Assessment of fatty infiltration of the hamstring muscles in chronic proximal hamstring ruptures and effect on clinical outcomes after surgical repair: a novel application of the Goutallier classification.

INTRODUCTION: Increased time to surgery has been previously associated with poorer clinical outcomes after surgical treatment of proximal hamstring ruptures, though the etiology remains unclear. The purpose of this study was to evaluate whether degree of muscle atrophy, as assessed using the Goutallier classification system, is associated with worse outcomes following surgical treatment of chronic proximal hamstring ruptures. MATERIALS AND METHODS: This was a retrospective case series of patients who underwent repair of proximal hamstring ruptures from 2012 to 2020 with minimum 2-year follow-up. Patients were included if they underwent primary repair of a proximal hamstring rupture ≥ 6 weeks after the date of injury and had accessible preoperative magnetic resonance imaging (MRI). Exclusion criteria were allograft reconstruction, endoscopic repair, or prior ipsilateral hip surgery. Patients were administered validated surveys: the modified Harris Hip Score (mHHS) and Perth Hamstring Assessment Tool (PHAT). Fatty atrophy on preoperative MRI was independently graded by two musculoskeletal radiologists using the Goutallier classification. Multivariate regression analysis was performed to evaluate associations of preoperative characteristics with muscle atrophy, as well as mHHS and PHAT scores. RESULTS: Complete data sets were obtained for 27 patients. A majority of this cohort was male (63.0%), with a mean age of 51.5 ± 11.8 years and BMI of 26.3 ± 3.8. The mean follow-up time was 62.6 ± 23.1 months, and the mean time from injury-to-surgery was 20.4 ± 15.3 weeks. The Goutallier grading inter-reader weighted kappa coefficient was 0.655. Regression analysis demonstrated that atrophy was not significantly associated with PHAT (p = 0.542) or mHHS (p = 0.574) at latest follow-up. Increased age was significantly predictive of muscle atrophy (ß = 0.62, p = 0.005) and was also found to be a significant predictor of poorer mHHS (ß = - 0.75; p = 0.037). CONCLUSIONS: The degree of atrophy was not found to be an independent predictor of clinical outcomes following repair of chronic proximal hamstring ruptures. Increasing age was significantly predictive of increased atrophy and poorer patient-reported outcomes.

Hip Arthroscopy Improves Sexual Function in Receptive Partners with Femoroacetabular Impingement Syndrome.

