6 months, KL Grade 2-4, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) -A (pain) total sum score ≥6, and index knee pain for >15 days during the prior month received the 1st injection of TA-ER on Day 1. Patients received the 2nd injection at the first visit (Week 12, 16, 20, or 24) at which repeat dose criteria were met (ie, patient benefited from and tolerated the 1st injection without safety concerns and was clinically indicated to receive the 2nd injection). Patients who received 2 injections were evaluated every 4 weeks up to 52 weeks after the 1st injection. Patients who did not benefit from the 1st injection at Week 12 completed at Week 12. Patients who did not meet repeat dose criteria by Week 24 completed at Week 24. Safety was evaluated via treatment-emergent adverse events (TEAEs), and by index-knee radiography at end of study. Exploratory efficacy endpoints included WOMAC-A (pain), -B (stiffness), -C (function), and Knee Injury and Osteoarthritis Outcome Score-Quality of Life following each injection. Results: Of 208 enrolled patients, 179 received 2 injections. Of these, 56 (31.3%) had KL Grade 2, 68 (38.0%) had KL Grade 3, and 55 (30.7%) had KL Grade 4. The patient population reflected the ‘real-world’ knee OA population (Table). Demographics and baseline disease characteristics were generally similar across KL grade subgroups; however, as expected, age and time since OA diagnosis increased with KL grade. Prior index-knee OA treatments did not correlate with KL grade except for increased use of IA hyaluronic acid. The incidence of TEAEs and index-knee TEAEs were similar across KL grades (Table). Most TEAEs were Grade 1 or Grade 2 and there were no unexpected TEAEs. There were no indications of chondrolysis, osteonecrosis, subchondral insufficiency fractures, or clinically significant subchondral bone changes in any subgroup. Response rates for the 1st injection and median times to 2nd
injection were 95% and 120 days for KL Grade 4, 96% and 118 days for KL Grade 3 and 94% and 113 days for KL Grade 2. Regardless of KL grade, mean WOMAC-A (pain) scores were comparable following injections (Figure). At 12 weeks after both the 1st and 2nd injections, mean scores were similar for patients with KL Grade 4 (1.34 and 1.36), KL Grade 3 (1.37 each), and KL Grade 2 (1.24 and 1.20) (Figure). Conclusion: Overall and across baseline KL grades, repeat administration of TA-ER using a dosing schedule tailored to patient response was well tolerated, with no radiographic evidence for an impact on cartilage. In this ‘real-world’ patient population, TA-ER reliably reduced OA symptoms with similar improvements observed after both injections across KL grade subgroups, including those with KL Grade 4 who may otherwise be considering TKA.
Paper 94 Recall Bias in Retrospective Assessment of Preoperative Patient Reported Outcomes Matthew J. Gotlin, MD1, Samuel Baron1, Matthew T. Kingery1, Joseph McCafferty, Medical Student2, Laith M. Jazrawi, MD1, Robert J. Meislin, MD1 1NYU Langone Orthopedic Hospital, New York, NY, 2New York Medical College, Valhalla, NY Objectives: Patient reported outcomes (PROs) are measures of function, disability, and health status that may offer a unique assessment of provider quality and performance. The gold-standard method for collecting PROs is the prospective assessment of preoperative to postoperative change. This requires data collection before an intervention and then again after the intervention. This method is not always feasible due to unforeseen cases or emergencies, logistical and infrastructure barriers, and cost issues. In such cases a retrospective approach serves as a potential alternative. In this model, a patient is asked to complete an assessment about their perceived preoperative status during a time period sometime after the surgery. Although this method has its advantages, there is a particular risk of recall bias. There are conflicting conclusions regarding the reliability of the recalled preoperative PROs after orthopedic procedures. The aim of our study was to assess the agreement between prospectively and retrospectively collected PROs for a common, low-risk procedure. Methods: Patients that underwent arthroscopic rotator cuff repair between May 2012 and September 2017 at the study institution were identified. Inclusion criteria consisted of primary arthroscopic rotator cuff repair and preoperative prospectively collected American Shoulder and Elbow Surgeons Standard Shoulder Assessment Form (ASES) scores. All of the patients completed the ASES form preoperatively at their pre-assessment appointment. Patients were then contacted in the postoperative period and asked to recall their preoperative condition while completing another ASES form. Results: Seventy-one patients were included in this analysis (mean age 56.18 ± 10.48 years). The mean duration of symptoms from initial onset to the time of surgery was 8.54 ± 9.28 months. There was an average of 37.53 ± 17.02 months between the preoperative ASES and the recall ASES. Recall ASES scores were significantly lower than preoperative ASES scores (31.65 ± 16.87 vs 50.92 ± 19.57, p < 0.001). Less severe preoperative shoulder dysfunction was predictive of a greater difference between preoperative ASES and recall ASES (β = -0.60, R2 = 0.350, p < 0.001) (see Figure). Each 10-point increase in preoperative ASES score was predictive of a 6.04 point greater mismatch between preoperative and recall ASES. Likewise, a longer symptomatic period prior to surgery was associated with a greater ASES mismatch (R2 = 0.063, p = 0.029). The duration of time between surgery and recall was not a significant predictor of a difference between preoperative and recall ASES. Conclusion: This study demonstrated that there is poor agreement between prospectively and retrospectively collected preoperative PROs in the setting of rotator cuff surgery. Patient’s recalled ASES scores were significantly lower than their prospectively recorded ASES scores. This could lead to an overestimation of perceived benefit or effectiveness of the intervention. Our data supports prior studies
that demonstrated that retrospective PROs are subject to recall bias and have been found to produce more favorable results than prospectively monitored health status data from the same patient. Our study supports the use of prospectively collected PROs and retrospective PROs should only be used in situations where baseline assessments are not possible.
