Clay Nuelle:
Welcome to the Arthroscopy Association of North America's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association of North America or the Arthroscopy Journal. Welcome everyone to a special edition of the Arthroscopy Journal Podcast, where we will summarize the award-winning papers from 2020. While 2020 was a regrettable year in many ways, there were many excellent papers published within the Arthroscopy Journal. And today we will summarize the four award-winning papers that received recognition in the January 2021 edition of the Arthroscopy Journal. I'm Clay Nuelle with TSAOG Orthopedics in San Antonio. And I'm joined today by my fellow Arthroscopy Journal Podcast hosts. First, we have Andy Sheean from the San Antonio Military Medical Center. Welcome, Andy.
Andy Sheean:
Hey, guys. Thanks for having me.
Clay Nuelle:
We have Justin Arner from the University of Pittsburgh. Welcome, Justin.
Justin Arner:
Thanks for having me. Excited to be here too.
Clay Nuelle:
And we have Chris Tucker from the Walter Reed Military Medical Center. Welcome Chris.
Chris Tucker:
Thanks, Clay. This is my debut on the other side of the microphone.
Clay Nuelle:
So we have four excellent papers. So we'll jump right into them right away and get into each of the summaries and then how each of us think that each of these benefit or influence our clinical practice. So the first paper is the clinical research excellence award winner, which is a paper entitled, No Difference in Functional Outcomes When lateral extra-articular tenodesis is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients. The Stability Study, which is a combination of authors with the lead author being Alan Getgood. So, Andy, if you could give us a quick summary of the background and the results of the study and then your overall thoughts on the study design and the results.
Andy Sheean:
Yeah. Thanks. I was excited to get assigned to this one because of the fact that I actually had the opportunity to do a podcast with Dr. Getgood about this very paper earlier this year. For those listeners that are not familiar with The Stability Trial, it really represents in my mind what I think should be considered the gold standard for clinical trials pertaining to surgical techniques in 2021. Incidentally, Dr. Getgood and his team took home a lot of hardware with this one. Clay, you mentioned the award it won, it also won the O'Donoghue Award for a paper published in [inaudible 00:02:26]. I'll mention briefly just to provide some context, but basically what Dr. Getgood and his team did was they embarked upon a prospective randomized controlled trial, comparing ACL reconstruction with hamstring autograft alone, to ACL reconstruction with hamstring autograft, plus the lateral extra-articular tenodesis.
Andy Sheean:
They looked at patient port outcome measures, failure rates, which they defined as both clinical failure and graph free rupture rates, as well as functional testing. At 24 months of followup, they had 150 out of 180 patients were randomized to the ACL lone group versus 149 out of 176 patients in the ACL plus tenodesis group. As far as their main findings go at six months, the authors reported that there were significant differences, with respect to pain scores and functional testing, with the ACL alone group having a higher patient port outcomes and a better participation and better outcomes with respect to their functional testing.
Andy Sheean:
However, at 12 months, these differences had essentially washed out. Now, I mentioned a minute ago that this study was actually part of a larger effort that was published earlier this year at AJSM. And, overall what the authors found is a pretty, I think, sobering statistics, as far as the overall failure rate for ACL reconstruction, both with and without lateral extra-articular tenodesis but the authors did find it fairly convincing fashion that adding a lateral extra-articular tenodesis resulted in significant reductions in clinical failures and re-rupture rates. As far as the limitations of this paper go, the authors were forthright and candid, with respect to some issues that they had regarding patient compliance and surgeon compliance with respect to participation in the functional outcome measures.
Andy Sheean:
That's not to say that people weren't doing them, but they acknowledged the fact that if one of their outcome measures was the proportion of patients that were willing to perform the functional outcome measures at predetermined intervals and they acknowledge the fact that surgeons may be reluctant to a reticent for patients to be doing pop tests and things like that, if they thought that the patients just weren't ready, they had some sort of muscular imbalance or some other reason to suspect that, that may put the reconstruction at risk. Overall, as I mentioned, this is a fantastic study. This again, should be, I think, considered the gold standard for us in terms of, how surgical trials or clinical trials that are evaluating, comparing two different surgical techniques are performed. It was multi-center, it was well powered. They had excellent follow-up. And so again, I think a great bit of congratulations go to these authors and I think it really is a thought-provoking study, and I'm sure we can, we can talk about the role for tenodesis.
