Hip Labral and Capsular Repair Are Unable to Restore Distractive Stability in a Biomechanical Model.

PURPOSE: To evaluate the change in hip distractive stability after a capsulotomy, labral tear, and simultaneous repair of both the capsule and the labrum in a biomechanical model. METHODS: Ten fresh-frozen human cadaveric hips were analyzed using a materials testing system to measure the distractive force and distance required to disrupt the hip suction seal under the following conditions: (1) native intact capsule and labrum, (2) 2- or 4-cm interportal capsulotomy (IPC), (3) labral tear, (4) T extension, (5) labral repair, (6) T extension repair, and (7) IPC repair. Each specimen was retested at 0° of flexion, 45° of flexion, and 45° of flexion with 15° of internal rotation. RESULTS: A significantly higher distractive force was required to rupture the suction seal in the intact condition compared with IPC (P = .012; 95% confidence interval [CI], 4.9-42.4); IPC and labral tear (P = .002; 95% CI, 11.3-49.4); IPC, labral tear, and T extension (P = .001; 95% CI, 13.9-51.5); IPC, labral repair, and T extension (P < .001; 95% CI, 20.8-49.7); IPC, labral repair, and T extension repair (P = .002; 95% CI, 12.5-52.4); and IPC repair, labral repair, and T extension repair (P = .01; 95% CI, 5.8-46.1). The IPC condition required a higher distractive force in isolation than when combined with a labral tear (P = .14; 95% CI, 1.2-12.0), T extension (P = .005; 95% CI, 2.8-15.3), or labral repair (P = .002; 95% CI, 4.4-18.8). CONCLUSIONS: The distractive resistance of an intact hip capsule and labrum was not restored once the soft tissues were violated, despite labral repair with a loop technique and capsular repair with interrupted figure-of-8 sutures. CLINICAL RELEVANCE: Time-zero complete capsular repair with concomitant labral repair may not be adequate to restore distractive hip stability after hip arthroscopy, reinforcing the use of postoperative precautions in the early postoperative period.

The Contribution of Soft Tissue and Bony Stabilizers to the Hip Suction Seal: A Systematic Review of Biomechanical Studies.

BACKGROUND: Previous biomechanical studies have identified capsular closure, labral repair or reconstruction, and osteochondroplasty as important surgical interventions to improve hip stability. PURPOSE: To investigate the outcome metrics used to quantify hip stability and assess and measure the relative contributions of the labrum, capsule, and bone to hip stability through a quantitative analysis. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed and Embase databases were searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies evaluated cadaveric hip biomechanics related to capsular, labral, and bony management during hip arthroscopy. Studies were assessed for distraction force and distance, fluid measures, and contact forces used to quantify the suction seal. Exclusion criteria included open surgery, arthroplasty, reorientation osteotomy, or traumatic dislocation. RESULTS: A total of 33 biomechanical studies comprising 322 hips that evaluated 1 or more of the following were included: distraction force or distance (24 studies), fluid measures (10 studies), and contact forces (6 studies). Compared with a capsulotomy or capsulectomy, capsular repair or reconstruction demonstrated greater resistance to distraction (standardized mean difference [SMD], 1.13; 95% CI, 0.46-1.80; P = .0009). Compared with a labral tear, a labral repair or reconstruction demonstrated less resistance to distraction (SMD, -0.67; 95% CI, -1.25 to -0.09; P = .02). Compared with a labral debridement, repair or reconstruction demonstrated greater resistance to distraction (SMD, 1.74; 95% CI, 1.23 to 2.26; P < .00001). No quantitative analysis was feasible from studies evaluating the effect of osseous resection due to the heterogeneity in methodology and outcome metrics assessed. CONCLUSION: Most biomechanical evidence supports capsulotomy repair or reconstruction to improve hip distractive stability at the end of hip arthroscopic surgery. While the repair of a torn labrum does not improve distractive resistance, it is superior to labral debridement in most biomechanical studies.