Paper 95 Return-to-Play after Concussion in American versus European Professional Soccer Players: A Comparative Short-Term Analysis of Performance and Longevity Sergio M. Navarro, BS1, Heather S. Haeberle, BS2, Albert S. Jang2, Salvatore Joseph Frangiamore, MD3, Lutul D. Farrow, MD4, Mark S. Schickendantz, MD5, Prem N. Ramkumar, MD, MBA6 1Baylor College of Medicine Program, Houston, TX, 2Baylor College of Medicine, Houston, TX, 3Summa Health Orthopaedics and Sports Medicine, Akron, OH, 4The Cleveland Clinic Sports Health Center, Garfield Heights, OH, 5Cleveland Clinic Sports Health, Cleveland, OH, 6Cleveland Clinic, Cleveland, OH. Objectives: Many studies have focused on the long-term impact of concussions in professional sports, but few have investigated short-term effects. This study examines concussion effects on individual players in the Major League Soccer (MLS) and English Premier League (EPL) by assessing 1) return-to-play (RTP) time, 2) career length, and 3) performance. Methods: Contracts, transactions, injury reports, and performance statistics from 2008-17 were obtained from the official MLS and EPL online publications. Players who sustained a concussion were compared with the 2008-17 non-concussed player pool. Career length was analyzed using Kaplan-Meier survival curves and athletes were stratified by player age, experience, and longevity. Player performance changes were evaluated between the years before versus after concussion. RTP and games missed were analyzed and compared. Results: Of the 1,784 eligible MLS and 2,001 eligible EPL players evaluated over the 10-year period, 102 MLS players sustained 165 concussions and 124 EPL players sustained 142 concussions resulting in injury protocol initiation. MLS players on average missed 7.5 games after a concussion, with 33.5 days missed, whereas EPL players on average missed 0.5 games after a concussion with 9.5 days missed, which was statistically different (p<0.001, p<0.0001). Performance was reduced at all non-goalie positions for goals and assists post-concussion for players in the MLS and in the EPL (p < 0.01). Concussed MLS players playing non-goalie positions scored 2.5 points/year less following a concussion and played in 20 fewer games/year on average. Concussed EPL players playing non-goalie positions scored 3.1 points/year less following a concussion and started in 5.8 fewer games/year on average. Concussed MLS and EPL goalies saw no significant change in performance, although EPL goalies played 3.2 additional games/year on average (p <0.05). The probability of playing a full season post-concussion was not significantly decreased compared with the non-concussed pool (p > 0.05) in both leagues. Conclusion: This study investigating the short-term effects of concussion on professional soccer players demonstrates that performance is reduced for non-goalie players, without a significant difference in career longevity between concussed and non-concussed controls.
