Dr. Chris Tucke...: Welcome to the Arthroscopy Journal Podcast. I'm Dr. Chris Tucker from the Walter Reed National Military Medical Center and founding editor of the podcast. Today, we are excited to be hosting our annual award-winning papers episode in which we feature the 2021 Arthroscopy Journal Research award-winning papers. I'm joined in this discussion by my other Arthroscopy Journal podcast host, Doctors Andrea Spiker from the University of Wisconsin.
Dr. Andrea Spik...: Hi Chris, it's a pleasure to be here tonight.
Dr. Chris Tucke...: Dr. Justin Arner from the University of Pittsburgh Medical Center.
Dr. Justin Arne...: Thanks Chris, excited about it, this should be a good conversation.
Dr. Chris Tucke...: And Dr. Travis Dekker from Eglin Air Force Base.
Dr. Travis Dekk...: Thanks for having me on Chris.
Dr. Chris Tucke...: Yeah, it's great to join you all in the discussion. So we're going to be doing a round table discussion format in which we review the various 2021 award-winning papers, which were announced in the January 2022 issue of the Arthroscopy Journal. The first article we will discuss is the 2021 award-winning paper for excellence in clinical research, entitled Platelet Rich Plasma in Patients with Partial Thickness Rotator Cuff Tears or Tendinopathy, Leads to Significantly Improved Short Term Pain Relief and Function Compared with Corticosteroid Injection, a Double-Blinded Randomized Control Trial, which was authored by lead author, Corey Kwong and senior author, Ian Lo and originally published in the February 2021 issue.
I'll start this discussion off with a brief synopsis of the article and my thoughts, and then I'll be followed by some additional commentary by Dr. Dekker. So this study was from a group of well-respected surgeons in Canada. It's a level one, double-blinded randomized controlled clinical trial, comparing platelet rich plasma or PRP, to standard corticosteroid injections in providing pain relief or improved function in patients with rotator cuff tendinopathy or partial thickness cuff tears. The group enrolled a total of 99 patients and confirmed the rotator cuff pathology on either ultrasound or MRI imaging.
They collected baseline demographics and randomized patients into one of two treatment arms, which included an ultrasound-guided injection of either PRP or corticosteroid at times zero, with assessments at baseline six weeks, three months and 12 months post-injection, of the visual analog score for pain, as well as the AS, ES and Western Ontario Rotator Cuff Index Scores. They defined failure as subsequent injection or either consent to undergo surgery or actual operative intervention. The results revealed of the 99 patients they enrolled and followed to completion, there were no differences in failures or progression to surgery between the two groups and both groups showed improvement in VAS and functional outcome scores at all time points, but the PRP group did have a superior improvement at VAS, ASCS and Western Ontario Rotator Cuff Index Scores at the three month post injection mark, which were all statistically significant.
The authors concluded that patients with cuff tear tendinopathy or partial thickness cuff tears, could experience clinical improvement in pain and functional scores with ultrasound-guided injection of both PRP or corticosteroid, and can have superior improvement at the short term, three month mark with the PRP, but that effect didn't last out to 12 months.
First off, I think it's a fairly highly quality study based on the design, the methodology and the execution and I particularly enjoyed that it addresses a condition that is frequently encountered in our sports medicine practice and an intervention that's commonly used in our clinics. I think it's a great example of clinical questions driving clinical research, and I applaud the authors for their hard work and the journal for recognizing their achievement. Secondly, I applaud the authors for their design as conducting these clinical trials is very labor intensive and requires considerable dedication and commitment to take it to completion.
To highlight the specifics of the injections themselves, the technique described using an ultrasound in both groups and involved subacromial injection of the corticosteroid and aesthetic mixture for that treatment arm, but to ensure the patient received the same injection feel, so to speak, they also got this placebo fenestration of the diseased cuff tendon. Whereas the PRP group received a three to five milliliter volume of injection directly into the site of the tendon pathology and then the remainder of the PRP just went into the subacromial space. That's important to note in that these techniques, which may be different from your current practice, would need to be replicated to experience or expect similar results.
An interesting finding to note is the overall failure rate of 28% within 12 months of injection for all comers. It was 23% in the PRP group and 33% in the corticosteroid group. Although that difference wasn't significant. Yet that didn't seem to be correlated to tear progression as follow-up ultrasound was available at three months in 98 of the 99 participants and at 12 months in 85% of them and there was a very low rate of progression to full thickness tear in only 4 to 6% of patients at study conclusion.
