Single-Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy.

PURPOSE: To determine whether tranexamic acid (TXA) is safe to administer preoperatively in patients undergoing hip arthroscopy by comparing the venous thromboembolic rate and complication rate between patients who did and did not receive TXA preoperatively. METHODS: This was a multicenter consecutive-cohort series of patients who underwent arthroscopic hip surgery between 2014 and 2021. The 2 cohorts comprised patients who did and did not receive TXA preoperatively (single dose of 1-2 g), after a practice change. Data were collected via chart review. Surgical outcomes included days until follow-up, visual analog scale pain score at first follow-up, total operating room (OR) time, number of arthroscopic fluid bags (3 L/bag), and complications and revision operations up to 1 year after surgery. The Mann-Whitney U test was performed for continuous variables, and the χ2 test, for categorical variables. RESULTS: A total of 862 patients were identified: 449 (52%) received TXA and 413 (48%) did not. Patient demographic characteristics including age, sex, height, weight, body mass index, smoking status, and procedures performed, as well as number of anchors used (3.5 anchors for no TXA vs 3.7 anchors for TXA) and traction time (38 minutes for no TXA vs 40 minutes for TXA), did not significantly differ between groups. Significantly more patients underwent prior hip arthroscopy in the TXA group (n = 45; primary, n = 404) than in the group that did not receive TXA (n = 25; primary, n = 388) (P = .03). Visual analog scale pain scores at the first follow-up visit (2.61 for no TXA vs 2.62 for TXA, P = .62) and the need for subsequent revision surgery (24 patients with no TXA vs 18 patients with TXA, P = .68) were not significantly different. TXA use was associated with less arthroscopic fluid utilization (5.9 bags of 3 L of fluid for no TXA vs 5.3 bags of 3 L of fluid for TXA, P < .01) and less total OR time (99.5 minutes for no TXA vs 90.0 minutes for TXA, P < .01). There was a higher overall complication rate in the group that did not receive TXA (n = 27) than in the group that did (n = 10) (P = .01). However, if lateral femoral cutaneous nerve neurapraxia was excluded, then no difference in complication rate was observed (P = .24). CONCLUSIONS: There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the 2 groups when lateral femoral cutaneous nerve neuritis was excluded. No difference in early pain control or revision surgery rate was observed between groups. Although there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. Preoperatively administered TXA is a safe adjunct medication in patients undergoing arthroscopic hip surgery. LEVEL OF EVIDENCE: Level III, retrospective multicenter consecutive series.

Hip Arthroscopy Simulator Training With Immersive Virtual Reality Has Similar Effectiveness to Nonimmersive Virtual Reality.

PURPOSE: To (1) compare the efficacy of immersive virtual reality (iVR) to nonimmersive virtual reality (non-iVR) training in hip arthroscopy on procedural and knowledge-based skills acquisition and (2) evaluate the relative cost of each platform. METHODS: Fourteen orthopaedic surgery residents were randomized to simulation training utilizing an iVR Hip Arthroscopy Simulator (n = 7; PrecisionOS) or non-iVR simulator (n = 7; ArthroS Hip VR; VirtaMed). After training, performance was assessed on a cadaver by 4 expert hip arthroscopists through arthroscopic video review of a diagnostic hip arthroscopy. Performance was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and Arthroscopic Surgery Skill Evaluation Tool (ASSET) scores. A cost analysis was performed using the transfer effectiveness ratio (TER) and a direct cost comparison of iVR to non-iVR. RESULTS: Demographic characteristics did not differ between treatment arms or by training level, hip arthroscopy experience, or prior simulator use. No significant differences were observed in OSATS and ASSET scores between iVR and non-iVR cohorts (OSATS: iVR 19.6 ± 4.4, non-iVR 21.0 ± 4.1, P = .55; ASSET: iVR 23.7 ± 4.5, non-iVR 25.8 ± 4.8, P = .43). The absolute TER was 0.06 and there was a 132-fold cost difference of iVR to non-iVR. CONCLUSIONS: Hip arthroscopy simulator training with iVR had similar performance results to non-iVR for technical skill and procedural knowledge acquisition after expert arthroscopic video assessment. The iVR platform had similar effectiveness in transfer of skill compared to non-iVR with a 132 times cost differential. CLINICAL RELEVANCE: Due to the accessibility, effectiveness, and relative affordability, iVR training may be beneficial in the future of safe arthroscopic hip training.