Paper 96 Does Short Rest with Thursday Night Games Influence Injury Rates in the NFL? Jose Raul Perez, MD, Jonathan Burke, MPH, Abdul Zalikha, BS, Nicholas Schiller, MS, Andrew NL Buskard, MS, Dhanur Damodar, MD, Lee D. Kaplan, MD, Michael G. Baraga, MD. University of Miami Sports Medicine Institute, Coral Gables, FL Objectives: The objective of this study was to evaluate the impact rest time between games may have on injury rates as it pertains to overall incidence, injury location and player position. Methods: For this descriptive epidemiological study, data was obtained from official NFL gamebooks. In-game injuries were queried for all regular season games from all 32 teams over the course of four seasons (2013 to 2016). Only injuries which resulted in a stoppage of time during gameplay were included. Player position and injured body part were taken from the following week’s injury report. Rest periods between games were classified as short (4 days), regular (6-8 days), or long (10+ days) rest. Positions were categorized into Quarterback, Skill (wide receiver, running back and defensive backs), Lineman, and Other (fullback, linebacker and tightend). Overall observed injury rates, as well as injury rates specific to anatomic location and player position, were analyzed in correlation to different rest periods. Statistical significance was determined using the ANOVAprocedure of observed mean injuries per game. Pairwise analysis, through 2 sample T-test, was conducted to assess statistical significance between short, regular and long rest. Results: A total of 2,846 injuries were identified throughout the four seasons. ANOVA testing of all 3 cohorts taken together demonstrated a statistically significant difference between injuries/game between short, regular, and long rest (p = 0.012). With short rest, a mean of 1.26 injuries/game were observed (95% CI 1.046, 1.470), which was statistically significantly different when compared to the 1.53 observed injuries/game with regular rest (95% CI 1.463, 1.601; p = 0.029). Games with short rest were not found to be significantly different when compared to the 1.34 observed injuries/game associated with long rest (95% CI 1.186, 1.486; p = 0.555). Regarding player positions, only the Other cohort achieved statistically significantly less observed injuries/game with games played on Thursday compared to regular (p=0.0002) and long (p = 0.026). The quarterback position was the only position which sustained more injuries than expected with games played on Thursday compared to both regular and long rest; however, these results did not reach statistical significance (p = 0.09). No statistical difference was found regarding injury location in correlation to differences in rest periods. Conclusion: Our data suggests that there is a significant association between the amount of rest between games and observed injuries in the NFL. Interestingly, Thursday night games were found to have fewer injuries per game when compared to games played on regular rest. Subgroup analysis revealed fewer observed injuries with short rest for linebackers, fullbacks, and tightends. Although quarterbacks were observed to have more injuries than expected on short rest, this did not reach statistical significance. The results of this study do not support that less rest associated with Thursday
night games leads to higher injury rates; however, quarterback injury rates may potentially be impacted with shortened rest.
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.
Paper 98 The Histopathology of the Degenerative Proximal Biceps Tendon Travis John Dekker, MD1, Angel Chen, MS2, Nicholas J. Kwon2, John Steele3, William C. Eward, DVM, MD2, Grant Garrigues4, Samuel Bruce Adams, MD5, Alison P. Toth, MD2. 1The Steadman Philippon Clinic, Vail, CO, 2Duke University, Durham, NC, 3Duke University Medical Center-Orthopaedic Residency Program, Durham, NC, 4Rush University, Chicago, IL, 5Duke University AFFL Hosps, Durham, NC Objectives: Surgical treatment of proximal biceps tendinopathy remains a source of great controversy. Current surgical treatment debates center around the fixation location and not the quality of the tendon because little is known about the intra-tendinous pathology to guide this debate. Therefore, this study aims to evaluate two distinct anatomic regions of pathologic biceps tendons with regard to intra-tendinous architecture, painful neurotransmitters, and inflammatory modulators: the intra-articular portion and the extra-articular portion lying in the bicipital groove. Methods: Eleven human degenerative biceps tendons were obtained post-tenodesis. They were divided into intra- and extra-articular portions. They underwent histologic staining with hematoxylin and eosin and Alcian blue as well as immunohistochemistry staining for substance P, tyrosine hydroxylase, and neurofilament. Tendon architecture was assessed according to the modified BONAR tendon score. Immunohistochemistry staining was quantified using ImageJ density analysis. Portions of the tendon sections were cultured for 48 hours and the resultant secretome was assessed for Substance P secretion with ELISA analysis. Results: Composite BONAR scores demonstrated pathologic tendons with no significant difference between the intra-articular biceps tendon and the portion of the tendon within the bicipital groove (p= 0.31). Immunohistochemistry (IHC) analysis demonstrated significantly (p<0.05) increased uptake of substance P in the bicipital groove tendon compared to the intra-articular tendon while tyrosine hydroxylase did not (p>0.05). Stained substance P and tyr hydroxylase was intimately associated with intra-tendinous vascularity. ELISA results demonstrated significantly increased secretion of substance P in the bicipital groove tendon compared to the intraarticular portion. Conclusion: This study shows abnormal architecture, increased release and staining of painful neurotransmitters, and secretion of substance P from the proximal biceps tendon up to the distal aspect of the bicipital groove. Despite varied surgical techniques for tenodesis, this study supports the removal of the entirety of the long head of the biceps to the distal portion of the bicipital groove.
