Editorial Commentary: Patients Who Achieve a Minimal Clinically Important Difference (Feel Better) Early After Hip Arthroscopy Have the Highest Rates of Long-Term Satisfaction.

Analyzing patient-reported outcomes using the lens of the minimal clinical important difference (MCID) and patient acceptable symptomatic state allows surgeons to assess patient recovery at the individual level and make necessary changes to management if necessary. When patients with femoroacetabular impingement achieve MCID 6 months after arthroscopic treatment, they achieve patient acceptable symptomatic state 2 years postoperatively 88% of the time. The findings highlight the importance of the postoperative recovery trajectory and illustrate a quantitative way to study the progress of individual patients along their care journey.

Opioid- and Motor-sparing with Proximal, Mid-, and Distal Locations for Adductor Canal Block in Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial.

BACKGROUND: The ideal location for single-injection adductor canal block that maximizes analgesia while minimizing quadriceps weakness after painful knee surgery is unclear. This triple-blind trial compares ultrasound-guided adductor canal block injection locations with the femoral artery positioned medial (proximal adductor canal), inferior (mid-adductor canal), and lateral (distal adductor canal) to the sartorius muscle to determine the location that optimizes postoperative analgesia and motor function. The hypothesis was that distal adductor block has (1) a superior opioid-sparing effect and (2) preserved quadriceps strength, compared with proximal and mid-locations for anterior cruciate ligament reconstruction. METHODS: For the study, 108 patients were randomized to proximal, mid-, or distal adductor canal injection locations for adductor canal block. Cumulative 24-h oral morphine equivalent consumption and percentage quadriceps strength decrease (maximum voluntary isometric contraction) at 30 min postinjection were coprimary outcomes. The time to first analgesic request, pain scores, postoperative nausea/vomiting at least once within the first 24 h, and block-related complications at 2 weeks were also evaluated. RESULTS: All patients completed the study. Contrary to the hypothesis, proximal adductor canal block decreased 24-h morphine consumption to a mean ± SD of 34.3 ± 19.1 mg, (P < 0.0001) compared to 64.0 ± 33.6 and 65.7 ± 22.9 mg for the mid- and distal locations, respectively, with differences [95% CI] of 29.7 mg [17.2, 42.2] and 31.4 mg [21.5, 41.3], respectively, mostly in the postanesthesia care unit. Quadriceps strength was similar, with 16.7%:13.4%:15.3% decreases for proximal:mid:distal adductor canal blocks. The nausea/vomiting risk was also lower with proximal adductor canal block (10 of 34, 29.4%) compared to distal location (23 of 36, 63.9%; P = 0.005). The time to first analgesic request was longer, and postoperative pain was improved up to 6 h for proximal adductor canal block, compared to mid- and distal locations. CONCLUSIONS: A proximal adductor canal injection location decreases opioid consumption and opioid-related side effects without compromising quadriceps strength compared to mid- and distal locations for adductor canal block in patients undergoing anterior cruciate ligament reconstruction.

Autologous Interleukin 1 Receptor Antagonist Blood-Derived Products for Knee Osteoarthritis: A Systematic Review.

PURPOSE: To systematically review the available clinical data regarding the use of autologous IL-1 receptor antagonist blood products (AILBPs) and their validity as an alternative intra-articular (IA) therapy for symptomatic knee osteoarthritis (OA). METHODS: The PubMed, MEDLINE, Embase, and Cochrane Library databases were searched from inception to June 2018. All randomized controlled trials (RCTs) and noncomparative studies that evaluated the clinical efficacy of AILBPs (i.e., autologous protein solution and autologous conditioned serum) for knee OA were included. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index. The secondary outcomes measured were the Knee Injury and Osteoarthritis Outcome Score, visual analog scale score, Short Form 36 (SF-36) score, radiographic scores, and adverse events, which were qualitatively analyzed. RESULTS: We included 8 studies, comprising 3 RCTs (Level II) and 5 noncomparative studies (Level IV), with a total of 592 patients (mean age, 56.4 years; 49.7% male patients). The RCTs represented high methodologic quality, whereas the noncomparative studies represented moderate to good quality. With AILBPs, 2 of 4 studies (50%) showed improvements in the Knee Injury and Osteoarthritis Outcome Score symptom and sport subscales, 5 of 7 studies (71%) achieved improvements in the Western Ontario and McMaster Universities Osteoarthritis Index score, and 4 of 5 studies (80%) attained improvements in the visual analog scale pain score from baseline to final follow-up. Most adverse events associated with AILBPs were mild to moderate in severity and were primarily localized to the injection site. CONCLUSIONS: Limited evidence substantiates that AILBPs are a safe and tolerable IA injection therapy that may improve pain parameters and functionality for mild to moderate knee OA patients and may be an effective adjunct for those unresponsive to traditional IA therapies. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Bone marrow stimulation decreases retear rates after primary arthroscopic rotator cuff repair: a systematic review and meta-analysis.