Early Postoperative Activities of Daily Living Do Not Adversely Affect Joint Torques or Translation Regardless of Capsular Condition: A Cadaveric Study.

PURPOSE: To evaluate the impact of capsular management on joint constraint and femoral head translations during simulated activities of daily living (ADL). METHODS: Using 6 (n = 6) cadaveric hip specimens, the effect of capsulotomies and repair was then evaluated during simulated ADL. Joint forces and rotational kinematics associated with gait and sitting, adopted from telemeterized implant studies, were applied to the hip using a 6-degrees of freedom (DOF) joint motion simulator. Testing occurred after creation of portals, interportal capsulotomy (IPC), IPC repair, T-capsulotomy (T-Cap), partial T-Cap repair, and full T-Cap repair. The anterior-posterior (AP), medial-lateral (ML), and axial compression DOFs were operated in force control, whereas flexion-extension, adduction-abduction, and internal-external rotation were manipulated in displacement control. Resulting femoral head translations and joint reaction torques were recorded and evaluated. Subsequently, the mean-centered range of femoral head displacements and peak signed joint restraint torques were calculated and compared. RESULTS: During simulated gait and sitting, the mean range of AP femoral head displacements with respect to intact exceeded 1% of the femoral head diameter after creating portals, T-Caps, and partial T-Cap repair (Wilcoxon signed rank P < .05); the mean ranges of ML displacements did not. Deviations in femoral head kinematics varied by capsule stage but were never very large. No consistent trends with respect to alterations in peak joint restrain torques were observed. CONCLUSIONS: In this cadaveric biomechanical study, capsulotomy and repair minimally affected resultant femoral head translation and joint torques during simulated ADLs. CLINICAL RELEVANCE: The tested ADLs appear safe to perform after surgery, regardless of capsular status, because adverse kinematics were not observed. However, further study is required to determine the importance of capsular repair beyond time-zero biomechanics and the resultant effect on patient-reported outcomes.

Editorial Commentary: The Hip Arthroscopy Volume-to-Competency Learning Curve Debate Is Complicated: Learning When "Enough Is Enough" Is a Lifetime Discipline.

As hip arthroscopy use grows, so does resident and fellow exposure, providing more "hands-on" learning opportunities. Nevertheless, hip arthroscopy is technically challenging, particularly noting that improved patient-reported outcomes and survivorship are reported after labral repair or reconstruction (vs debridement) as well as routine capsular closure. Undoubtedly a requisite number of cases is required to reach the saturation point of the "learning curve." A recent review shows that traction time, complication rates, and reoperation rates decrease with increasing case volumes, but there is a wide range of cases reported after which the learning curve "plateaus," ranging from 30 to 520 cases. A large database study shows that hip arthroscopy readmissions and complications are significantly lower in high-volume centers. However, large database studies may include biases requiring attention. First, the rates are relatively low across the entire cohort. Second, more younger patients were treated in the greater-volume centers, which may contribute to the difference in outcomes observed. Finally, older patients (often >50 years old) with concomitant osteoarthritis are also associated with greater complication, readmission, and reoperation rates. Such patients may not be selected as candidates for hip arthroscopy by greater-volume surgeons. The hip arthroscopy volume to competency learning curve debate is complicated. Learning when "enough is enough" is a lifetime discipline.

Multimodal analgesia did not improve post-operative pain scores, reduce opioid consumption or reduce length of stay following hip arthroscopy.