Thus, they concluded that while pretty much all patients can universally expect some pain and functional relief at short and long term follow up from an injection, either steroid or PRP, more than 25% of these patients ultimately fail this treatment and require another injection or surgery. The study had many strengths, including its design level of evidence, its methods, strict inclusion and exclusion criteria, and a fairly long follow up. Limitations included the heterogeneity of the two group's baseline pain and functional scores despite being randomized and the lack of a control arm.
However, overall, I do agree with the editors of the journal in that this is deserving of recognition as an outstanding clinical research paper, and it's highly recommended to those of us who treat patients with rotator cuff disease, Dr. Dekker, I welcome your thoughts and comments on the article as well.
Dr. Travis Dekk...: Well, Chris, thanks for having me on and thank you for your excellent synopsis of the article. Biologics remain a great interest regardless of pathology at the moment for both patients and surgeons alike. It's not a day that goes by in clinic where somebody's asking about some type of biologic or stem cell injection. PRP for shoulder pathology seem to be gaining great momentum in terms of their efficacy. The Journal has published great studies evaluating the benefits of PRP with the use of surgical interventions, for medium to large rotator cuff tears in those at risk patients. Doctors Kwong and colleagues present a great study to help further our knowledge, adding tools to our armamentarium when treating patients with a very common pathology. There have been extensive studies demonstrating the benefits of pain relief with the use of corticosteroid injections in the setting of partial rotator cuff tears.
Additionally, there have been equal studies to demonstrate tissue degradation and higher risk of re-tear after repair, with the use of preoperative corticosteroid shoulder injections. So I think this paper provides a great base for us as surgeons to present to patients, for possible additional modalities of non-operative or conservative measures, that could provide pain relief that is equal to that of corticosteroid injections. In other words, this was a great study to demonstrate non-inferiority even at one year with possible benefits at three months.
Of note and as you pointed out, the techniques performed in this article, differentiating the injection types is of upmost importance to pro point out. The corticosteroid injection remains a feasible and easy injection to do at bedside and clinic, as this was performed in a routine fashion in the subacromial space, while the PRP injection was directed directly into the tendon itself, which would require ultrasound guidance. As a result for this to be clinically applicable and to be reproducible, injection recommendations would need to be performed in a similar fashion to expect similar results.
Additionally, the authors point out that even in their study, nearly 25% of patients go on to require surgical intervention, regardless of that non-operative injection type. So overall, it's very clear to me why this manuscript was chosen for an award as it balances the idea of new and innovative approaches with critical scientific evaluation compared to our current gold standard, that we are able to utilize at this time. I applaud the authors and their great effort, along with their contributions as we continue to try to optimize patient care, both operatively and conservatively.
Dr. Chris Tucke...: Thanks, Travis, I appreciate your thoughtful comments. We'll next review, the 2021, award-winning paper for Excellence in Basic Science Research entitled Can Osteochondroplasty for Femoral Acetabular Impingement Increases Microinstability in Deep Flexion: A Cadaveric Study, which was authored by lead author, Geoffrey Ng and senior author, Jonathan Jeffers, and originally published in the January 2021 issue. Dr. Arner, if you'd give us your summary of the article and your thoughts and commentary first, to then be followed by some additional comments from myself.
Dr. Justin Arne...: Thanks, Chris. Yeah, I thought this was a great biomechanical study out of London, England, which basically to summarize was 12 fresh frozen cadaveric hips with FAI. And how did they tell they had FAI? I was curious. They got CTs on all of them and confirmed with a few different parameters that they had cam lesions. So basically they wanted evaluate the effect of a T capsulotomy and cam resection on motion and the creation of microinstability. So they tested range of motion, translation, and then determined microinstability after the three conditions that I mentioned, T capsulotomy, and then after doing femoroplasty, and then after closing the capsule. So they did the femoroplasty in an open fashion through the T capsulotomy. And they said they determined the appropriate amount of resection based on their direct visualization.
And then they got a new CT scan afterwards to confirm that there was no over resection. So I think it was a really well designed and well implemented study. They used a robotic testing system and optical markers to evaluate this and determined the amount of translation of the center of the hip to determine micro instability. So they did a really nice job with that. So one thing we would expect of their results is they found the external rotation increased after capsulotomy. None of the other motions increased besides external rotation, which is what we would expect and has been seen in the other literature. And then after they closed it, the capsule, this improved by about four degrees, the external rotation decreased about four degrees. Pretty much the most interesting finding of this study was that in 90 degrees of hip flexion, they found a 31% increase in microinstability after the femoroplasty.