Contributions of the Abductor Muscles to Rotational and Distractive Stability of the Hip in a Biomechanical Cadaveric Model.

Background: The gluteus minimus (GMin) and gluteus medius (GMed) are important dynamic stabilizers of the hip, but quantitative data on their biomechanical roles in stabilizing the hip are currently lacking. Purpose: To (1) establish a reproducible biomechanical cadaveric model of the hip abductor complex and (2) characterize the effects of loading the GMin and GMed on extraneous femoral rotation and distraction. Study Design: Controlled laboratory study. Methods: A total of 10 hemipelvises were tested in 4 muscle loading states: (1) unloaded, (2) the GMin loaded, (3) the GMed loaded, and (4) both the GMin and GMed loaded. Muscle loads were applied via cables, pulleys, and weights attached to the tendons to replicate the anatomic lines of action. Specimens were tested under internal rotation; external rotation; and axial traction forces at 0°, 15°, 30°, 60°, and 90° of hip flexion. Results: When loaded together, the GMin and GMed reduced internal rotation motion at all hip flexion angles (P < .05) except 60° and reduced external rotation motion at all hip flexion angles (P < .05) except 0°. Likewise, when both the GMin and GMed were loaded, femoral distraction was decreased at all angles of hip flexion (P < .05). Conclusion: The results of this study demonstrated that the GMin and GMed provide stability against rotational torques and distractive forces and that the amount of contribution depends on the degree of hip flexion. Clinical Relevance: Improved understanding of the roles of the GMin and GMed in preventing rotational and distractive instability of the hip will better guide treatment of hip pathologies and optimize nonoperative and operative therapies.

Arthroscopic Coracoid Transfer in the Lateral Decubitus Position is Safe and Effective at Short-Term Follow-Up.

Purpose: To report on operative and clinical outcomes in a series of shoulders treated with arthroscopic Latarjet performed in the lateral decubitus position. Methods: Patients with shoulders that underwent arthroscopic Latarjet in the lateral decubitus position were identified. Data were retrospectively collected, including patient demographics, operative times, intra- and postoperative complications, and clinical and functional outcomes. Descriptive statistics were performed. Results: Eighteen shoulders in 17 patients were included in the study with a mean follow-up of 14 ± 12.1 months (range, 4-39 months). The mean operative time for all procedures was 132.2 ± 18.0 minutes, and the mean operative time for the first half of the cohort was significantly longer than that of the second half (141.6 ± 14.2 minutes vs 122.8 ± 17.0 minutes, P = .02). There were no intraoperative complications, and no patients required a conversion to open surgery. One patient experienced a recurrent dislocation after a traumatic event but was able to be treated nonoperatively. Preoperative and postoperative patient-reported outcome measures (PROMs) were able to be collected on 8 of 18 patients (44.4%). Although all PROMs demonstrated improvements postoperatively, only the Single Assessment Numeric Evaluation score and American Shoulder and Elbow Surgeons Shoulder Index displayed a statistically significant increase (P < .05). Five of 8 (62.5%) shoulders demonstrated bony fusion on postoperative computed tomography scan. Of those eligible, 100% of patients returned to sport or felt that they could return if they wanted to. Conclusions: The arthroscopic Latarjet is an effective procedure for managing glenohumeral instability and can safely be performed in the lateral decubitus position. Level of Evidence: Level IV, therapeutic case series.

Evaluation and Management of the Athlete's Hip.

Hip and groin pain is common in athletes, and there are many possible underlying pathologies. It is important to describe athletic hip pathology in the context of sport-specific physiologic loads and biomechanical demands. Three distinct types of athletes with this pathology are collision athletes, hypermobility athletes, and endurance athletes. Although there is considerable overlap between sports, athletes with hip pain should always be evaluated in the context of their sport. Understanding the effect of sport-specific biomechanical demands may help with both diagnosis and treatment of athletic hip pathology; however, each athlete's injury should be analyzed on an individual basis.