BACKGROUND: Despite the optimization of biomechanical and patient factors in the setting of rotator cuff repair (RCR), postoperative retear rates remain high in many series reported in the literature. Preclinical studies have suggested bone marrow stimulation (BMS) at the rotator cuff footprint may reduce the rate of retear after RCR. The objective of this meta-analysis was to analyze the clinical evidence investigating the effect of arthroscopic RCR, with and without BMS, on rotator cuff healing and functional outcomes. METHODS: PubMed, MEDLINE, Embase, and the Cochrane Library were searched through December 2017. Two reviewers selected studies based on the inclusion criteria and assessed methodologic quality. Pooled analyses were performed for continuous and binomial variables where appropriate. RESULTS: Four studies (365 patients), including 2 Level I randomized controlled trials and 2 Level III retrospective comparative cohort studies were included. There was no statistical difference in the Disabilities of the Arm, Shoulder and Hand score, University of California Los Angeles Shoulder Rating Scale score, or the Constant score between the BMS and conventional repair groups. The pooled retear rates were 18.4% (28 of 152) and 31.8% (56 of 176) for patients treated with and without BMS, respectively. The pooled analysis of rotator cuff retear rates from the 4 studies (328 patients) showed a statistically significant difference favoring BMS over conventional repair (odds ratio, 0.42; 95% confidence interval, 0.25-0.73; P = .002; I2 = 0%). CONCLUSION: BMS reduces the retear rate after RCR but shows no difference in functional outcomes compared with conventional repair. This study provides evidence for the use of BMS as a potential cost-effective biological approach toward improving rotator cuff healing.

Repair of full-thickness rotator cuff tears in patients aged younger than 55 years.

PURPOSE: The purpose of this study was to conduct a systematic review of the available evidence regarding clinical outcomes after open or arthroscopic repair of full-thickness rotator cuff tears in young patients. METHODS: Medline, PubMed, and Embase were reviewed to find all studies examining full-thickness rotator cuff repairs in patients aged younger than 55 years and with a minimum of 1 year of follow-up. RESULTS: We found 7 studies that met the inclusion criteria. The mean patient age was 41.7 years (range, 16.2 to 54 years), and the mean time from injury was 66.1 months. Eighty-one percent of the included patients had a traumatic tear. The rotator cuff repair was supplemented by acromioplasty in 96.6% of patients, distal clavicle resection in 34.6%, and biceps tenodesis in 16.1%. Postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment was the most commonly reported outcome score, with a mean postoperative score of 82.0 (4 studies). Improvement was shown in all studies that reported on postoperative strength. All studies that assessed pain showed an improvement in the postoperative setting. Overall, 82% of the shoulders had satisfactory results. CONCLUSIONS: Full-thickness rotator cuff tears in patients aged younger than 55 years are mostly traumatic in origin and respond well to open and arthroscopic rotator cuff repair, as shown by good patient-reported outcomes, significant pain relief, improvement in strength, and high satisfaction postoperatively. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Platelet-rich plasma in the management of articular cartilage pathology: a systematic review.