And again, this was something they were careful about not to over resect. So they did it an appropriate femoroplasty, and then found microinstability at 90 degrees of flexion. And this was equated to about 1.9 millimeters compared to the intact state where the cadaveric hips still have the cam morphology. So as we all know here, the data historically has shown that under resection of the cam, is the most common reason for revision surgery. So many surgeons have been trending more, to become more aggressive in recent years to kind of make sure we get all the femoroplasty completed in a complete way. However, in more recent years, we've really found that over resection has a lot of downsides too, which we found in the literature that lower patient reported outcomes and higher rates of conversion to total hip replacement has been seen with over resection.
So we think, at least in part, that this is due to the labral suction seal being lost, but certainly there's more to learn in that scenario. In this study, they again indicated that over resection wasn't done, yet they still saw instability in flexion which really begs the question, are we over resecting patients where we think that we're not? This is an open scenario where they're staring right at the cam and they're still seeing microinstability. And the other question, does a small cam give some benefit to the hip with regards to stability? But, that obviously has to be balanced by some of the chondral damage that maybe this stability leads to. So, another question is 1.9 millimeters, a bad thing? And I think it's like a lot of studies, this leads to more questions, which is great and I think how we go along with the field and push the field forward.
And I was involved in this study with Dr. Philippon looking at cam over resection patients where placed a piece of folded iliotibial band allograft in the region of the over resection. And it really seems like this is more of a salvage procedure. So we basically really have to make sure we get this right the first time with our femoroplasty. And the question is, what is right? And we, to be honest, don't know, even in 2022. But like most things in life, moderation is key. And we have to find that happy medium. And we know specific postop, alpha angle studies have shown, don't really lead to necessarily better outcomes and some believe the inoperative exam is key, but it's difficult to reproduce all functional motions in the operating room.
So in summary, this is a really well done in vitro cadaveric analysis that at times zero showed excessive motion after an appropriate cam resection was seen. So we really need to be careful and cautious, and I think more studies need to be done to investigate our appropriate care morphology. But it's really an exciting time in hip arthroscopy, it's really growing before our eyes. So it'll be interesting in the upcoming decades how much this changes. So thanks Chris.
Dr. Chris Tucke...: Thanks Justin. That was a fantastic summary. I enjoyed reading this paper myself. I think all my residents who've ever done a hip scope with me know this is probably one of my favorite areas of interest to discuss with them intraoperatively, with respect to the technical aspects of just doing an osteochondroplasty. So I did enjoy reading this kind of bench research and basic science research on the topic.
As you eloquently discussed, I think this paper contributes to the practice of all surgeons performing hip arthroscopy, as it does add to our understanding of this complicated topic in the factors that contribute to potential postoperative iatrogenic, microinstability. As we all know, the prevalence of FAI in treatment in the sports world has exploded in recent years. And with it, our understanding of the pathology involved and its treatment options has also evolved and improved. The term microinstability wasn't really even used a decade or more ago, and now it's fairly well recognized and it refers to this symptomatic, excessive motion of the femoral head within the acetabulum during functional activities.
That motion is bad. It can contribute to altered loading of the articulate cartilage, potential acceleration of the arthritic disease process. But, as you also referred to, microinstability as multifactorial, it can be attributed to osseous cam morphology. It can also be attributed to soft tissue, the capsule or iatrogenic. I think these authors did a nice meticulous investigation in a stepwise fashion, which you described nicely, of the various steps in doing FAI hip arthroscopy, to determine what each one's contribution was. And like you said, their main finding, was that this cam resection can increase the micro instability by 31%, they calculated, at 90 degrees of hip flexion.
I think, like you said, it relates to the disruption of that labral suction seal as the area of resection passes under that labrum. But I think it's just confirming what we all already know, which is that one, nothing we do is ever entirely benign, the concept of there is no free lunch. And two, the best treatment approach is customizing surgery to the patient. In this case, that means a custom femoral osteoplasty to match that pathology with the patient involved. There's other things to take into consideration, variables like the labral status, in this study, they obviously didn't address the labrum, they left it intact. The soft tissue conditions in general, ligamentous laxity, gender, age, activity level, et cetera.
So the adage of first do no harm, certainly holds true in hip arthroscopy, the dangers of over resection and creating that dreaded cliff sign and pathologic microinstability, are equally as challenging to manage, as under resection and failure to relieve that impingement in the first place. So I think we're all just striving to be like Goldilocks and just get it just right.