PURPOSE: To determine whether different regimens of multimodal analgesia will reduce postoperative pain scores, opioid consumption, costs and hospital length-of-stay following hip arthroscopy. METHODS: From 2018 to 2021, 132 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) were included in this prospective, single-center randomized controlled trial. Patients were randomized into four treatment groups: (1) Group 1-Control: opioid medication (oxycodone-acetaminophen 5 mg/325 mg, 1-2 tabs q6H as needed), Heterotopic ossification prophylaxis-Naprosyn 500 mg twice daily × 3 weeks); (2) Group 2-Control + postoperative sleeping aid (Zopiclone 7.5 mg nightly × 7 days); (3) Group 3-Control + preoperative and postoperative Gabapentin (600 mg orally, 1 h preoperatively; 600 mg postoperatively, 8 h following pre-op dose); (4) Group 4-Control + pre-medicate with Celecoxib (400 mg orally, 1 h preoperatively) The primary outcome was pain measured with a visual analog scale, monitored daily for the first week and every other day for 6 weeks. Secondary outcomes included opioid consumption, healthcare resource use, and hospital length of stay. RESULTS: Patient characteristics were similar between groups. There were no statistically significant differences in pain scores between groups at any timepoint after adjusting for intra-operative traction time, intra-operative opioid administration and preoperative pain scores (p > 0.05). There were also no significant differences in the number of days that opioids were taken (n.s.) and the average daily morphine milligram equivalents consumed (n.s.). Similarly, there were no statistically significant differences in length of stay in the experimental groups, compared with the control group (n.s.). Finally, there were no differences in cost between groups (n.s.). CONCLUSION: The routine use of Zopiclone, Celecoxib and Gabapentin did not improve postoperative pain control or reduce length-of-stay following hip arthroscopy. Therefore, these medications are not recommended for routine postoperative pain control following hip arthroscopy. LEVEL OF EVIDENCE: l.

Total Hip Arthroplasty in Patients Aged 40 to 60 Years Old: A Population-Based Study.

BACKGROUND: Contemporary total hip arthroplasty (THA) has resolved many implant longevity concerns in younger patients. Patients in their fourth and fifth decades of life are projected to be the fastest-growing demographic of THA patients. We aimed to assess this demographic to: 1) evaluate the rate of THA over time; 2) evaluate the cumulative incidence of revision; and 3) identify risk factors for revision. METHODS: A retrospective population-based study of patients between 40 and 60 years old undergoing primary THA was conducted using administrative data from a large clinical data repository. A total of 28,414 patients were included for analysis with a mean age of 53 years (range, 40-60 years) and median follow-up of 9 years (range, 0-17 years). Linear regressions were used to assess annual rates of THA in this cohort over time. Kaplan-Meier analysis was used to determine cumulative incidence of revision. Multivariate Cox proportional hazards models were used to determine association of variables with revision risk. RESULTS: The annual rate of THA in our population increased by 60.7% over the study period (P < .0001). Cumulative incidence of revision was 2.9% at 5 years and 4.8% at 10 years. Younger age, women, non-osteoarthritis diagnosis, medical complications, and annual surgeon volume ≤ 60 THA were associated with increased revision risk. CONCLUSION: Demand for THA continues to dramatically increase in this cohort. Risk of revision was low but multiple risk factors were identified. Future studies will help delineate the effect of these variables on revision risk and assess implant survivorship beyond 10 years.

Cadaveric Biomechanical Evaluation of Capsular Constraint and Microinstability After Hip Capsulotomy and Repair.

Background: It remains unclear if capsular management contributes to iatrogenic instability (microinstability) after hip arthroscopy. Purpose: To evaluate changes in torque, stiffness, and femoral head displacement after capsulotomy and repair in a cadaveric model. Study Design: Controlled laboratory study. Methods: A biomechanical analysis was performed using 10 cadaveric hip specimens. Each specimen was tested under the following conditions: (1) intact, (2) portals, (3) interportal capsulotomy (IPC), (4) IPC repair, (5) T-capsulotomy (T-cap), (6) partial T-cap repair, and (7) T-cap repair. Each capsular state was tested in neutral (0°) and then 30°, 60°, and 90° of flexion, with forces applied to achieve the displacement-controlled baseline limit of external rotation (ER), internal rotation (IR), abduction, and adduction. The resultant end-range torques and displacement were recorded. Results: For ER, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; capsular repairs failed to restore torque and stiffness at 0°; and IPC repair failed to restore stiffness at 30° (P < .05 for all). For IR, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; and capsular repairs failed to restore torque or stiffness at 0°, 30°, and 60° and failed to restore stiffness at 90° (P < .05 for all). For abduction, IPC significantly decreased torque at 60° and 90° and decreased stiffness at all positions; T-cap reduced torque and stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). For adduction, IPC significantly reduced torque at 0° and reduced stiffness at 0° and 30°; T-cap reduced torque at 0° and 90° and reduced stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). There were no statistically significant femoral head translations observed in any testing configurations. Conclusion: Complete capsular repair did not always restore intact kinematics, most notably at 0° and 30°. Despite this, there were no significant joint translations to corroborate concerns of microinstability. Clinical Relevance: Caution should be employed when applying rotational torques in lower levels of flexion (0° and 30°).