OBJECTIVE: Using systematic review methodology, we endeavored to answer the following questions concerning the treatment of osteochondral pathology: (1) what pathologies have been treated in vivo with the use of platelet-rich plasma (PRP); (2) what methods of PRP preparation and delivery have been reported; (3) what assessment tools and comparison group have been used to assess its effectiveness; and (4) what are the clinical outcomes of its use. DATA SOURCES: A systematic literature search was performed of the OVID, EMBASE, and Evidence Based Medicine Reviews databases to identify all studies published up to October 2012 that assessed clinical outcomes of the use of PRP for the treatment of chondral and osteochondral pathology, excluding those including concomitant management of acute fractures or ligament reconstruction. DATA EXTRACTION: The included studies were reviewed and the following data were extracted and tabulated: study authors' year and journal, study design and level of evidence, pathology treated, methods of PRP preparation and delivery, and clinical outcome scores. DATA SYNTHESIS: Ten studies were included in the final analysis. The majority of studies assessed the use of PRP in the treatment of degenerative osteoarthritis of the knee or hip (representing 570 of a total of 662 joints). The majority of patients were treated with intra-articular injections, whereas 2 studies used PRP as an adjunct to surgical treatment. Significant improvements in joint-specific clinical scores (7 of 8 studies), general health scores (4 of 4 studies), and pain scores (4 of 6 studies) compared with baseline were reported up to 6-month follow-up, but few studies provided longer-term data. No studies reported worse scores compared with baseline at final follow-up. Three of 4 comparative studies reported significantly better clinical and/or pain scores when compared with hyaluronic acid injections at similar follow-up times. CONCLUSIONS: Currently, there is a paucity of data supporting the use of PRP for the management of focal traumatic osteochondral defects. There is limited evidence suggesting short-term clinical benefits with the use of PRP for symptomatic osteoarthritis of the knee, but the studies published to date are of poor quality and at high risk for bias. Further high-quality comparative studies with longer follow-up are needed to ascertain whether PRP is beneficial, either alone or as an adjunct to surgical procedures, in the management of articular cartilage pathology.

Acetabular cup revision combined with tensor facia lata reconstruction for management of massive abductor avulsion after failed total hip arthroplasty.

We report on 17 patients with massive abductor avulsions after total hip arthroplasty (THA) treated with medialization of the acetabular component and tensor fascia lata (TFL) reconstruction. All patients had severe limp, positive Trendelenburg sign, and avulsion of the abductor insertion confirmed on MRI. Mean age was 69 years (range, 50-83 years), and mean follow-up period was 36 months (range, 18-78 months). After surgery, 9 patients had no limp (47%), 8 patients had a mild limp, and abductor power improved from mean 2.5/5 to mean 3.8 (P < 0.0001). At latest follow-up, the Harris Hip Score was excellent in 6 hips (37%), good in 7 (43%) hips, and fair or poor in 3 (23%). Two patients with mild limp were not satisfied with their procedure.

Outcomes of osteochondral allograft transplantation in the knee.

PURPOSE: The objectives of this study were (1) to conduct a systematic review of clinical outcomes after osteochondral allograft transplantation in the knee and (2) to identify patient-, defect-, and graft-specific prognostic factors. METHODS: We searched PubMed, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies that evaluated clinical outcomes in adult patients after osteochondral allograft transplantation for chondral defects in the knee were included. Pooled analyses for pertinent continuous and dichotomous variables were performed where appropriate. RESULTS: There were 19 eligible studies resulting in a total of 644 knees with a mean follow-up of 58 months (range, 19 to 120 months). The overall follow-up rate was 93% (595 of 644). The mean age was 37 years (range, 20 to 62 years), and 303 patients (63%) were men. The methods of procurement and storage time included fresh (61%), prolonged fresh (24%), and fresh frozen (15%). With regard to etiology, the most common indications for transplantation included post-traumatic (38%), osteochondritis dissecans (30%), osteonecrosis from all causes (12%), and idiopathic (11%). Forty-six percent of patients had concomitant procedures, and the mean defect size across studies was 6.3 cm(2). The overall satisfaction rate was 86%. Sixty-five percent of patients (72 of 110) showed little to no arthritis at final follow-up. The reported short-term complication rate was 2.4%, and the overall failure rate was 18%. Heterogeneity in functional outcome measures precluded a meta-analysis; a qualitative synthesis allowed for the identification of several positive and negative prognostic factors. CONCLUSIONS: Osteochondral allograft transplantation for focal and diffuse (single-compartment) chondral defects results in predictably favorable outcomes and high satisfaction rates at intermediate follow-up. Patients with osteochondritis dissecans and traumatic and idiopathic etiologies have more favorable outcomes, as do younger patients with unipolar lesions and short symptom duration. Future studies should include comparative control groups and use established outcome instruments that will allow for pooling of data across studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Anatomical considerations in multiligament knee injury and surgery.

The management of multiligament knee injury mandates a comprehensive understanding of the anatomy on all sides of the joint. Imperative to repair or reconstructive procedures is an intimate knowledge of the structure of the cruciate and collateral ligaments, as well as the complex confluence of structures that comprise the posteromedial and posterolateral corners. Beyond the ligamentous anatomy, the surgeon must also be aware of the potential for neurologic and vascular compromise-both from injury and from treatment-that can often complicate multiligament knee injuries. In this article, we outline the basic anatomy and biomechanical function of the ligamentous structures of the knee, structures at risk, and the patterns of injury seen with knee dislocations and multiple ligament knee injuries in general.