Patient Outcomes Are Not Improved by Platelet-Rich Plasma Injection Onto the Capsule at the Time of Closure During Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Purpose: To determine the effect of platelet-rich plasma (PRP) injection onto the capsule at time of closure on outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Methods: Patients who underwent hip arthroscopy between January 2014 and December 2021 were retrospectively identified. The first cohort included patients who received PRP injection onto the capsule following capsular closure at the conclusion of the case. The second cohort did not receive PRP. Pain scores on a visual analog scale, Modified Harris Hip Scores, Single Assessment Numeric Evaluation (SANE), as well as Patient-Reported Outcomes Measurement Information System Physical Function scores were obtained preoperatively as well as at multiple time points postoperatively up to 2 years. Results: In total, 345 patients were included in the study, with 293 in the PRP cohort and 52 in the non-PRP cohort. There was no significance difference in age (P = .69), sex, or preoperative pain (P = .92) and patient-reported outcome scores between the 2 groups (modified Harris Hip Score, P = .38; Patient-Reported Outcomes Measurement Information System Physical Function, P = .48), except for preoperative SANE scores, which had a greater baseline in the PRP group (P < .001). Using both observed data as well as repeated measure analysis of variance model to estimate for missing data after baseline, we found there were no differences in visual analog scale pain scores nor patient-reported outcome scores at any time point. There was similarly no difference in change from baseline for SANE scores. There was no difference in rate of revision surgery between the 2 cohorts (P = .66). Conclusions: Based on the results of this study, intraoperative PRP injection onto the capsule at the time of capsular closure does not improve outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Level of Evidence: Level III, retrospective comparative study.

Microbial Colonization of Capsular Traction Sutures in Hip Arthroscopic Surgery.

Background: A common practice in hip arthroscopic surgery is the utilization of capsular traction sutures that can be incorporated into the capsular repair site at the end of the procedure, potentially seeding the hip joint with colonized suture material. Purpose: To investigate the rate of the microbial colonization of capsular traction sutures used during hip arthroscopic surgery and to identify patient-associated risk factors for this microbial colonization. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 50 consecutive patients who underwent hip arthroscopic surgery with a single surgeon were enrolled. There were 4 braided nonabsorbable sutures utilized for capsular traction during each hip arthroscopic procedure. These 4 traction sutures and 1 control suture were submitted for aerobic and nonaerobic cultures. Cultures were held for 21 days. Demographic information was collected, such as age, sex, and body mass index. All variables underwent bivariate analysis, and variables with a P value <.1 underwent further analysis in a multivariate logistic regression model. Results: One of 200 experimental traction sutures and 1 of 50 control sutures had a positive culture. Proteus mirabilis and Citrobacter koseri were isolated in both these positive experimental and control cultures from the same patient. Age and traction time were not significantly associated with positive cultures. The rate of microbial colonization was 0.5%. Conclusion: The rate of the microbial colonization of capsular traction sutures used in hip arthroscopic surgery was low, and no patient-associated risk factors were identified for microbial colonization. Capsular traction sutures used in hip arthroscopic surgery were not a significant potential source of microbial contamination. Based on these results, capsular traction sutures can be incorporated in capsular closure with a low risk of seeding the hip joint with microbial contaminants.

Femoral Head Vascularity After Arthroscopic Femoral Osteochondroplasty: An In Vivo Dynamic Contrast-Enhanced MRI Study.

Background: A serious concern with surgical procedures around the hip joint is iatrogenic injury of the arterial supply to the femoral head (FH) and consequent development of FH osteonecrosis. Cam-type morphology can extend to the posterosuperior area. Understanding the limit of the posterior superior extension of the femoral osteochondroplasty is paramount to avoid underresection and residual impingement while maintaining FH vascularity. Purpose/Hypothesis: The aim of this study was to quantify the impact of arthroscopic femoral osteochondroplasty on the FH vascular supply. It was hypothesized that keeping the superior extension of the resection zone anterior to the 12-o'clock position would maintain FH vascularity. Study Design: Case series; Level of evidence, 4. Methods: Ten adult patients undergoing arthroscopic femoroacetabular impingement (FAI) surgery were included in the study. Computed tomography (CT) scans were obtained before and after arthroscopic osteochondroplasty to define the extension of resection margins. To quantify FH vascularity, postoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) was obtained at 2 time points: immediately after surgery and at the 3-month follow-up. Custom MRI analysis software was used to quantify perfusion. Results: CT scan analysis demonstrated that the superior resection margin was maintained anterior to the 12-o'clock position in half of the patients. The remining 5 patients had a mean posterior extension of 11.4° ± 7.5°. The immediate postoperative DCE-MRI revealed diminished venous outflow in the operative side but no difference in overall FH perfusion. At the 3-month follow-up DCE-MRI, there was no perfusion difference between the operative and nonoperative FHs. Conclusion: This study provides previously unreported quantitative MRI data on in vivo perfusion of the FH after the commonly performed arthroscopic femoral osteochondroplasty for the treatment of cam-type FAI. Maintaining resection margins anterior to the 12-o'clock position, or even 10° posteriorly, was not observed to impair perfusion to the FH.