Editorial Commentary: Failure to Return to Sport, or Rather a Failure to Attempt a Return After Hip Arthroscopy Is Not Correlated With Poor Clinical Outcome: The Devil Is in the Details.

While hip arthroscopy has been shown to be highly effective at improving pain and restoring function, postoperative outcome reporting remains heterogeneous, particularly as it relates to return to sport (RTS). Previous studies have identified significant variability in RTS rates, and often studies fail to accurately report on the population of patients who do not attempt RTS for reasons other than their hip. Despite failing to attempt an RTS, patients can still experience statistically significant, and clinically meaningful improvements in patient-reported outcome measures. Clinical results of those who do not RTS may be otherwise similar to results experienced by a group of high-level athletes who have successful RTS. Failure to attempt to RTS does not equate to a poor clinical outcome. To improve the clinical utility of future published RTS rates, better consensus on the means of evaluating and reporting on a patients' readiness for RTS are required. Additionally, comprehensive reporting should include identifying patients who do not RTS for reasons other than their hip.

Improvement in pain and patient-related outcome measures following hip arthroscopy in patients with femoroacetabular impingement syndrome and concomitant generalized ligamentous laxity: a systematic review.

PURPOSE: Within orthopaedic sports medicine, concomitant ligamentous laxity is often found to be a negative prognostic factor for post-operative outcomes following various procedures. The effect of ligamentous laxity on outcomes following hip arthroscopy remains infrequently reported. Therefore, the purpose of this study is to report on the outcomes of hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) with concomitant generalized ligamentous laxity (GLL). METHODS: A systematic search was performed in Medline, EMBASE, CENTRAL, and SPORTDiscus (from inception to April 2021) for studies reporting outcomes following hip arthroscopy for symptomatic FAIS in patients with concomitant GLL. RESULTS: Six studies representing 213 patients and 231 hips were included. Outcomes of pain and functional scores as measured by VAS, Harris Hip Score, and Hip Disability and Osteoarthritis Outcomes Score were tabulated. A mean improvement of 4.8 on VAS was observed. Improvements of 30.0 on HHS, 33.1 for ssHOS, and 23.9 for ADL-HOS were observed. CONCLUSION: Hip arthroscopy is an effective method of alleviating pain and improving function with statistically significant improvements in all PROM in patients with concomitant FAIS with GLL. LEVEL OF EVIDENCE: IV. PROSPERO REGISTRATION: CRD42021248864.

Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures.

BACKGROUND: As health care shifts to value-based models, one strategy within orthopedics has been to transition appropriate cases to outpatient or ambulatory settings to reduce costs; however, there are limited data on the efficacy and safety of this practice for isolated ankle fractures. The purpose of this study was to compare the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF). METHODS: All patients who underwent ORIF of isolated closed ankle fractures at 2 affiliated hospitals between April 2016 and March 2017 were identified retrospectively. Demographic characteristics, including age, gender, comorbidities and injuryspecific variables, were collected. We grouped patients based on whether they underwent ankle ORIF as an inpatient or outpatient. We determined case costing for all patients and analyzed it using multivariate regression analysis. RESULTS: A total of 196 patients (125 inpatient, 71 outpatient) were included for analysis. Inpatients had a significantly longer mean length of stay than outpatients (54.3 h [standard deviation (SD) 36.3 h] v. 7.5 h [SD 1.7 h], p < 0.001). The average cost was significantly higher for the inpatient cohort than the outpatient cohort ($4137 [SD $2285] v. $1834 [SD $421], p < 0.001). There were more unimalleolar ankle fractures in the outpatient group than in the inpatient group (42 [59.2%] v. 41 [32.8%], p < 0.001). Outpatients waited longer for surgery than inpatients (9.6 d [SD 5.6 d] v. 2.0 d [SD 3.3 d], p < 0.001). Fourteen patients (11.2%) in the inpatient group presented to the emergency department or were readmitted to hospital within 30 days of discharge, compared to 5 (7.0%) in the outpatient group (p = 0.3). CONCLUSION: In the treatment of isolated closed ankle fractures, outpatient surgery was associated with a significant reduction in length of hospital stay and overall case cost compared to inpatient surgery, with no significant difference in readmission or reoperation rates. In medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.