BACKGROUND: Hip pain due to femoroacetabular impingement (FAI) is thought to adversely impact sexual satisfaction because of exacerbation of symptoms with hip ROM. However, the effect of FAI on sexual satisfaction and improvement after surgery to treat FAI is largely absent from published studies, despite patients' apparent interest in it as registered by the frequent appearance of these topics on online anonymous discussion platforms. In addition, details regarding its impact on the decision to pursue surgery and the success of hip arthroscopy in alleviating FAI-related sexual dysfunction based on the specific role assumed during intercourse (penetrative versus receptive) remains unknown. QUESTIONS/PURPOSES: Given that sexual intercourse involves different amounts of hip ROM depending on whether patients assume the penetrative or receptive role, this study evaluated the effect of FAI and hip arthroscopy on sexual activity based on role. Compared with patients who participate in the penetrative role during sexual intercourse, do patients who participate in the receptive role (1) experience greater difficulty with sexual function because of FAI symptoms, (2) take longer to return to sexual intercourse after hip arthroscopy, and (3) experience greater improvements in reported sexual function after hip arthroscopy for FAI? METHODS: This was a retrospective cohort study of patients undergoing hip arthroscopy for FAI. Between January 2017 and December 2021, 293 patients were treated with hip arthroscopy for FAI and enrolled in our longitudinally maintained database. Among all patients treated surgically, 184 patients were determined to be potentially eligible for study inclusion based on a minimum follow-up of 6 months postoperatively. The 6-month timepoint was chosen based on published data suggesting that at this timepoint, nearly 100% of patients resumed sexual intercourse with minimal pain after hip arthroscopy. Of the potentially eligible patients, 33% (61 patients) could not be contacted by telephone to obtain verbal consent for participation and 9% (17 patients) declined participation, leaving 106 eligible patients. Electronic questionnaires were sent to all eligible patients and were returned by 58% (61 patients). Forty-two percent of eligible patients (45) did not respond to the questionnaire and were therefore excluded from the analysis. Two percent (2) completed most survey questions but did not specify their role during intercourse and were therefore excluded. The mean age of included patients was 34 ± 9 years, and 56% were women The mean follow-up time was 2 ± 1 years. In total, 63% of included patients reported participating in the receptive role during sexual intercourse (49% receptive only and 14% both receptive and penetrative). Hip symptoms during sexual intercourse preoperatively and postoperatively were evaluated using a questionnaire created by our team to answer our study questions, drawing from one of the only published studies on the matter and combining the questionnaire with sexual position-specific questions garnered from arthroplasty research. Patients who reported participating in the receptive role during intercourse (either exclusively or in addition to the penetrative role) were compared with those who participated exclusively in the penetrative role. There were no specific postoperative recommendations in terms of the timing of return to sexual intercourse, other than to resume when comfortable. RESULTS: Overall, 61% of patients (36 of 59) reported that hip pain somewhat or greatly interfered with sexual intercourse preoperatively. Patients who participated in receptive intercourse were more likely to experience preoperative hip pain that interfered with intercourse than patients who participated exclusively in penetrative intercourse (odds ratio 5 [95% confidence interval 2 to 15]; p = <0.001). Postoperatively, there was no difference in time until return to sexual activity between those in the penetrative group (median 6 weeks [range 2 to 14 weeks]) and those in the receptive group (median 6 weeks [range 4 to 14 weeks]; p = 0.28). Postoperatively, a greater number of patients participating in the penetrative role reported no or very little pain, compared with patients participating in the receptive role (67% [14 of 21] versus 49% [17 of 35]). However, with regard to preoperative to postoperative improvement, patients who participated in the receptive role had greater pain with positions involving more hip flexion and abduction and experienced a greater improvement than their penetrative counterparts in these positions postoperatively. Despite this improvement, however, 33% of patients (7 of 21) participating in the penetrative role and 51% of patients (18 of 35) participating in the receptive role continued to report either some or a great amount of pain at final follow-up. CONCLUSION: Hip pain secondary to FAI interferes with sexual relations, particularly for partners who participate in the receptive role. Postoperatively, both patients participating in receptive and penetrative intercourse resumed sexual intercourse at a median of 6 weeks. After hip arthroscopy, the greatest improvement in pain was seen in receptive partners during sexual positions that involved more hip flexion and abduction. Despite this improvement, most patients, regardless of sexual role assumed, reported some degree of residual pain. Patients planning to undergo arthroscopic surgery for FAI, particularly those who participate in receptive intercourse, should be appropriately counseled about reasonable postoperative expectations based on our findings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Psychological Readiness to Return to Sport (RTS) and RTS Rates Are Similar in Patients After Either Bilateral or Unilateral Anterior Cruciate Ligament Reconstruction.

Purpose: To compare psychological readiness to return to sport (RTS), RTS rate, level of return, and time to return between patients who underwent bilateral anterior cruciate ligament reconstruction (ACLR) and those who underwent unilateral ACLR. Methods: The electronic medical record at a single academic medical center was queried for patients who underwent ACLR from January 2012 to May 2020. The inclusion criteria were skeletally mature patients who underwent either single or sequential bilateral ACLR and who had undergone either the primary ACLR or second contralateral ACLR at least 2 years earlier. Bilateral ACLRs were matched 1:3 to unilateral reconstructions based on age, sex, and body mass index. Psychological readiness to RTS was assessed using the validated ACL Return to Sport After Injury (ACL-RSI) scale. This, along with time to return and level of RTS, was compared between the 2 cohorts. Results: In total, 170 patients were included, of whom 44 underwent bilateral ACLR and 132 underwent unilateral ACLR. At the time of the first surgical procedure, patients in the unilateral cohort were aged 28.8 ± 9.4 years and those in the bilateral cohort were aged 25.7 ± 9.8 years (P = .06). The average time difference between the first and second surgical procedures was 28.4 ± 22.3 months. There was no difference in psychological readiness to RTS (50.5 in bilateral cohort vs 48.1 in unilateral cohort, P = .66), RTS rate (78.0% in unilateral cohort vs 65.9% in bilateral cohort, P = .16), percentage of return to preinjury sport level (61.2% in unilateral cohort vs 69.0% in bilateral cohort, P = .21), or time to return (41.2 ± 29.3 weeks in unilateral cohort vs 35.2 ± 23.7 weeks in bilateral cohort, P = .31) between the 2 cohorts. Conclusions: Compared with patients who undergo unilateral ACLR, patients who undergo bilateral ACLR are equally as psychologically ready to RTS, showing equal rates of RTS, time to return, and level of return. Level of Evidence: Level III, retrospective cohort study.