Regular-Season Injury Rates in the National Football League After an Attenuated Preseason Due to COVID-19.

Background: The preseason is a crucial time period for professional athletes to prepare for the upcoming season. However, due to the coronavirus 2019 (COVID-19) pandemic, the 2020 National Football League (NFL) preseason was canceled. As the regular season progressed, an increased number of injuries became apparent. Purpose/Hypothesis: The purpose of this study was to compare injury rates between the 2019 and 2020 NFL regular seasons after the canceled 2020 preseason. It was hypothesized that injury rates in the 2020 season would be the same or higher compared with 2019. Study Design: Descriptive epidemiology study. Methods: A public database of all 32 NFL teams was used to examine the movement of all players to injured reserve status as well as every player who missed a regular-season game due to injury for both the 2019 and the 2020 NFL regular seasons. Data collection consisted of tallying the total number of reported musculoskeletal injuries for each team. Comparisons of injury rates between the 2 seasons were made using a Wilcoxon signed-rank statistical analysis. Results: The total number of musculoskeletal injuries was 632 for the 2019 regular season and 765 for the 2020 regular season (P = .0324). Compared with 2019, statistically significant increases in injury rates in 2020 were seen for calf or Achilles tendon strain (17 vs 39; P = .009), groin injury (25 vs 46; P = .018), and anterior cruciate ligament tear (14 vs 29; P = .016). There were several other increased trends in soft tissue injury rates in the 2020 season (eg, hamstring injury [87 vs 114; P = .085]); however, these did not reach statistical significance. Conclusion: This study showed a significant increase in total injuries during the 2020 COVID-19-affected NFL regular season compared with 2019. Several major soft tissue injuries reached statistical significance in their increase from 2019 to 2020 after the cancellation of the 2020 preseason due to COVID-19. These findings suggest that organized team preseason training and conditioning could have an effect on the prevention of sport-related injury at the highest level.

Prevalence of femoroacetabular impingement in elite baseball players.

CAM-type femoroacetabular impingement continues to be an underrecognized cause of hip pain in elite athletes. Properties inherent to baseball such as throwing mechanics and hitting may enhance the risk of developing a cam deformity. Our goal is to gain an appreciation of the radiographic prevalence of cam deformities in elite baseball players. Prospective evaluation and radiographs of 80 elite baseball players were obtained during the 2016 preseason entrance examination. A sports medicine fellowship-trained orthopedic surgeon with experience treating hip disorders used standard radiographic measurements to assess for the radiographic presence of cam impingement. Radiographs with an alpha angle >55° on modified Dunn views were defined as cam positive. Of the 122 elite baseball players included in our analysis, 80 completed radiographic evaluation. Only 7.3% (9/122) of players reported hip pain and 1.6% (4/244) had a positive anterior impingement test. The prevalence of cam deformities in right and left hips were 54/80 (67.5%) and 40/80 (50.0%), respectively. The mean alpha angle for cam-positive right and left hips were 64.7 ± 6.9° and 64.9 ± 5.8°, respectively. Outfielders had the highest risk of right-sided cam morphology (Relative Risk (RR) = 1.6). Right hip cam deformities were significantly higher in right-handed pitchers compared with left-handed pitchers (P = 0.02); however, there was no significant difference in left hip cam deformities between left- and right-handed pitchers (P = 0.307). Our data suggest that elite baseball players have a significantly higher prevalence of radiographic cam impingement than the general population.