Hip arthroscopy utilization and reoperation rates in Ontario: a population-based analysis comparing different age cohorts.

BACKGROUND: Older age (> 40 yr) and osteoarthritis are negative prognostic variables for hip arthroscopy, but their impact has not been quantified from a population standpoint. The purpose of this study was to perform a population-based analysis of hip arthroscopy utilization and associated 2- and 5-year reoperation rates and complications in different age cohorts. METHODS: Administrative databases from Ontario, Canada, were retrospectively reviewed to identify patients aged 18-60 years who underwent hip arthroscopy between 2006 and 2016. Patients were stratified into 2 cohorts: 18-39 and 40-60 years of age. Patients were followed for 2 and 5 years to capture the occurrence of subsequent surgery (repeat arthroscopy or total hip arthroplasty) and postoperative complications. RESULTS: A total of 1906 patients underwent hip arthroscopy, 818 (42.9%) of whom were aged 40-60 years. In the entire cohort, revision surgery occurred in 6.5% and 15.1% of cases at 2 and 5 years, respectively. Revision surgery rates were significantly higher among patients aged 40-60 years at 2 (10.8% v. 3.2%, p < 0.001) and 5 years (22.7% v. 8.2%, p < 0.001) than among those aged 18-39 years. Revision rates were higher among patients aged 50-60 years than among those aged 40-49 years at 2 years (14.3% v. 9.1%, p = 0.027). Complication rates did not differ between cohorts. Regression analysis revealed higher 2- and 5-year odds of secondary surgery in patients aged 40-49 years (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.70-4.22; OR 2.82, 95% CI 1.87-4.25; p < 0.001), patients aged 50-60 years (OR 4.39, 95% CI 2.67-7.22; OR 3.44, 95% CI 2.11-5.62; p < 0.001) and those with osteoarthritis (OR 2.41, 95% CI 1.39-4.20; p = 0.002; OR 1.76, 95% CI 1.00-3.09; p = 0.049). CONCLUSION: Revision surgery rates following hip arthroscopy are significantly higher among older patients and those with concomitant osteoarthritis. Although the data have limitations, they provide useful information to guide surgical decision-making.

Mild to moderate osteoarthritis is not considered a contraindication to arthroscopic treatment of symptomatic femoroacetabular impingement: results of an international survey.