Andy Sheean:
I think it is not, a particularly positive paper. I should say it puts hamstring autograft reconstruction in particularly positive light given these clinical failure rates. At the same time, I think it also paints a fairly convincing argument for the efficacy of adding a lateral extra-articular tenodesis in certain patient populations.
Clay Nuelle:
That's a terrific summary, I think. Yeah. You know, this is a really powerful study, really powerful trial. I mean, and certainly one that has gotten a lot of attention and rightly so. I mean, this is the big one first for us sports surgeons is ACL reconstruction in young patients, particularly young active patients in cutting and pivoting sports. I mean, those are the patients that retire. Those are the patients that fail or have issues. And those are the ones that definitely keep us up at night when, when those things occur.
Clay Nuelle:
So anytime you have 618 patients in a randomized control trial, that's pretty powerful and data that we definitely should pay attention to, but you alluded to kind of some of the things that some of the detractors talk about, and some people kind of talk about with it in terms of hamstrings and how much and whether or not that plays a certain role or plays a certain limitation in it. And then the benefits versus not benefits of adding an LAT, with every kind of ACL patient or maybe with the higher risk patients with hyper-laxity or things like that. So has this study changed your practice at all, or your thought process, would you approach a pivoting athlete that's less than 25 years of age?
Andy Sheean:
To a large extent, yes. So I think that the people, surgeons tend to be reluctant to, I think, seriously about adding extra-articular tenodesis for a couple of different reasons. One, I think that there's a very real concern about over constraining the knee and what the long-term consequences of that are. I think there's some technical ways to avoid that, that Dr. Getgood and I spoke about in our podcast. But I think that at least in the short term, what this study shows us is that at the two year mark, patients are doing well with respect to their functional status. And there isn't really any reason to think that in the short term that the tenodesis is leading to some sort of a Barrett kinematics or some of the reasons as to why we would think that the patients wouldn't be tolerating the procedure well.
Andy Sheean:
It's not unexpected, based upon these... It's not unexpected that patients are going to have more lateral based knee pain following a tenodesis between three and six months after surgery. But again, I think that the big take home from this paper is that surgeons, at least in the short-term should feel confident that the tenodesis, it may very well decrease graph re-rupture and clinical failure without immediate clinical sequela over constraint. To answer your question specifically, how it affects my practice, I don't really do a whole lot of hamstring autograft.
Andy Sheean:
That's why I'm so excited to hear about the stability to trial, which is actually just getting underway where their authors are going to be looking at adding a tenodesis to either quadriceps, tendon autograft, or BTB autograft. And so I think those are going to be, that's going to be a really interesting thing to keep an eye out for. But, I think that the tenodesis, it hasn't really affected my practice in the primary setting, but this paper, even though it's about primary cell reconstruction, I'm just thinking more about it with respect to revision ACL as well, especially in those patients where I don't really think I can attribute their failure to any one particular technical error or anything like that.
Clay Nuelle:
Those are terrific points. Let's go down the line. Justin, does this paper affect your practice or change your practice at all?
Justin Arner:
Yeah, I think I'd echo what both of you guys mentioned that I think like Andy suggested the important thing it seems like with lateral extra-articular tenodesis is how you do it. I was lucky enough to be involved in a study here, a robotics study, where we used a graft and did more the reconstruction. We really were careful not to over tension the graft and put it in the landmarks that have been described. I know they've kind of varied, but, I think if, if you're not over constraining the graft and obviously Dr. Getgood is not doing that with his skillset and comfort with this procedure. But I think like Andy mentioned, if you're evaluating, especially revision and you look at slope and alignment and all of those things, the technical errors that he mentioned, I think it's safe to do as long as you're really not going to over-tension the graft and putting it in the appropriate position. So I think that's a real key here and why I think this study is and this trial is also a successful one.
Clay Nuelle:
Excellent points as well. Chris, how about you?