Our third article of the podcast is the 2021 award-winning paper for Excellence in Systematic Review Meta-Analysis Research, entitled, Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Network Meta-Analysis, which was authored by lead author, Marty Davey and senior author, Kirk Campbell, and originally published in the April 2021 issue. Dr. Dekker, would you give us your summary of this work and your thoughts?
Dr. Travis Dekk...: Yes. This well done systematic review and meta-analysis performed by Doctors Davey and Campbell is a level two analysis of randomized control trials and provides an excellent review evaluating perioperative care and pain management for one of the most common procedures that we perform in sports orthopedic medicine. Our favorite, ACL reconstruction, the authors critically looked and found randomized control trials, evaluating peripheral nerve blocks, intraarticular injections, perioperative oral and intravenous medications, TXA, cold therapy with compression, along with nerve block adjuncts. As you can imagine, there are tons of studies that involve pain control modalities in the setting of ACL reconstruction. They were able to identify a total of 409 randomized control trials, while only 74 met their inclusion criteria. So there were a lot of excellent and relevant findings, and I'll do my best to highlight the relevant findings.
The modality that met inclusion criteria that produced the most articles for review included peripheral nerve blocks. I can imagine that most of us and most of the listeners provide nerve blocks for their ACL patients. And so they identified a total of 34 studies evaluating different types of nerve blocks in the setting of ACL reconstruction. They showed equivalence amongst the most commonly utilized peripheral nerve blocks to include those ephemeral sciatic nerve blocks, femoral nerve blocks, and that of the adductor canal. As a result of demonstrating no difference in terms of pain relief amongst the blocks, the authors point out the possible detrimental effects that femoral nerve blocks may have on postoperative rehabilitation. And so we should carefully consider block choice as it pertains to our individual patients.
Another interesting finding that is probably less well known to orthopedic surgeons is the use of block adjuncts. The two adjuncts that demonstrated improved effects of the block include magnesium sulfate dexamethasone. There's no difference when they use quantity. These two adjuncts demonstrated improved pain relief up to 18 hours after surgery, which equated to lower opioid consumption. I found this portion of the manuscript to be very beneficial to my own practice and have even discussed this now with my anesthesiologist that perform the peripheral nerve blocks. Additionally, a multitude of oral, anti-inflammatories were evaluated to include Toradol, Celecoxib, ibuprofen, all of which showed efficacy in decreasing postoperative pain, anywhere from 4 to 24 hours after surgery.
Interestingly, Gabapentin demonstrated improved postoperative pain control when given preoperatively compared to that for Gabalin or Lyrica. An additional perioperative medication being utilized across orthopedics now is TXA. Our joints and arthroplasty colleagues have been using this for years, and they think this is starting to catch on with sports medicine and they found three randomized controls trials, specifically looking at the use of TXA in the setting of ACR reconstruction and it's effect on postoperative pain.
Two out of the three studies demonstrated improved pain relief with the use of TXA. They attributed this to lower rates of hemarthrosis up to four weeks out from surgery. Lastly, I think most surgeons do utilize cryotherapy and they evaluated cryotherapy with compression to alleviate postoperative pain. They identified a multitude of randomized control trials evaluating this modality with the majority of those demonstrating improved pain control with less opioid use over a variety of time periods.
So in conclusion, their most conclusive findings found peripheral nerve blocks with adjuncts, along with intraarticular injections, utilizing bupivacaine with an additional adjunct provided is sustained postoperative pain relief, which decreased the overall opioid consumption. With that, I'd like to get the thoughts and takeaways from Dr. Andrea Spiker and how this article will impact not only her practice, but the practice of the listeners.
Dr. Andrea Spik...: Thanks Travis. That was an excellent summary of this award-winning systematic review. First of all, you mentioned this, but I found the vast number and variety of studies on pain control after ACL was just staggering. So you mentioned they found 406 randomized controlled studies. There were 5,341 studies in general on pain control that met their inclusion criteria. So I think that proved that there's really no gold standard for how to treat pain after ACL reconstruction. And there are so many different ways to approach this, as you mentioned. It's a really important topic to approach, and I'm glad that the authors broached this. As the authors mentioned within their discussion, it's clear that we need to try to find ways to decrease the amount of opioids prescribed and used after all orthopedic surgeries, including ACL reconstruction. So this is a good step in the right direction to finding a way to reduce opioid consumption.