A Superolateral Cam Lesion Location Increases Odds of Total Hip Arthroplasty 5 Years After Hip Arthroscopy.

PURPOSE: To determine if radiographic cam location is associated with hip survivorship and postoperative patient-reported outcomes (PROs) at 5-year follow-up. METHODS: We conducted a review of prospectively collected data of patients with cam lesions who underwent hip arthroscopy for femoroacetabular impingement syndrome. Cam lesions were categorized into 3 locations: superolateral, anterolateral, or anterior. Conversion to total hip arthroplasty (THA), revision rates, and reoperation rates were assessed. Patient-reported outcome measures, including modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS), were collected preoperatively and at 5-year follow-up. RESULTS: Of the 156-patients, 125 met the final criteria (80.1%). Mean age was 41.1 ± 12.7 years. Seventy-one patients (56.8%) had superolateral cam lesions, 41 (32.8%) had anterolateral lesions, and 13 (10.4%) had anterior lesions. Revision rates within 5 years were 7.7% for anterior, 24.4% for anterolateral, and 14.1% for superolateral lesions; conversions to THAs were 15.4% for anterior), 7.3% for anterolateral, and 8.5% for superolateral. Reoperations were 23.1% for anterior, 29.3% for anterolateral, and 21.1% for superolateral. The superolateral cohort was younger than the anterior and anterolateral cohorts (anterior, 46.6 ± 12.2 years; anterolateral, 44.7 ± 12.2 years; superolateral, 38.1 ± 12.3 years; P = .006). Multivariable analysis showed the anterolateral group was significantly predictive of lower odds of undergoing THA compared to the superolateral group (odds ratio, 0.01; 95% CI, <0.01-0.72; P = .03). There were no differences in the 5-year improvement in mHHS (anterior, 32.4; anterolateral, 36.8; superolateral, 33.0; P = .29) or NAHS (anterior, 34.8; anterolateral, 39.0; superolateral, 37.3; P = .65). CONCLUSIONS: A superolateral cam lesion increases the odds of conversion to THA within 5 years of hip arthroscopy compared to those with anterolateral lesions on multivariable analysis. Those with superolateral lesions were significantly younger compared to those with anterior or anterolateral lesions. Cam lesion location did not affect improvement in PROs at 5-year follow-up. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Five-Year Outcomes of Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Among Female Patients: Higher Body Mass Index Is Associated With Reduced Clinically Significant Outcomes.

PURPOSE: To evaluate the impact of age, body mass index (BMI), and symptom duration on 5-year clinical outcomes among females following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: We conducted a retrospective review of a prospectively collected database of hip arthroscopy patients with a minimum 5-year follow-up. Patients were stratified by age (<30, 30-45, ≥45 years), BMI (<25.0, 25.0-29.9, ≥30.0), and preoperative symptom duration (<1 vs ≥1 year). Patient-reported outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Pre- to postoperative improvement in mHHS and NAHS was compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Hip survivorship rates and minimum clinically important difference (MCID) achievement rates were compared with Fisher exact test. Predictors of outcomes were identified using multivariable linear and logistic regression. P values <.05 were considered significant. RESULTS: In total, 103 patients were included in the analysis with a mean age of 42.0 ± 12.6 years (range, 16-75) and mean BMI of 24.9 ± 4.8 (range, 17.2-38.9). Most patients had symptoms of duration ≥1 year (60.2%). Six patients (5.8%) had arthroscopic revisions, and 2 patients (1.9%) converted to total hip arthroplasty by 5-year follow-up. Patients with BMI ≥30.0 had significantly lower postoperative mHHS (P = .03) and NAHS (P = .04) than those with BMI <25.0. Higher BMI was associated with reduced improvement in mHHS (ß = -1.14, P = .02) and NAHS (ß = -1.34, P < .001) and lower odds of achieving the mHHS MCID (odds ratio [OR] = 0.82, P = .02) and NAHS MCID (OR = 0.88, P = .04). Older age was predictive of reduced improvement in NAHS (ß = -0.31, P = .046). Symptom duration ≥1 year was predictive of higher odds of achieving the NAHS MCID (OR = 3.98, P = .02). CONCLUSIONS: Female patients across a wide range of ages, BMIs, and symptom durations experience satisfactory 5-year outcomes following primary hip arthroscopy, but higher BMI is associated with reduced improvement in patient-reported outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Acellular Collagen Matrix Patch Augmentation of Arthroscopic Rotator Cuff Repair Reduces Re-Tear Rates: A Meta-analysis of Randomized Control Trials.