Chris Tucker:
Yeah, actually I had a conversation about this very topic just today in clinic with one of my colleagues. And we were speaking specifically to the indications for doing the lateral extra-articular changes, according to the stability trials, indications and specifically who they select it to do it for. My population is potentially a little more unique than others because I practice at a military medical center. And so my patients who are young and active who have ACL injuries, tend not to be so much competitive cutting or pivoting athletes, but more the military athlete where they probably have unique job requirements that we have to take into consideration, whether they're a dog handler and they get on their knees to handle a dog and have to climb walls and obstacle courses, or if they work on a ship and they do some unique profession where I'm always kind of putting a torque on their knee, but it's not necessarily in a competitive athletic environment.
Chris Tucker:
So I think for me, this study was important because it helped to educate me on kind of some of the overall concepts of why this seems to work and for whom it potentially works. And I apply those to my kind of patient specific requirements, kind of in a unique way. The people I consider doing this on and currently is primarily revision cases. I haven't transitioned to doing it for primary ACLs yet, but I do get a fair number of patients who do actually request autograph hamstring for one reason or another. And if that's the graft of choice for them, this does enter into the equation to potentially discuss with them the risks and benefits of doing it as an augment, for that graft selection. So, it has worked its way into my practice. I think it has helped some patients.
Clay Nuelle:
Yeah, those are great additions. I would say I echo all the points you guys do. In my practice, I typically do lateral extra-articular tenodesis for revisions, most of the time. But, that said, it certainly... I've done more of them in the last couple of years than I did in the previous few years before that I would say. And so definitely looking forward to the results of the stability to trial and what that'll add. I think that'll be a really powerful tool as Andy mentioned in the combination with this study. It may give us some better information for how to treat this otherwise, still somewhat difficult problem for each of us going forward. So we'll move on to the next paper. And so the next paper is the Basic Science Research excellence award winner.
Clay Nuelle:
The paper is titled All-Inside Lateral Meniscal Repair via Anterolateral Portal Increases Risk of Vascular Injury: A Cadaveric Study. The primary author was David Mao. And so Justin, can you take us through a summary of that and then your overall initial thoughts, with the results?
Justin Arner:
Yeah, absolutely. Thanks Clay. This is a nice study from Singapore, actually that outlined, I think is timely because the all inside devices I think are changing a little bit and there's more discussion about newer generations of those and people are getting comfortable with them. So, risk of nerve injury is kind of the things that people have talked about mostly before, as well as arterial injury. They're low risk, but obviously it's devastating, some of the studies are 8.6% and 0.03% for arterial injuries. And we all know the popliteal artery is typically more lateral and it's just under 10 millimeters from the posterior plateau. So the good things and nice things about this study was it was 10 fresh frozen cadavers. And they kind of did the worst case scenario, which I think is appropriate with a study like this that's a cadaveric study.
Justin Arner:
So they kept the depth to 20 millimeters and it was a commonly used all inside device that they used. And they basically picked a 0.5 millimeters from the root, but then the medial and lateral meniscus. And then they use the device either coming from the medial portal or from the lateral portal. And they kept the knee at 90 degrees just for ease of use with the way it was held in the leg holder. And they basically considered, if that point of the tip was less than 10 millimeters that they thought that was a risky situation. So, when they did the measurements, the thing that was most striking and the title implies is that, if you come from the lateral portal, that the distance from the artery is on average 4.7 millimeters and if you come Contra laterally from the antero-medial portal, it's 13 millimeters.
Justin Arner:
So, their discussion just like Dr. Miller discussed in a few podcasts this year, actually about a similar topic that if you can, especially with the lateral meniscus, it's probably safer to come from the contralateral portal. Uh, they did mention that on the lateral side that, if he came from the same, same side, that half of them five out of 10 were less than five millimeters, which is a little bit concerning and all of them are less than 10 millimeters. So there was quite a bit of range there.
Justin Arner:
The other thing I think to glean from this is that just because you're coming from the medial side, they didn't find that it was totally without risk. That two of them were less than five millimeters and four of the 10 were less than 10 millimeters. So they had to find similar findings with the vein, but it was a little further away. And then looking at the medial side, they had a similar trend that if you came to this from the lateral medial coral to the medial meniscus, that it was closer versus coming from the lateral side, 12.8 versus 23.8 millimeters, and kind of similar trends with how many were considered risky, but it wasn't as close as we would expect the lateral side to be since that's where the artery sits.