One significant limitation to this study was based on its study methodology and that was that the authors couldn't look at the adverse effects of each of these modalities. So for example, one thing that I deal with in my own practice is the concern of falls related to nerve blocks or delayed return of muscle function. And similarly with interarticular injections, they couldn't get granular with the risks of potential damage to the interarticular cartilage. And with TXA use the question of whether it led to coagulopathy complications could not be assessed.
And one of their new ones they weren't able to look into is the different types of injections for different autographs used during surgery. For example, local anesthetic injected directly into a hamstring harvest site or along the quadriceps graft harvest site. And they couldn't delve into variations and pain and postoperative recovery, which may be quite different when concomitant procedures like meniscal repair are performed.
So these are all areas which could use further study, which of course could add to the thousands of existing studies on this topic. But I thought this was an excellent review in summarizing what data is out there. And as you mentioned, it's directly applicable to our own practices where we can work together to try to find ways to decrease opioid consumption in our ACL patients.
Dr. Chris Tucke...: Thanks, Travis and Andrea. The sheer volume of articles that went into this systematic review was staggering. And you did an impressive job of summarizing it and delivering that in a fairly concise way. And I agree and echo both of your comments, that this is extremely applicable to pretty much any orthopedic surgeon who practices sports medicine and does ACL surgery, to the betterment of our patients. So thank you for that excellent discussion.
Finally, our last article of the podcast will be the 2021 award-winning paper for Excellence in Resident Fellow Research, entitled, Development and Internal Validation of Supervised Machine Learning Algorithms for Predicting Clinically Significant Functional Improvement in a Mixed Population of Primary Hip Arthroscopy, which was authored by lead author, Kyle Kunze and senior author, Shane Nho, and originally published in the May 2021 issue. Of note, we featured this article in its own podcast, episode 129, released on September 27th, 2021, in which Dr. Andrea Spiker interviewed Dr. Nho and had an in-depth discussion of his study and commentary. So Dr. Spiker, can you share with us your summary of the article and your thoughts?
Dr. Andrea Spik...: Absolutely. Thanks Chris. So the premise of this article was to develop and then to validate a machine learning algorithm to predict which patients would demonstrate significant functional improvements after hip arthroscopy. So the authors who hailed from the Hospital of Special surgery and Midwest Orthopedics at Rush, then took it even a step further and sought to develop a clinical application capable of providing patients and the surgeons counseling those patients, with an individualized risk profile. This application would then give patients an idea of how likely they would be to have a clinically significant improvement in function after hip arthroscopy surgery.
So this study really gets to the million dollar question in orthopedic surgery in general, as well as arthroscopic surgery and hip arthroscopy specifically. And that question is, who will do well after surgery? So knowing the answer to this question will really help us as we indicate patients for this procedure, help us counsel patients, and then help us understand what is normal and expected after surgery versus what clinical course may indicate a problem in hip arthroscopy recovery.
So to get the answer to this question, the authors performed a retrospective review of consecutive hip arthroscopy patients between 2012 and 2017 performed by a single high volume hip arthroscopist, Dr. Shane Nho. They excluded revision hip arthroscopy patients, those who had dysplasia, [inaudible], and those who have less than two years of follow up. The primary outcome measure was the minimal clinically important difference or MCID for the hip outcome score activities of daily living at two years, postoperatively. I'll refer to this patient reported outcome measure as a HOS-ADL from here on out.
So the HOS-ADL subscale lists a number of activities and then it has patients rates, whether they have no difficulty, slight difficulty, moderate difficulty, extreme difficulty, or are unable to perform that task. It also asks the patient to rate his or her current level of function on a scale from zero to 100, with 100% being their level of function prior to their hip problem.
So machine learning just to get everybody on the same page, is defined as the use of statistical techniques that facilitate the process of learning or improvement of tasks used by machines, such as computers, and machine learning allows modeling of complex, non-linear associations and can perform dynamic predictions as further data is introduced into an algorithm. So in total, these authors were able to include 818 patients, a median age of 32, 69% were female, and of these patients, 74% achieved MCID for the HOS-ADL. The authors created five different machine learning algorithms and identified one which performed the best and of the patient characteristics that they entered into this algorithm, they identified the eight most important features for predicting MCID after hip arthroscopy. These included patient body mass index, age, preoperative HOS-ADL score, preoperative pain level, sex, Tonnis grade, symptom duration of greater than two years and greater than one drug allergy.