Comparable Torque to Failure Using the Simple Stich Versus the Figure-of-Eight Configuration for Hip Capsular Closure Following an Interportal Capsulotomy: A Cadaveric Study.

PURPOSE: To measure and compare the torque to failure and stiffness of the capsular repair construct consisting of four-suture simple stitches to a two-figure of eight stitches repair construct in external rotation following an interportal capsulotomy. METHODS: Six pairs of fresh-frozen cadaveric hemipelves were divided into two capsular repair groups. All hips underwent a 40-mm interportal capsulotomy from the 12 o'clock position to the 3 o'clock position. Capsular closure was performed using either the two stitches in a figure of eight or with four simple stitches. Afterward, each hemipelvis was securely fixed to the frame of a mechanical testing system with the hip in 10° of extension and externally rotated to failure. Significance was set at P < .05. RESULTS: The average failure torque was 86.2 ± 18.9 N·m and 81.5 ± 8.9 N·m (P = .57) for the two stitches in a figure of eight and the four simple stitches, respectively. Failure stiffness was also not statistically different between groups and both capsular closure techniques failed at similar degrees of rotation (P = .65). CONCLUSION: Hip capsular repair using either the four simple stitch or two-figure of eight configurations following interportal capsulotomy demonstrated comparable failure torques and similar stiffness in a cadaveric model. CLINICAL RELEVANCE: Adequate and comprehensive capsular management in hip arthroscopy is critical. Capsular repair following capsulotomy in femoroacetabular impingement surgery has been associated with higher patient-reported outcomes when compared to capsulotomy without repair. Therefore, determining which capsular closure construct provides the higher failure torque is important.

An Increased Allograft Width for Circumferential Labral Reconstruction Better Restores Distractive Stability of the Hip: A Cadaveric Biomechanical Analysis.

BACKGROUND: Questions remain about whether circumferential labral reconstruction (CLR) using an iliotibial band (ITB) allograft can effectively restore the labral suction seal of the hip. HYPOTHESES: (1) CLR with an ITB allograft >6.5 mm would restore distractive stability force to that of the intact labrum. (2) CLR with an ITB allograft >6.5 mm would achieve significantly superior distractive stability force compared with CLR with an ITB allograft <6.5 mm. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 6 fresh-frozen pelves with attached femurs (n = 12 matched hemipelves) from male donors were procured and dissected free of all soft tissue, including the hip capsule but preserving the native labrum, transverse acetabular ligament, and ligamentum teres. Potted hemipelves were placed in a saline bath and securely fixed to the frame of a hydraulic testing system. A 500-N compressive load was applied, followed by femoral distraction at a rate of 5.0 mm/s until the suction seal ruptured. Force and femoral displacement were continually recorded. Force versus displacement curves were plotted, the maximum force was recorded, and the amount of femoral distraction to rupture the suction seal was determined. After intact testing, the labrum was excised, and specimens were retested using the same protocol. CLR was subsequently performed twice in a randomized fashion using (1) an ITB allograft with a width >6.5 mm (7.5-9.0 mm) and (2) an ITB allograft with a width <6.5 mm (4.5-6.0 mm). Specimens were retested after each CLR procedure. Force (in Newtons) and femoral distraction (in millimeters) required to rupture the suction seal were measured and compared between the 4 testing states (intact, deficient, CLR <6.5 mm, and CLR >6.5 mm) using repeated-measures analysis of variance. RESULTS: On average, intact specimens required 148.4 ± 33.1 N of force to rupture the hip suction seal, which significantly decreased to 44.3 N in the deficient state (P < .001). CLR with ITB allografts <6.5 mm did not improve the maximum force (63 ± 62 N) from the deficient state (P = .42) and remained significantly lower than the intact state (P < .01). CLR with ITB allografts >6.5 mm recorded significantly greater force to rupture the suction seal (135.8 ± 44.6 N) compared with both the deficient and CLR <6.5 mm states (P < .01), with a mean force comparable with the intact labrum (P = .59). The amount of femoral distraction to rupture the suction seal demonstrated similar findings. CONCLUSION: In a cadaveric model, CLR using ITB allografts >6.5 mm restored the distractive force and distance to the suction seal rupture to values comparable with hips with an intact labrum. CLR using ITB allografts >6.5 mm outperformed CLR with ITB allografts <6.5 mm, demonstrated by a significantly higher force to rupture the suction seal and increased distraction before the rupture. CLINICAL RELEVANCE: The results of this cadaveric investigation suggest that using wider labral allografts during CLR will provide the distractive force required to rupture the suction seal and immediate postoperative stability of the hip, although further studies are required to determine if these results translate to improved clinical outcomes.