PURPOSE: Hip arthroscopy offers a minimally invasive approach for the treatment of femoroacetabular impingement (FAI). Although osteoarthritis (OA) is a known negative prognostic factor for arthroscopy, it is unclear if patients with FAI and concomitant mild to moderate OA benefit from hip preservation surgery. The goal of this study was to evaluate current practice patterns among surgeons experienced in FAI management in the treatment of patients between 40 and 60 years of age with symptomatic FAI and concomitant OA of varying severity. METHODS: A 12-question cross-sectional survey was distributed using a secure electronic survey portal. The survey sought to determine surgical treatment of FAI in patients between the ages of 40 and 60 years old with concomitant OA of various degrees. Surveys were completed electronically and anonymously, with invitations distributed to members of the American Orthopaedic Society for Sports Medicine, International Society for Hip Arthroscopy, Arthroscopy Association of Canada, Canadian Orthopaedic Association, and both current and former Fowler Kennedy sports medicine fellows. RESULTS: A total of 76 orthopedic surgeons who treat FAI completed the survey. All respondents routinely treat FAI arthroscopically, while only 43.7% have utilized an open surgical approach. Nearly all respondents (96.0%) would consider performing hip arthroscopy in patients over 40 years of age. The respondents ranked an absence of OA (Tönnis 0 or 1) as the most important factor in deciding to move forward with surgery, while a positive response to diagnostic injection was considered the least important factor of the options given. Respondents felt that the role for hip arthroscopy in patients with symptomatic FAI decreased with increasing age and worsening degree of osteoarthritis. In patients 40-50 years old with Tönnis 1, willingness to perform surgery was 89.5%; while with Tönnis 2 this was reduced to 39.5% and with Tönnis 3 it was 5.3%. In patients 50-60 years old with Tönnis 1, 80.3% of respondents found arthroscopy to be beneficial; while with Tönnis 2 this was reduced to 22.4% and with Tönnis 3 it was 2.6%. CONCLUSIONS: Most respondents consider arthroscopy a viable option for patients aged 40-60 years old with mild osteoarthritis (Tönnis 1), while worsening osteoarthritis (Tönnis 3) results in greater rates of non-arthroscopic treatment. The role of arthroscopy with moderate osteoarthritis (Tönnis 2) remains unclear and should be a focus for future studies. LEVEL OF EVIDENCE: Level V.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age.

PURPOSE: Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use. METHODS: A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage. RESULTS: Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use. CONCLUSION: Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use. LEVEL OF EVIDENCE: Level III.

The Medial structures of the knee have a significant contribution to posteromedial rotational laxity control in the PCL-deficient knee.

PURPOSE: Various reconstruction techniques have been employed to restore normal kinematics to PCL-deficient knees; however, studies show that failure rates are still high. Damage to secondary ligamentous stabilizers of the joint, which commonly occurs concurrently with PCL injuries, may contribute to these failures. The main objective of this study was to quantify the biomechanical contributions of the deep medial collateral ligament (dMCL) and posterior oblique ligament (POL) in stabilizing the PCL-deficient knee, using a joint motion simulator. METHODS: Eight cadaveric knees underwent biomechanical analysis of posteromedial stability and rotatory laxity using an AMTI VIVO joint motion simulator. Combined posterior force (100 N) and internal torque (5 Nm) loads, followed by pure internal/external torques (± 5 Nm), were applied at 0, 30, 60 and 90° of flexion. The specimens were tested in the intact state, followed by sequential sectioning of the PCL, dMCL, POL and sMCL. The order of sectioning of the dMCL and POL was randomized, providing n = 4 for each cutting sequence. Changes in posteromedial displacements and rotatory laxities were measured, as were the biomechanical contributions of the dMCL, POL and sMCL in resisting these loads in a PCL-deficient knee. RESULTS: Overall, it was observed that POL transection caused increased posteromedial displacements and internal rotations in extension, whereas dMCL transection had less of an effect in extension and more of an effect in flexion. Although statistically significant differences were identified during most loading scenarios, the increases in posteromedial displacements and rotatory laxity due to transection of the POL or dMCL were usually small. However, when internal torque was applied to the PCL-deficient knee, the combined torque contributions of the dMCL and POL towards resisting rotation was similar to that of the sMCL. CONCLUSION: The dMCL and POL are both important secondary stabilizers to posteromedial translation in the PCL-deficient knee, with alternating roles depending on flexion angle. Thus, in a PCL-deficient knee, concomitant injuries to either the POL or dMCL should be addressed with the aim of reducing the risk of PCL reconstruction failure.

Scoping review of complications associated with epinephrine use in arthroscopy fluid.