Justin Arner:
So again, I think that it's good that they picked kind of the worst case scenario, but, as they mentioned in the paper, there's probably a little less risk than they're showing here based on the flection. And they also inserted the device at the meniscal capsular junction rather than the specific point in the meniscus, which I think is more reproducible. They also kind of discussed their findings with some of the other studies that were published in arthroscopy, such as MRI studies.
Justin Arner:
They used the caliper here and did a pretty elegant dissection with a posterior approach and I think got some really nice measurements and comparing that to MRI, their argument is little more accurate, getting that three dimensional view with a caliper, which I think is true. And there are a large variation there, study, I think is a representative of the population like Dr. Miller and you folks had discussed with him in the podcast that if you have a smaller knee or a female knee, those things should be taken into account. And I guess, my opinion is about the study that, basically would echo with Dr. Miller mentioned that he doesn't use blocks.
Justin Arner:
I think it's a good idea if you're working on a ladder outside of the need, for watch out for a sciatic block or perennial nerve block and make sure you're checking the neurovascular status afterwards. And we wonder, should we limit the penetration depth to 14 or 16 millimeters and Dr. Miller said in the podcast 12 or 14 millimeters. So, if we kind of limit that depth, maybe we're a little safer. And the other thing is whenever you're deploying that device to make sure, I think you're not pushing deeper, because if you push the button and everything, and you advance it further, that's a little riskier. And the other thing, like I mentioned was that regarding the peek implants that are used in this study and some of the other ones, I think some of the newer implants that are all suture, at least give us a little more peace of mind. If we have issues with them, maybe they would cost less plus injury to the knee. So I think it was a nice study.
Clay Nuelle:
Yeah. I think it was a really well done study. So do you think we should be doing less all inside lateral meniscus repairs or does it change your approach at all when you see say, a vertical or longitudinal posterior horn lateral meniscus tear.
Justin Arner:
Yeah. It's a great question. I think just based on my training, I have a more comfortable, and I have more experience with inside-out repairs. And that's what I've been kind of doing the mainstay of my practice starting, obviously more recently than you guys, but I think, it plays a role. I mean, there's certainly been plenty of studies comparing all inside devices versus inside-out and shows no difference. There's some risks obviously dissecting back there. But if you know the anatomy, I think it's safe. So I would say that inside out, I think still is the gold standard. But it's hard if you don't have the help that's familiar with it. And I'm sure everyone here and everyone listening has had the frustrations with trying to have a team that is not as familiar with the physical, with the hard tight medial compartment that has a huge big bucket handle and you're trying to pass the needle. So, I think there's a role for it, but I think personally, I think inside-out stores the standard in my mind.
Clay Nuelle:
Chris, what do you think if you see a... Let's say you see an isolated longitudinal posterior horn lateral meniscus tear, in the red white zone or whatever? How are you repairing that? Or what are you doing?
Chris Tucker:
Yeah. My thought process on meniscus repairs has evolved from personal experience and also data that's come out. I think the inside-out technique still does remain the gold standard as Justin said. I think there's plenty of studies to support that bio-mechanically as well. But I think there is a role for all inside anchors. Currently my approach is if it's an isolated tear that's amenable to repair, with a single anchor or maybe two, i.e a tear length, less than 15, 18 millimeter where I can get one and or two all inside anchors in, I will consider doing that if it's a large peripheral tear, whether it's municipal capsular separation, or red, red, or red white zone, it's a large bucket handle or it's more extensive. My default is to do inside-out repairs just for the biomechanical stability it gives me and the ability to safely [inaudible 00:20:47].
Chris Tucker:
As Justin alluded to, it is difficult, based upon the help that you have, I'm fortunate to operate the majority of my time at a medical center where I have resident help. And so part of it is educational, but part of it is also having a really skilled assistant who's going to assist with those cases that can be difficult. I think, I do operate at a surgery center at times where I could be by myself with one tech and that makes those cases more difficult. But, that's part of the challenge, just improving your surgical skill and your ability to kind of direct your team. But, I think this is an interesting study and I enjoy it because it reinforces a concept I learned early on in training, which was specifically for these meniscus repairs.