Calculating Intraoperative Fluid Deficit to Prevent Abdominal Compartment Syndrome in Hip Arthroscopy.

Abdominal compartment syndrome (ACS) is a rare but potentially fatal complication that can occur during hip arthroscopy. This usually occurs as a result of arthroscopic fluid passing into the retroperitoneal space through the psoas tunnel. From the retroperitoneal space, the fluid can then enter the intraperitoneal space through defects in the peritoneum. Previous studies have identified female sex, iliopsoas tenotomy, pump pressure, and operative time as potential risk factors for fluid extravasation. We present a method to measure intraoperative fluid deficit during hip arthroscopy to alert surgeons to possible ACS. Our proposed technique requires diligent intraoperative monitoring of fluid output through various suction devices, including suction canisters, puddle vacuums, and suction mats. The difference is then calculated from the fluid intake from the arthroscopic fluid bags. If the difference is greater than 1500 mL, then the anesthesiologist and circulating nurse are instructed to examine the abdomen for distension every 15 minutes. This, combined with other common symptoms such as hypotension and hypothermia, should alert the surgical team to the development of ACS. Despite limitations to this technique, this approach offers an objective method to calculate intra-abdominal fluid extravasation.

The Incidence of Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome and Labral Pathology Increased by 85% Between 2011 and 2018 in the United States.

PURPOSE: The purpose of this study was to investigate the incidence of hip arthroscopy in patients with labral pathology in the United States from 2011-2018 using a large national database. METHODS: Patients who underwent hip arthroscopy from 2011-2018 were identified using Current Procedural Terminology (CPT) codes in the PearlDiver Patients Records Database (Colorado Springs, CO), which is a national database of orthopedic insurance records, including Medicare patients. The incidence of surgeries, age, and gender were all recorded. Groups were analyzed using SPSS version 24 (IBM, Armonk NY). CPT codes 29914/15/16 were introduced January 1, 2011 which is when we began our analysis. CPT-29999 and laterality were not assessed. RESULTS: In total, 35,966 arthroscopies were identified between 2011 and 2018 from a randomly selected sample of 30 million orthopaedic patients from the PearlDiver Mariner dataset. The incidence increased by 85% from 2011 to 2018 (7.31 cases vs 13.54 cases per 100,000 patients). The distribution of the age of patients undergoing hip arthroscopy was bimodal with the mode of each peak at 18 years old and 42 years old, respectively. Females underwent surgery more frequently (67.9%) than males (32.1%). The most common CPT code for hip arthroscopy was 29914 (43.9) which corresponds to a hip arthroscopy with femoroplasty. CONCLUSIONS: Our findings corroborate those of previous studies and support the increase in incidence of hip arthroscopy in the United States. We indicate an overall increase of 85% from 2011 to 2018 and support previous trends, such as higher incidence of hip arthroscopy in women. Our study also supports a decreasing mean age for patients, likely due to improved diagnostics and surgeon familiarity and comfort with the procedure. LEVEL OF EVIDENCE: Level 3, Retrospective Comparative Study.

Ulnar Neuritis and Its Affect on Outcomes of Elbow Ulnar Collateral Ligament Reconstruction.