PURPOSE: To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes of arthroscopic rotator cuff repair (ARCR) with and without acellular collagen matrix patch (ACMP) augmentation. METHODS: A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing ACMP augmentation and a control for ARCR were included. Clinical outcomes were compared using Revman, and a P value < .05 was considered to be statistically significant. RESULTS: Five RCTs with 307 patients were included. Overall, 11% of patients treated with ACMP augmentation and 34% of patients in the control group had a re-tear (P = .0006). The mean Constant score was 90.1 with ACMP augmentation, and 87.3 in controls (P = .02). Additionally, there was a significant higher American Shoulder and Elbow Surgeons score with ACMP augmentation (87.7 vs 82.1, P = .01). CONCLUSIONS: The RCTs in the literature support the use of ACMP augment as a modality to reduce re-tear rates and improve outcomes after ARCR. LEVEL OF EVIDENCE: Level II, Meta-Analysis of Level II Studies meta-analysis of Level II studies.

Measure Twice, Cut Once: The Future of Digitally Planned Knee Osteotomies.

It is important to highlight the use of patient-specific cutting guides for knee joint osteotomies. Rationale, pitfalls, and planning of conventional osteotomy techniques are examined. The benefits of using patient-specific guides focusing on the potential for improved accuracy, efficiency, and safety are reviewed. The versatility of guides to manipulate the slope in both the coronal and sagittal planes, as well as its ability to accommodate concomitant procedures, is discussed. The time and cost differentials between standard cutting guides and three-dimensional-guided templating are also discussed.

Kinesiophobia and Pain Catastrophizing Leads to Decreased Return to Sport Following Autologous Chondrocyte Implantation but Does Not Affect Return to Work.

OBJECTIVE: To evaluate the effect of fear of reinjury on return to sport (RTS), return to work (RTW), and clinical outcomes following autologous chondrocyte implantation (ACI). DESIGN: A retrospective review of patients who underwent ACI with a minimum of 2 years in clinical follow-up was conducted. Patient-reported outcomes collected included the Visual Analog Scale (VAS) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Kinesiophobia and pain catastrophizing was assessed using the Tampa Scale of Kinesiophobia-11 (TSK-11) and Pain Catastrophizing Scale (PCS), respectively. Patients were surveyed on their RTS and RTW status. RESULTS: Fifty-seven patients (50.9% female) were included in our analysis. Twenty-two (38.6%) patients did not RTS. Of the 35 patients (61.4%) who returned, nearly half (48.6%) returned at a lower level of play. TSK-11 (P = 0.003), PCS (P = 0.001), and VAS pain scores (P < 0.001) were significantly greater in patients that did not RTS than in those who returned. All KOOS subscores analyzed were significantly lower (P < 0.001) in patients that did not RTS than in those who returned at the same level or higher. Of the 44 (77.2%) patients previously employed, 97.7% returned to work. Increasing TSK-11 scores were associated with lower odds of returning to sport (P = 0.003). CONCLUSION: Fear of reinjury decreases the likelihood that patients will return to sport after ACI. Patients that do not return to sport report significantly greater levels of fear of reinjury and pain catastrophizing and lower clinical knee outcomes. Nearly all patients were able to return to work after surgery. LEVEL OF EVIDENCE: IV case series.

Clinical Presentation and Outcomes of Sacral Stress Fractures in Athletes: A Case Series of 13 Patients.