Chris Tucker:
It was grilled into me and training to always look at the axial cuts on the preoperative MRI, just looking for the aberrants, arterial variations that could be close to the posterior capsule and to identify where they are and I think doing that mental exercise before every meniscus case just is a good habit to get into, for the trainees or early practice surgeons who are listening to the podcast. I think, learning good habits early on, I think this study helps reinforce just that concept, of case preparation.
Clay Nuelle:
Andy, any other final points to add?
Andy Sheean:
Yeah, I think from a teaching standpoint, for those of us that teach residents, I think this is a great paper because as Justin mentioned, the methods are elegant, straightforward, and it's all about angles and it's all about trajectory. And I think that those are really important things when you're teaching people how to do arthroscopy, is teaching them to think about angles of attack and the ways in which that you can optimize getting your instrument from point A to point B. And in this situation, thinking about the ways in which those angles are going to affect the proximity of the tips of those instruments to bad name structures. And so I think that this is mandatory reading for trainees and residents that are learning the arthroscopy and learning the nuances of meniscal repair.
Clay Nuelle:
Yeah. I think those are great points. I agree with all of you guys, I would say the lateral side, as Justin mentioned, have a much lower index or a much lower threshold for doing an inside-out repair. The lateral side is going to be just difficult because not only do you have the popliteal vasculature or neurovascular bundle pretty close by, but obviously you have the popliteal hiatus too. And so, the utility of doing an inside-out repair and the ability to use small bone needles and really direct those needles perfectly in the exact location that you want them, with whatever inside-out kind of guidance system you utilize is really powerful, I think so. Definitely a really good paper.
Clay Nuelle:
Well, let's move on to the next one. So the next one, is the award winner for a systematic review and meta analyses and research excellence. This paper is entitled Operative Versus Nonoperative Treatment of Femoroacetabular Impingement Syndrome: A Meta-analysis of Short-Term Outcomes. The primary author first author is Tim Dwyer. Chris, can you give us a summary of this and your initial thoughts on the outcomes?
Chris Tucker:
Absolutely, Clay. So the purpose of this study was to compare the outcomes of patients with FAI treated with hip arthroscopy, versus those treated with physical therapy alone. It was a meta analysis, as you said, the authors reviewed the Pub Med Embase and Cochrane library databases, and identified randomized controlled trials of operative versus non-operative treatment. In summary, their inclusion criteria were studies that incorporated patients who were aged 16 years or older, who had both clinical and radiographic diagnoses of FAI. Their outcomes measures, primary outcome measure was the International Hip Outcome Tool 33 or iHOT 33 which as we know is a outcome measure designed to evaluate the hip related quality of life in young patients with non arthritic hip pain.
Chris Tucker:
Then they had a number of secondary outcomes, including the hip outcome score, other health related quality of life measures, healthcare costs, as well as MCID and past scores when available. They found only three randomized control trials that were level one studies that they included. This totaled 650 patients with a follow rate of 90% and it averaged 11 and a half months of followup. The mean age of the patients was 35 and half of them roughly were male, half female. The strength of the study was that all three randomized controlled trials that they included were of high methodologic quality and had a low risk of bias.
Chris Tucker:
The outcomes of their meta analysis showed that ultimately patients treated with operative management did have improved preoperative to postoperative change scores on the IHOT 33 as compared to non-operative management with a mean difference of 3.46. And on the iHOT 33 scale, it's a 100 point scale. So, the mean difference between surgery versus non-surgery or physical therapy-based treatment was roughly 3.5 points. There was only one study in the group analysis that evaluated the NCID or the minimal clinically important difference and that was basically 51% of the operative patients achieved the MCID. And they also, that same study was the only one to evaluate for the past or the patient acceptable symptomatic state.
Chris Tucker:
Again, it was roughly 50% or half at exactly 48%, and that was on the hip outcomes score activities of daily living scale. So ultimately in conclusion, this meta analysis found that FAI syndrome treated with surgery via hip arthroscopy does have statistically superior hip-related outcomes in the short term, compared with treatment with physical therapy alone, and thus kind of lies both the strength and the weakness of the study. I think it was extremely high quality meta analysis, but one of the inherent limitations is just the limitation of available information that's out there. With only one study evaluating the actual clinical significance of this difference that was found, I think that just calls into question, the overall approach of management of FAI with surgery as a first line versus a second line treatment.