Purpose: To identify if addition of epinephrine to irrigation fluid can result in any intra-operative or post-operative complications. It was hypothesized that significant adverse events would be identified with the use of epinephrine in arthroscopic fluid.Methodology: In accordance with PRISMA guidelines (Appendix 2), an electronic database search was conducted, from inception to February 2019 including MEDLINE, EMBASE, Cochrane, CENTRAL, and Scopus (MeSH search). All English-language studies that addressed complications associated with arthroscopic use of epinephrine were included. Defined outcome measures were any reported intra- or post-operative adverse events secondary to epinephrine use. Data collection included: patient demographics, comorbidities, surgical intervention, epinephrine concentration in irrigation fluid, reported complications, and details of the associated clinical prodrome.Results: Three hundred and ninety-three abstracts were screened with 22 studies identified and reviewed in detail. Of these seven case reports and four randomized trials met the inclusion criteria (1999-2017). The case reports encompassed nine patients (seven females and two males) with an average age of 38.8 years (range 19 to 52 y). Five had shoulder arthroscopies, two had knee scopes and two had hip scopes. A pattern of reported complications was noted in all reports in association with epinephrine including hypertension, tachycardia with or without evolving arrhythmia and/or pulmonary edema. One patient died. Of the four randomized trials, three did not report any adverse events in relation to epinephrine with one trial associating epinephrine to the occurrence of hypotensive bradycardic events in the setting of shoulder arthroscopy in the beach-chair position.Conclusion: While a causal association cannot be established, Anesthetists and Orthopedic Surgeons should be aware of the noted pattern of symptoms in patients undergoing epinephrine-assisted arthroscopy.Clinical relevance: While the incidence of epinephrine-related complications is rare, this review raises awareness to the pattern of reported symptoms, as it could help with identification and treatment should this rare complication be encountered.

Biomechanical evaluation of a hybrid suture and anchor-based hip capsular repair.

BACKGROUND: Hip capsulotomies, performed routinely during hip arthroscopy, can contribute to adverse joint kinematics. Direct repair is not always feasible. Therefore, the aim of this study was to evaluate the biomechanics of a conventional all-suture repair versus a hybrid suture and anchor-based capsular repair. METHODS: Nine paired (n = 18) hips were tested on a joint-motion simulator, utilizing optical trackers to capture kinematic data. Pairs were randomly allocated to capsular repair type and tested as (1) intact, (2) after T-capsulotomy, and (3) repair each at 0°, 45°, and 90° flexion. Internal and external rotation torques and abduction/adduction torques of 3 N·m were applied and rotational range of motion and joint translations recorded. FINDINGS: At 0°, following repair there were no significant differences in joint rotation or translations between repairs (p > 0.134). At 45°, both repair types restored motion to near intact values, with no significant differences between groups. Similarly, there were no significant differences in joint translations between repairs. At 90°, both types of capsular repair failed to restore rotational range of motion, with persistent increases in motion (47.0 ± 16.7°) compared to the intact condition (44.1 ± 15.8°, p = 0.006); however, there were no significant differences between repair groups. There were no significant differences in joint translations between repairs. INTERPRETATION: Use of a hybrid repair produced comparable joint rotation and translation under all testing conditions as an all-suture repair. As such, this technique represents a viable option for capsular repair where proximal capsular tissue is deficient.

Iliopsoas Release: A Systematic Review of Clinical Efficacy and Associated Complications.

OBJECTIVE: To perform a systematic review of the findings of iliopsoas release as it relates to resolution of snapping, improvement of groin pain, and associated complications. DESIGN: Systematic review. DATA SOURCES: Four electronic databases PubMed/MEDLINE, EMBASE, CINAHL, and Web of Science were searched, identifying all literature pertaining to surgical treatment of a snapping hip/coxa saltans, iliopsoas impingement, or iliopsoas tendinitis. A total of 818 studies were identified. Two reviewers independently screened the titles, abstracts, and full-text articles for eligibility. ELIGIBILITY CRITERIA: All studies published in English that reported on iliopsoas release for snapping hip/coxa saltans, iliopsoas impingement, or iliopsoas tendinitis reporting outcomes or associated complications were eligible. RESULTS: A total of 48 articles were included in this review. Three surgical indications were identified for iliopsoas release, internal snapping hip, labral tear secondary to iliopsoas impingement, and iliopsoas tendinopathy after total hip arthroplasty. Arthroscopic techniques seemed to be superior to open techniques with regards to reoccurrence of snapping (5.1% vs 21.7%) and groin pain relief (89.1% vs 85.6%) with fewer complications (4.2% vs 21.1%) overall. CONCLUSIONS: Both open and arthroscopic iliopsoas releases have been shown to be successful treatment options regardless of the surgical indications identified in this review. Arthroscopic release demonstrated a decreased failure rate, fewer complications, and improved outcomes when compared with open procedures.