They then created an open access website where you can enter patient information and click a button, which will churn out a prediction. And this calculation gives the probability of achieving clinical success as a percentage and then it also gives some visual aids to break down the details even further. When I think about the strengths of the study, utilizing a massive amount of data from patients, the authors were able to make a large stride toward personalized medicine. They were also able to identify some preoperative factors that played a role in patient outcome, which were modifiable or semi modifiable. So for example, because a high BMI was predictive of a worse outcome, weight loss before surgery could be utilized, or if somebody had more than one drug allergy, targeted allergy intervention before surgery could be attempted. And in compiling this publicly accessible digital application, they're really taking a step toward personalized medicine, which I believe is going to become more of a part of our practices in the future.
I think the main weakness of the study was simply that it was based on a large single surgeon, single institution cohort. So it will require external validation to determine its generalizability. But all in all, the authors did a really commendable job of trying to get to the crux of the question of who will do well after arthroscopy. And then they went above and beyond by sharing this application with the public, allowing other surgeons and even patients to have a better understanding of their chances of doing well after hip arthroscopy. And if the listeners want to check out this digital application, the web address is listed within the manuscript, which can be found on arthroscopyjournal.org. So I'll pass this on to Dr. Justin Arner next. I'd love to hear your thoughts and comments on this article as well.
Dr. Justin Arne...: Thanks Andrea, you had a great summary there. Like you mentioned, I think it's really an impressive amount of work that these authors put together and really a ton of patients like you mentioned. It's really high level, they get into the language of how to put these together. And certainly a lot of it's very foreign to me. So, I think I'd like to applaud them because this is really pushing, like you mentioned, this field forward and it's, I think, the future of our paths. The other important part is that you mentioned it's a free service, so you can log onto your website, which is really admirable.
I think there's a really nice editorial also by Josh Harris, an Associate Editor of the Journal, which I think is really important. And as Chris mentioned, your podcast with Shane Nho is great. I certainly recommend everyone listen to that. But, a few things I think that are important, that are good points to make are that, not all surgeons have the skillset or volume like Shane Nho has there. So, are all of our outcomes exactly, be able to be predicted by this model? Certainly it's the best we have, but we kind of have to use this in our practice if we're lower volume surgeons which most people in the country and world I'm sure are, compared to Shane Nho's practice. So it makes it a little bit tricky to predict that way.
And there's lots of factors and certainly they did a lot of work to distill this down, but there's some others out there looking at depression and anxiety and as you mentioned allergies, which are, I think really important for people that take care of hips are aware of that, it's a real consideration. And as you mentioned, and as mentioned in your podcast, that I think this is helpful with informed consent. And I think patients really love it using use of technology and the buzzword of artificial intelligence. If you pull this computer program up on your clinic computer and show them the graph and where they fall in and discuss the specifics of them, I think, patients really like that.
And I think one question is, are we able to get this to catch on? I think if we're able to get more and more people to use this and validate the study and talk more about it, I think this is certainly better than a typical just [inaudible] that we had come up with, with hip scope patients, because their outcome is a little less predictable, I think. And certainly the surgical intervention is very high demanding until you get that learning curve. And even after that, so appreciate you letting me talk about, I think, it's a great study and again, your podcast is really incredible. I recommend everyone taking a listen to that.
Dr. Chris Tucke...: Yeah. Thanks, Andrea and Justin, those were fantastic comments on really a wonderful article, interesting to read. And as you said, Justin, I think it's pushing the field forward and I can't over emphasize enough, if you really are into this, checkout Andrea's podcast from back in September, episode 129. She really gets into the nitty gritty and picks the brain of the senior author on this paper.
Well, that wraps up our discussion of the four award-winning papers from 2021. I want to thank Doctors Justin Arner, Andrea Spiker and Travis Dekker for joining me for this episode, but more importantly, for their hard work throughout the past year, hosting the podcast. It's been fun and educational. I think we have a bright outlook and we've got some great momentum heading into 2022. So personally for myself to you guys, thanks so much for everything you do.
Dr. Andrea Spik...: Thanks, Chris.
Dr. Justin Arne...: Chris, it's always a great time and a great learning experience. I appreciate the opportunity.
Dr. Travis Dekk...: Yeah, Chris, it's been an awesome ride so far and look forward to the next year.
Dr. Chris Tucke...: Well, this concludes this edition of the Arthroscopy Journal Podcast. As always, if you enjoy the podcast, please leave us a five star review and we welcome your comments and your feedback. The views expressed in the podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
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