Chris Tucker:
When you have a meta analysis that shows a statistical significance, which in this case was 3.5 points on 100 point scale, you also have to clinically discuss the importance of that small difference and whether that's clinically beneficial. Only one of the three level one studies did that. And the one that did show that essentially only half the patients who underwent surgery achieved, what was it? Satisfactory symptomatic state or achieved a benefit that was larger than what the minimally important change has been determined to be. Their secondary outcome measure of cost effectiveness was also reported.
Chris Tucker:
Essentially there was two out of the three studies that showed that hip arthroscopy was much more costly than physical therapy. In one study, it was 10 times greater costs. And in the other study, it was three times greater. However, again, this is a meta analysis of short-term results for short-term outcomes. And as many papers that look at cost-effectiveness have shown using a financial model to look at cost-effectiveness requires calculating economic burden on society, direct indirect costs over the long-term. So I think that's potentially a premature conclusion to draw from this particular paper, that surgery is more costly. I think it was an interesting finding to be noted, but not necessarily extrapolated as the end-all conclusion. That's kind of the summary of the article. We can discuss the specifics of it further if you like.
Clay Nuelle:
Yeah. That's a terrific summary, Chris. Well, so what do you think, should we be operating on the majority of symptomatic patients with FAI?
Chris Tucker:
I think it's interesting. I think hip patients in general require a significant amount of patient counseling education and investment in expectation. Those three principles are paramount, I think in caring for hip patients in general, and this paper helped with that. I think because it sought to answer at least one of the key questions that patients commonly have, which is, "What are my expected outcomes and what's the cost benefit ratio of doing this or doing it now versus later, or doing physical therapy first?" I think what we can counsel patients now is that, surgery's not necessarily going to be cost-effective. It's potentially going to have some increased risk of co-morbidities and your outcomes will likely have a chance of improving partially with either option, either physical therapy or surgery. But unfortunately you have to temper your expectations that your return to sport and return to pre-injury level and your satisfaction, has a chance of not being significantly beneficial.
Chris Tucker:
So my approach is to not use surgery as a first line treatment. I typically exercise caution with offering somebody surgery at the first consultation. I typically encourage everyone to have a course of conservative management, which includes a physical therapy based program, which unfortunately even in this meta analysis, wasn't standardized, but I think a good exercise-based physical therapy program for a period of time to see if they can achieve reasonable improvement of symptoms. If that fails, I think for the correct patient with clinical and radiographic AI, with the absence of arthritis in any of the other risk factors with failure, I think it does play a role.
Clay Nuelle:
I think that's a terrific approach. What do you think Justin? Does this meta analysis, does this change your practice at all? Or does it reinforce what you're already doing in your approach currently?
Justin Arner:
Yeah. I think it reinforces it. I think, I guess I would pretty much echo everything. Chris mentioned that how clinically significant are some of these numbers is certainly something in just research in general, we're starting to realize is more important than just the numbers and how many people are returning to sport at the same level. And certainly the cost effectiveness thing needs some more work. And also the short term aspect, I know there are some studies that show with the proprioception, the labrum, if you fix the labrum and don't do an adequate or appropriate cam decompression that people can still do well for a year, maybe even longer.
Justin Arner:
So certainly we need longer term outcomes. And I think it's coming, we're getting better with, with hip research, I think. And we're just kind of breaking the tip of iceberg, which is an exciting time that we're able to see that happen. But certainly the struggle with getting the right type of physical therapy from people that are from far away, is a challenge sometimes. But I think important and they certainly, it takes time to have a long discussion and patient education. And I think that's really essential.
Clay Nuelle:
I think those are great points too. Andy, you know, most of the papers we look at now, we know we're talking a lot more about minimum clinically important difference or MCID or patient acceptable symptomatic state pass, and some of these other kind of more clinically relevant things. And certainly statistical significance is still important and is still reported. But how much do you, when you analyze these types of papers and read these papers, how much do you look for specifically for things like the MCID in the past versus kind of the historical statistical significance?
Andy Sheean:
Yeah. So I think that we are obligated to be looking at those metrics. I think that just looking at a P value of less than 0.05, that's an obsolete way of assessing these patient port outcomes data. I think that the Arthroscopy Journal has been on the vanguard of really pushing that and encouraging our reviewers when they're reviewing manuscripts to be pressing authors on making sure that those data are submitted. So I think in that respect, it's something that's mandatory, I think in 2021, for readers to be thinking about way more than just a P value of less than 0.05.