Outcomes of treatment of multiple ligament knee injuries.

Knee dislocations are rare and potentially devastating injuries. Significant displacement of the tibia and femur commonly disrupts multiple knee ligaments and also often results in profound disruption to the surrounding soft tissue envelope. Open wounds and neurologic and vascular insult can put the involved limb in jeopardy. Following reduction, the optimal management of the dislocated knee is unknown. Surgery to repair and/or reconstruct torn structures likely affords superior long-term function over nonoperative immobilization strategies. The role of early versus delayed surgery, repair versus reconstruction, and autograft versus allograft tissue for reconstruction remain topics of debate. High-quality research efforts to investigate these controversies are hampered by the heterogeneous nature of the injuries themselves and the many treatment strategies available.

Neurological Complications Related to Elective Orthopedic Surgery: Part 2: Common Hip and Knee Procedures.

Many anesthesiologists may not be familiar with the rate of surgical neurological complications of the hip and knee procedures for which they are providing local anesthetic-based anesthesia and/or analgesia. Part 2 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common hip and knee procedures, including arthroscopic hip and knee surgery and total hip and knee replacement. WHAT'S NEW: As the popularity of regional anesthesia continues to increase with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective hip and knee procedures.

Neurological Complications Related to Elective Orthopedic Surgery: Part 3: Common Foot and Ankle Procedures.

Part III of a review series on neurological complications of orthopedic surgery, this article describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common elective foot and ankle procedures for which anesthesiologists may administer regional anesthesia. Relevant information is broadly organized according to type of surgical procedure to facilitate reference by anesthesiologists and members of the anesthesia care team. WHAT'S NEW: As the popularity of regional anesthesia continues to increase with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective foot and ankle procedures.

Neurological Complications Related to Elective Orthopedic Surgery: Part 1: Common Shoulder and Elbow Procedures.

Many anesthesiologists are unfamiliar with the rate of surgical neurological complications of the shoulder and elbow procedures for which they provide local anesthetic-based anesthesia and/or analgesia. Part 1 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common shoulder and elbow procedures, including open and arthroscopic shoulder procedures, elbow arthroscopy, and total shoulder and elbow replacement. Despite the many articles available, the overall number of studied patients is relatively low. Large prospective trials are required to establish the true incidence of neurological complications following elective shoulder and elbow surgery. WHAT'S NEW: As the popularity of regional anesthesia increases with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective shoulder and elbow procedures.

Outcomes of arthroscopic Bankart repair in collision versus noncollision athletes.

The purpose of the study was to compare the recurrence rate of arthroscopic Bankart repair with suture anchors in collision vs noncollision athletes. Sixty-four patients who underwent arthroscopic shoulder stabilization using suture anchors for recurrent anterior dislocation were identified. Forty-three patients (22 collision and 21 noncollision) were evaluated at a minimum 24-month follow-up. The recurrence rate was reported, and functional outcomes (American Shoulder and Elbow Society, Western Ontario Shoulder Index, and Short Form 12) were evaluated. Statistical analysis was performed using chi-square test and Student's t test with a 95% confidence interval and a significance level set at a P value less than .05. The overall dislocation recurrence rate was 4.6% (2 of 43 patients); the dislocation recurrence rate in collision athletes was 9% (2 of 22 patients), and no redislocations occurred in noncollision athletes. No statistical differences existed in Western Ontario Shoulder Index score (73.5% in collision and 73.4% in noncollision athletes; P=.831), American Shoulder and Elbow Society score (91.2 in collision and 80.7 in noncollision athletes; P=.228), and Short Form 12 score (108.5 in collision and 101.2 in noncollision athletes; P=.083). Average external rotation loss was 6.8° in collision and 5.5° in noncollision athletes (P=.864). Ninety percent of collision athletes vs 95% of noncollision athletes were satisfied. Seventy-three percent of collision and 81% of noncollision athletes were able to return to sport at their preinjury levels. Collision athletes had higher recurrence rates after arthroscopic shoulder stabilization compared with noncollision athletes, but no statistical difference was found. Functional outcomes according to American Shoulder and Elbow Society, Western Ontario Shoulder Index, and Short Form 12 were similar.