BACKGROUND: No study has specifically evaluated how ulnar neuritis and ulnar nerve transposition affect outcomes in baseball players undergoing ulnar collateral ligament (UCL) reconstruction (UCLR). PURPOSE: To evaluate the effects of ulnar neuritis and ulnar nerve transposition in baseball pitchers undergoing UCLR in regard to return to sport, time to return to sport, and need for revision or additional surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: At a single institution, all consecutive baseball pitchers undergoing UCLR between 2002 and 2015 were identified. Ulnar neuritis was diagnosed preoperatively by the following criteria: ulnar nerve symptoms, Tinel sign at the elbow, symptomatic subluxation, and numbness/paresthesia in an ulnar nerve distribution of the hand. The primary outcome of the study was return to sport. The secondary outcomes of the study were time to return to sport, length of playing career, and revision or additional surgery. RESULTS: A total of 578 UCLRs were performed in baseball players; of these, 500 UCLRs were performed in pitchers. Ulnar neuritis was diagnosed in 97 (19.4%) baseball pitchers presenting with UCL injury. There were no significant differences in patient characteristics or surgical techniques performed for reconstruction between baseball pitchers with and without ulnar neuritis. In review of injury characteristics, ulnar neuritis was significantly more likely to be diagnosed in pitchers with an acute onset of UCL injury (P = .03). Transposition of the ulnar nerve was more commonly performed in players with ulnar neuritis (47%) versus those without ulnar neuritis (10%; P = .0001). The players who had ulnar neuritis and underwent UCLR had a significantly lower odds of returning to sport (odds ratio, 0.45; P = .04); however, no significant difference was found for time to return to sport and length of playing career for those with and without ulnar neuritis (P = .38 and .51, respectively). CONCLUSION: The study suggests that ulnar neuritis, when present preoperatively in baseball pitchers undergoing UCLR, may adversely affect their ability to return to sport, whereas ulnar nerve transposition at the time of UCLR does not alter the ability to return to sport.

Arthroscopic Latarjet Procedure Utilizing a Latarjet With Cortical Button Fixation Performed in the Lateral Position.

Shoulder instability is a commonly seen pathology. The Latarjet procedure was first described in 1954 to address recurrent instability or patients with glenoid bone loss. Since its introduction, the procedure has been widely adopted and modified, including being performed all-arthroscopically. Various arthroscopic techniques have been described, but we present a technique performed in the lateral decubitus position that takes advantage of a pneumatic arm holder. After arthroscopic diagnosis, multiple accessory portals are established and used to accomplish the technique. Next, the coracoid is prepared and cut using a cannulated drill guide, followed by arthroscopic glenoid preparation using a cannulated drill system to ensure appropriate position of the coracoid. The subscapularis split is performed arthroscopically, and finally the coracoid is fixed with use of the EndoButton device.

Biomechanical Comparison of Capsular Repair, Capsular Shift, and Capsular Plication for Hip Capsular Closure: Is a Single Repair Technique Best for All?

BACKGROUND: In hip arthroscopy, the best capsular closure technique to prevent microinstability in some patients while preventing overconstraints in other patients has yet to be determined. PURPOSE: To evaluate the biomechanical effects of capsular repair, capsular shift, and combination capsular shift and capsular plication for closure of the hip capsule. STUDY DESIGN: Controlled laboratory study. METHODS: Eight cadaveric hips (4 male and 4 female hips; mean age, 55.7 years) were evaluated in 7 conditions: intact, vented, capsulotomy, side-to-side repair, side-to-side repair with capsular plication (interval closure between iliofemoral and ischiofemoral ligaments), capsular shift repair, and capsular shift repair with plication. Measurements, via a 360° goniometer, included internal and external rotation with 1.5 N·m of torque at 5° of extension and 0°, 30°, 60°, and 90° of flexion. In addition, the degree of maximum extension with 5 N·m of torque and the amount of femoral distraction with 40 N and 80 N of force were obtained. Repeated-measures analysis of variance and Tukey post hoc analyses were used to analyze differences between capsular conditions. RESULTS: At lower hip positions (5° of extension, 0° and 30° of flexion), there was a significant increase in external rotation and total rotation after capsulotomy versus the intact state (P < .05). At all hip flexion angles, there was a significant increase in external rotation, internal rotation, and total rotation as well as a significant increase in maximum extension after capsulotomy versus capsular shift with plication (P < .05 for all). At all flexion angles, both capsular closure with side-to-side repair (with or without plication) and capsular shift without capsular plication were able to restore rotation, with no significant differences compared with the intact capsule (P > .05). Among repair constructs, there were significant differences in range of motion between side-to-side repair and combined capsular shift with plication (P < .05). CONCLUSION: At all positions, significantly increased rotational motion was seen after capsulotomy. Capsular closure was able to restore rotation similar to an intact capsule. Combined capsular shift and plication may provide more restrained rotation for conditions of hip microinstability but may overconstrain hips without laxity. CLINICAL RELEVANCE: More advanced closure techniques or a combination of techniques may be needed for patients with hip laxity and microinstability. At the same time, simple repair may suffice for patients without these conditions.