Clay Nuelle:
Yeah, I think that's great. And I think those are great points and I think it's just going to make all of these things so much more clinically-relevant for all of us, hopefully going forward and clinically-applicable. So the final award winning paper was the Resident Fellow Research Excellence Award winner, and it was a paper entitled Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial. The primary author was James Higgins, Dr. James Higgins. This is a study that was done out of Toronto and it was a randomized control trial at a single center that compared a mobile app versus regular normal in-person visits after ACL reconstruction in patients aged 60 to 70 years old.
Clay Nuelle:
So they basically randomized total of 60 patients into these two different groups, one group that had a mobile app that they just had on their phone and input some of their pain scores and then how they were feeling and some of those types of things into the app that could then be reviewed by the surgeon and the surgeon's team. Versus actually seeing the surgeon in person at their normal visits, that they would see them at one, two and six week follow-up and their primary outcome was to evaluate whether or not that would reduce the number of overall visits. And then also to analyze the costs both to the healthcare system and to the personal patient costs. And so the results showed that the app group, as you would expect it attended a mean of 0.36 in-person visits. And what they quantified as an in-person visit is either a visit to the surgeon or possibly a visit to their primary care physician or to the ER, because of a potential complication, which would normally on average be three visits for their standardized follow-up.
Clay Nuelle:
In the app group, patients spent a total of $211 Canadian, less than the conventional group over that six weeks on personal costs. And the healthcare system costs were less than the app group at $157.50 versus $202. So there was no difference in patient satisfaction, convenience or complication rates or overall clinical outcome measures between the two groups. So their overall conclusions were that the mobile app could potentially eliminate a significant number of in-person visits during the first six post-operative weeks. And patients that undergo ACL reconstruction than overall cost savings to both the patient and the healthcare system.
Clay Nuelle:
So I think this was an interesting study and certainly one that is very timely and appropriate, in a pandemic year when everybody's trying to limit in-person everything, including in-person visits to the physician or in the health care followup. And so I think certainly as telemedicine has exponentially exploded and grown and other avenues of trying to reach patients and follow up patients and continue to interact with patients other than face-to-face or in-person think any of those things are something that they're very valuable and something that's definitely going to be a powerful tool for us going forward. And especially I think that initial post-operative period, and particularly in this patient group, and I'll let each of you guys speak to how you do it, but for my ACL reconstructions, I'd like to see you have them get into physical therapy within the first two to three days after surgery.
Clay Nuelle:
I do like to have that be in-person because I like to have the therapist, not only have them start moving the knee and starting range of motion and starting strengthening exercises, but that therapist is also a person that can help them kind of push them and give them the confidence they need to start their rehab off on the right foot. And so I think in-person physical therapy for this particular procedure and post-op rehab is vitally important, but certainly maybe, some of the post-op clinic visits with the surgeon themselves could be limited or it could be definitely aided or followed up on utilizing a mobile app.
Clay Nuelle:
So I think it's a good study and something that certainly potentially could be very useful in a surgeon's practice going forward. So we'll go down the list. Andy, what do you think? Would you like to have an app that the patients can interact with you?
Andy Sheean:
Maybe. I mean, I think that the bias of my training was to see people early and often, especially after ACL reconstruction. And so I see all of my patients within seven days postoperative. I would echo what you said about getting people in as soon as practical physical therapy, post-operative, two to three days, certainly is ideal. And so I think that it's interesting that the data certainly are compelling, but I think in that first six week period for me, that's what I really want to keep keeping a really close eye on folks, independent of their wounds look fine, which is obviously what we're looking at always, but do they have an effusion? How's their quad tendon early on? Is this someone that may need an aspiration early, if that's something that you believe in?
Andy Sheean:
My ACL reconstruction patients are the patients that I worry about some of them, most, because I'm just trying to do everything I can to mitigate the likelihood of them getting stiff, obviating a necessity for return to the operating room for a manipulation or anesthesia. So again, compelling data for sure. And again, as you mentioned, very timely, but, I'll probably continue to stay more on the old-fashioned old school side of things for the time being.