The Impact of Resident Involvement on Surgical Outcomes following Anterior Cruciate Ligament Reconstruction.

Hands-on participation in the operating room (OR) is an integral component of surgical resident training. However, the implications of resident involvement in many orthopaedic procedures are not well defined. This study aims to assess the effect of resident involvement on short-term outcomes following anterior cruciate ligament reconstruction (ACLR). The National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent ACLR from 2005 to 2012. Demographic variables, resident participation, 30-day complications, and intraoperative time parameters were assessed for all cases. Resident and nonresident cases were matched using propensity scores. Outcomes were analyzed using univariate and multivariate regression analyses, as well as stratified by resident level of training. Univariate analysis of 1,222 resident and 1,188 nonresident cases demonstrated no difference in acute postoperative complication rates between groups. There was no significant difference in the incidence of overall complications based on resident level of training (p = 0.109). Operative time was significantly longer for cases in which a resident was involved (109.5 vs. 101.7 minutes; p < 0.001). Multivariate analysis identified no significant predictors of major postoperative complications, while patient history of chronic obstructive pulmonary disease was the only independent risk factor associated with minor complications. Resident involvement in ACLR was not associated with 30-day complications despite a slight increase in operative time. These findings provide reassurance that resident involvement in ACLR procedures is safe, although future investigations should focus on long-term postoperative outcomes.

Arthroscopic Bankart Repair With Remplissage in Comparison to Bone Block Augmentation for Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review.

PURPOSE: The purpose of this systematic review is to examine the rates of postoperative recurrence of instability, functional outcomes, and complications after treatment with bone augmentation procedures or arthroscopic Bankart repair with remplissage for recurrent anterior shoulder instability in the setting of subcritical glenoid bone loss. METHODS: EMBASE, PubMed, and MEDLINE were searched from database inception until June 2019 for articles examining either bone block augmentation to the glenoid or Bankart repair with remplissage (BRR) in the setting of subcritical glenoid bone loss. Search and data extraction were performed by 2 reviewers independently and in duplicate. A separate analysis was done for comparative studies. RESULTS: Overall, 145 studies were identified, including 4 comparative studies. Across all studies, postoperative recurrence rates ranged from 0% to 42.8% for bone block augmentation and 0% to 15% for Bankart repair with remplissage. In comparative studies reporting subcritical glenoid bone loss, rates were 5.7% to 11.6% in the Latarjet group and 0% to 13.3% in the Bankart repair with remplissage group. However, in all studies reporting 10% to 15% mean glenoid bone loss, there was an increased rate of recurrent instability with arthroscopic soft tissue repair (6.1% to 13.2%) in comparison with bony augmentation (0% to 8.2%). Lastly, complication rates ranged from 0% to 66.7% for the bone block group and 0% to 2.3% for arthroscopic Bankart repair with remplissage. CONCLUSION: Both bone block augmentation and Bankart repair with remplissage are effective treatment options for recurrent anterior shoulder instability in patients with bipolar bone loss but subcritical glenoid bone loss. Both have comparable functional outcomes, albeit bone block procedures carry an increased risk of complications. Arthroscopic BRR may be associated with a higher failure rate for preoperative glenoid bone loss >10%. Therefore, it may represent a stabilization procedure best suited for cases of recurrent anterior instability with glenoid bone loss <10% and the presence of a significant, off-track Hill-Sachs lesion. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.