BACKGROUND: Sacral stress fractures are a rare cause of low back pain in athletes. Given the low incidence of these fractures, there is a scarcity of data on symptomatology, risk factors, and clinical outcomes. HYPOTHESIS: Patients diagnosed with sacral stress fractures would be athletes presenting with low back pain. STUDY DESIGN: Case series of 13 patients with sacral stress fractures. LEVEL OF EVIDENCE: Level 4. METHODS: We conducted a retrospective review of medical records to identify patients diagnosed with sacral stress fractures at a single academic institution. Fractures were diagnosed on noncontrast T2-weighted magnetic resonance imaging scans and categorized using the Bakker classification system. Subjects were administered an electronic survey that asked about (1) the onset, time course, and location of pain and other symptoms; (2) time to treatment and treatment modalities pursued; (3) sports performance and time to return to sport; and (4) risk factors for stress fractures. RESULTS: Of 18 eligible patients, 13 (72.2%) completed the survey with mean follow-up of 49.6 months (range, 1-144 months). Mean age was 28.0 years (range, 18-52 years); 9 patients (69.2%) were female, of whom 7 (77.8%) were premenopausal. The most common fracture type was Bakker type B (8 patients; 61.5%). Most patients presented with acute lumbosacral back pain in the setting of running/jogging activities. All patients underwent nonoperative treatment for an average of 3.8 months (range, 0-8 months) and three-quarters reported pain resolution at last follow-up. Rate of return to sport was 83.3%, but most patients reported ongoing deficits in running performance. CONCLUSION: Sacral stress fractures commonly present as acute lumbosacral back pain provoked by running sports. While the pain associated with these fractures prevents most athletes from participating in sports, nonoperative management appears to be an effective treatment modality with a high rate of return to sport.

Patients who undergo bilateral medial patellofemoral ligament reconstruction return to sport at a similar rate as those that undergo unilateral reconstruction.

PURPOSE: Lateral patellar instability is a debilitating condition not only to athletes, but also to a wide range of highly active individuals. Many of these patients experience symptoms bilaterally, though it is unknown how these patients fair with return to sports following a second medial patellofemoral ligament reconstruction (MPFLR). The purpose of this study is to evaluate the rate of return to sport following bilateral MPFLR compared to a unilateral comparison group. METHODS: Patients who underwent primary MPFLR with minimum 2-year follow-up were identified from 2014 to 2020 at an academic center. Those who underwent primary MPFLR of bilateral knees were identified. Pre-injury sport participation and Tegner score, Kujala score, Visual Analog Score (VAS) for pain, satisfaction, and MPFL-Return to Sport after Injury (MPFL-RSI) scale were collected. Bilateral and unilateral MPFLRs were matched in a 1:2 ratio based on age, sex, body mass index, and concomitant tibial tubercle osteotomy (TTO). A sub-analysis was performed regarding concomitant TTO. RESULTS: The final cohort consisted of 63 patients, including 21 patients who underwent bilateral MPFLR, matched to 42 unilateral patients at mean follow-up of 47 ± 27 months. Patients who underwent bilateral MPFLR returned to sport at a rate of 62% at a mean of 6.0 ± 2.3 months, compared to a unilateral rate of 72% at 8.1 ± 4.2 months (n.s.). The rate of return to pre-injury level was 43% among bilateral patients and 38% in the unilateral cohort. There were no significant differences in VAS pain, Kujala, current Tegner, satisfaction, and MPFL-RSI scores between cohorts. Approximately half of those (47%) who failed to return to sport cited psychological factors and had significantly lower MPFL-RSI scores (36.6 vs 74.2, p = 0.001). CONCLUSION: Patients who underwent bilateral MPFLR returned to sports at a similar rate and level compared to a unilateral comparison group. MPFL-RSI was found to be significantly associated with return to sport. LEVEL OF EVIDENCE: III.

To Cross the Cervicothoracic Junction? Terminating Posterior Cervical Fusion Constructs Proximal to the Cervicothoracic Junction Does Not Impart Increased Risk of Reoperation in Patients With Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To evaluate the effect of caudal instrumentation level on revision rates following posterior cervical laminectomy and fusion. METHODS: A retrospective review of a prospectively collected database was performed. Minimum follow-up was one year. Patients were divided into two groups based on the caudal level of their index fusion construct (Group 1-cervical and Group 2- thoracic). Reoperation rates were compared between the two groups, and preoperative demographics and radiographic parameters were compared between patients who required revision and those who did not. Multivariate binomial regression analysis was performed to determine independent risk factors for revision surgery. RESULTS: One hundred thirty-seven (137/204) patients received fusion constructs that terminated at C7 (Group 1), while 67 (67/204) received fusion constructs that terminated at T1 or T2 (Group 2). The revision rate was 8.33% in the combined cohort, 7.3% in Group 1, and 10.4% in Group 2. There was no significant difference in revision rates between the 2 groups (P = .43). Multivariate regression analysis did not identify any independent risk factors for revision surgery. CONCLUSION: This study shows no evidence of increased risk of revision in patients with fusion constructs terminating in the cervical spine when compared to patients with constructs crossing the cervicothoracic junction. These findings support terminating the fusion construct proximal to the cervicothoracic junction when indicated. LEVEL OF EVIDENCE: III.