Clay Nuelle:
Justin, you're a fellow Pitt guy like Andy. You fall on everybody in-person yourself, or would you like to have an app help you out?
Justin Arner:
Yeah, I think I agree with both of you for the ACL, the reasons Andy mentioned. That if you have someone that got a little stiff, you just never want that to happen and seeing them and having a therapist, making sure that they're getting full extension early on, I think is essential. But, I get excited about studies like this because I think in the future with so many different studies and the European [inaudible 00:39:34] for example, they're not sending people to therapy for quite a while, six weeks or longer before they're doing anything. I know this is Arthroscopy Journal Podcast, for those that do total knees, maybe there's probably a role for apps like this and different devices that the physical therapist can monitor.
Justin Arner:
So I think it's an exciting type of thing that we'll see over our careers slowly change. And the postoperative times with visits will probably change. And like you mentioned, with the COVID and inpatient visits, I think it's an exciting time and I'm sure insurance companies will find how to financially make this most beneficial. So it's good to see some data like this, I think.
Clay Nuelle:
Chris, what do you think?
Chris Tucker:
Personally, I'm pretty excited about studies like this. I'm a big fan of any tools that I can add to my armamentarium that potentially help with patient compliance. And I think that's really what these apps have kind of a high yield in potentially contributing to. I absolutely agree with everybody's comments about the in-person evaluation and the necessity to kind of follow patients, in-person physically and personally to make sure that they're hitting the landmarks you want them to hit. But, I've worked a therapist into my preop clinic where I actually have them see me, I have the therapist see the patient alongside me do preoperative patient education.
Chris Tucker:
That's potentially a luxury I have in the military system having the freedom to kind of schedule that sort of visit. But I think it helps a ton for setting the patient up for success to know what they're going to be doing immediately after surgery for the first one to two weeks, before they may be getting a formal physical therapy appointment. And then that same therapist of mine also does kind of a hybrid treatment model where he has an internet-based system where he has communication with the patient through a website with updated and protocol adjustments. So, not quite as streamlined and fancy as an app, but I think anything that helps a patient to be compliant and educated, I'm all for trying it out as an adjunct.
Chris Tucker:
I think, like you said Clay, in the midst of a pandemic, I think a lot of our systematic weaknesses have been exposed. And I think the struggle for reimbursement with insurance companies will continue to be... They'll continue to tighten the wallet and make access to resources like physical therapy only more limited, not more expensive. So I think anything that we can do to help our patient overall care, I'm open to trying or listening to.
Clay Nuelle:
Yeah. I think those are great points. I think it's just another avenue or another arrow in our remote or internet-based quiver, if you will. In addition to the formal telemedicine visits and other things that certainly all of us are becoming more and more accustomed to, and probably will be at least for the foreseeable future and maybe for long-term future, a part of medical practice and something that'll be a very frequent thing going forward. That's a great summary of all four of those articles. In addition to that, we have the most downloaded article and the most cited article from 2015, The Arthroscopy Journal likes to publish those two things, five years after the fact to kind of go back and highlight popular articles.
Clay Nuelle:
The most downloaded article from 2015 was entitled Subscapularis tendon tear classification based on 3-dimensional anatomic footprint: A cadaveric and prospective clinical observational study. The first officer on that was Dr. Jae Chul Yoo. And finally the most cited article from 2015 was entitled Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review with the primary author being Jonathan Frank in association with Josh Harris and Shane Nho among others from the Rush group. So if you have not downloaded or cited either of those articles at some point, then definitely go do that.
Clay Nuelle:
So, this concludes this edition of the Arthroscopy Journal Podcast, and that puts a wrap on 2020, hopefully for all of us, Andy, thanks for joining me. Justin, thanks for joining me. Chris, thanks for joining me.
Justin Arner:
Thanks a lot, guys.
Andy Sheean:
This was really fun. Appreciate it.
Chris Tucker:
Yeah. Thanks for having me on this episode and thanks for all your hard work over the past year, guys. Fantastic. I'm looking forward to 2021.
Clay Nuelle:
That concludes 2020 for The Arthroscopy Journal Podcast. As always, if you enjoy the podcast, please remember to give us a five star review on your podcast device, and we look forward to adding more and reviewing more interesting articles and more great things to come on the podcast in 2021. Thank you all.