Stay Ipsilateral: An Analysis of Tibial Tunnel Distance Between Cruciate Ligament Reconstruction and Posterior Meniscal Root Repair.

PURPOSE: To establish mean distance or identify intersection between tibial tunnels for posterior meniscal root repair in the setting of anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction. METHODS: Twelve cadaver knees and 12 solid foam synthetic tibiae were used. ACL and PCL tunnels were drilled for single-bundle reconstruction, and both medial and lateral posterior root repair tunnels were drilled. Specimens underwent computed tomography scanning and shortest distances between tunnels in all planes were measured by 2 readers. Distances were compared between groups using a t-test. RESULTS: In ACL reconstruction, the medial meniscal root tunnel was not significantly closer to the cruciate tunnel when drilled from either medial or lateral side (P = .333). The lateral meniscal root tunnel was significantly closer when drilled from medial compared to lateral side (P < .001). In PCL reconstruction, both medial (P = .037) and lateral (P = .028) meniscal root tunnels were significantly closer to the PCL tunnel when drilled from the contralateral side of the tibia. CONCLUSION: This study demonstrates that posterior meniscal root repair tunnels are often placed within a few millimeters and can even intersect cruciate ligament reconstruction tunnels in the proximal tibia. CLINICAL RELEVANCE: The information in this study may assist surgeons in planning for cruciate ligament reconstruction with concomitant posterior meniscal root repair.

All-Arthroscopic Anatomic Length-Tension Biceps Tenodesis With Unicortical Button.

The long head of the biceps tendon is a frequent cause of persistent anterior shoulder pain. Biceps tenodesis is a popular choice for surgical management of this pathology, with myriad approach and fixation variations described. We describe an all-arthroscopic suprapectoral biceps tenodesis in the anatomic length-tension relation using a unicortical button. This technique offers an alternative method that provides proper tendon fixation at anatomic length with minimized additional surgical morbidity and postoperative complications.

Proximal Overresection During Femoral Osteochondroplasty Negatively Affects the Distractive Stability of the Hip Joint: A Cadaver Study.

BACKGROUND: Contact between the acetabular labrum and articular cartilage of the femoral head creates a suction seal that helps maintain stability of the femoral head in the acetabulum. A femoral osteochodroplasty may occasionally extend proximally into the femoral head, diminishing the articular surface area available for sealing contact. PURPOSE: To determine whether proximal overresection decreases the rotational and distractive stability of the hip joint. STUDY DESIGN: Controlled laboratory study. METHODS: Six hemipelvises in the following conditions were tested: intact, T-capsulotomy, osteochondroplasty to the physeal scar, and 5- and 10-mm proximal extension. The pelvis was secured to a metal plate, and the femur was potted and attached to a multiaxial hip jig. Specimens were axially distracted using a load from 0 to 150 N. For rotational stability testing, 5 N·m of internal and external torque was applied. Both tests were performed at different angles of flexion (0°, 15°, 30°, 60°, 90°). Displacement and rotation were recorded using a 3-dimensional motion tracking system. RESULTS: The T-capsulotomy decreased the distractive stability of the hip joint. A femoral osteochondroplasty up to the physeal scar did not seem to affect the distractive stability. However, a proximal extension of the resection by 5 and 10 mm increased axial instability at every angle of flexion tested, with the greatest increase observed at larger angles of flexion (P < .01). External rotation increased significantly after T-capsulotomy in smaller angles of flexion (0°, P = .01; 15°, P = .01; 30°, P = .03). Femoral osteochondroplasty did not create further external rotational instability, except when the resection was extended 10 mm proximally and the hip was in 90° of flexion (P = .04). CONCLUSION: This cadaveric study demonstrated that proximal extension of osteochondroplasty into the femoral head compromises the distractive stability of the hip joint but does not affect hip rotational stability. CLINICAL RELEVANCE: Clinically, this study highlights the importance of accuracy when performing femoral osteochondroplasty to minimize proximal extension that may increase iatrogenic instability of the hip joint.