Return to Sport After Ulnar Collateral Ligament Tears Treated with Platelet-Rich Plasma Injections is Influenced by Length of Rehabilitation and Leukocyte Content of Injections: A Systematic Review.

PURPOSE: To analyze the current literature assessing return to sport (RTS) outcomes after platelet-rich plasma (PRP) injections for the nonoperative treatment of ulnar collateral ligament (UCL) injuries. METHODS: A systematic review of PubMed, Embase, and Web of Science databases was conducted in June 2023 to identify studies assessing RTS after PRP injections for UCL injuries. Tear severity, leukocyte content of PRP, rehabilitation protocol, and RTS outcomes were collected. Heterogeneity was assessed through proportional random-effects models for RTS and return to preinjury level of play (RTLP) with subgroup analysis by rehabilitation length, leukocyte content of PRP, and tear severity. RESULTS: Eight studies with 278 partial-thickness and 44 full-thickness tears were identified. The mean age of patients ranged from 17.3 to 26 years. The mean RTS time after injection ranged from 5.2 to 25.4 weeks. High heterogeneity was observed among studies, with RTS rates ranging from 46% to 100% (I2 = 83%) and RTLP rates ranging from 34% to 100% (I2 = 83%). Studies with the longest rehabilitation programs (12-14 weeks) had RTS rates of 87% to 100% (I2 = 0%). RTS rates among athletes treated with leukocyte-poor and leukocyte-rich PRP ranged from 73% to 100% (I2 = 30%) and 52% to 88% (I2 = 84%), respectively. Subanalysis of RTS by tear severity demonstrated high variability, with partial-thickness rates ranging from 59% to 100% (I2 = 55%) and full-thickness rates ranging from 27% to 100% (I2 = 63.2%). CONCLUSIONS: Studies assessing RTS after PRP injections are highly heterogeneous; however, current data suggest nonoperative RTS and RTLP rates ranging from 46% to 100% and 34% to 100%, respectively. Studies with at least 12 weeks of rehabilitation and studies using leukocyte-poor PRP demonstrated low heterogeneity and greater RTS rates. Alternatively, high heterogeneity was observed among both partial- and full-thickness tears. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Borderline Dysplastic Hips Undergoing Hip Arthroscopy Achieve Equivalent Patient Reported Outcomes When Compared With Hips With Normal Acetabular Coverage: A Systematic Review and Meta-Analysis.

PURPOSE: To systematically review and meta-analyze studies reporting lateral center edge angle as it relates to patient-reported outcome (PRO) measures and clinically notable outcome assessments for patients undergoing hip arthroscopy for femoroacetabular impingement syndrome or labral pathology with borderline dysplastic hips (BDH). METHODS: PubMed, EMBASE, and the Web of Science Core Collection databases were queried for articles evaluating lateral center edge angle as a predictor of PRO after hip arthroscopy. Articles were eligible for meta-analysis if they compared PROs measures between patients with normal acetabular coverage and borderline dysplasia and were at least level III evidence. Continuous random-effects models with standardized mean differences were used to compare postoperative Hip Outcome Score-Activities of Daily Living and sports subscales, modified Harris Hip Score, international Hip Outcome Tool scores, Satisfaction, and Visual Analog Scale Pain scores between normal coverage and borderline dysplastic groups. RESULTS: Overall, 989 hips undergoing arthroscopy from six investigations were included in this meta-analysis, including 315 borderline dysplastic subjects (mean age 27.5 years) and 674 subjects with normal coverage (mean age 26.9 years). Borderline dysplastic and normal coverage cohorts were followed for an average of 37.0 and 36.8 months, respectively. Postoperative PRO measures (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, modified Harris Hip Score, international Hip Outcome Tool-12, Satisfaction, and Visual Analog Scale Pain) collected approximately three years after hip arthroscopy were not markedly different between subjects with BDH when compared with patients with normal coverage. CONCLUSIONS: In a meta-analysis of the available literature, patients with BDH are able to equally reach statistically similar clinical outcomes after isolated hip arthroscopy as compared with control subjects without dysplasia at short-term follow-up. A BDH should not be considered a contraindication to hip arthroscopy when optimal PRO achievement is the goal. LEVEL OF EVIDENCE: Level III, Systematic Review and Meta-Analysis.

Patient-Reported Outcomes Measurement Information System Is Not as Responsive as Legacy Scores in Detecting Patient Outcomes in Hip Preservation: A Systematic Review.

PURPOSE: To evaluate publication trends of Patient-Reported Outcomes Measurement Information System (PROMIS) in hip preservation literature, assess the usage of PROMIS as an outcome measure, and evaluate correlations of all available published PROMIS domains with legacy patient-reported outcomes (PROs). METHODS: The PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Google Scholar databases were queried for articles evaluating PROMIS scores among hip preservation populations. Inclusion criteria consisted of studies with Level IV evidence or above (per the Sackett et al. levels of evidence), such as case series and cohort studies, reporting on perioperative use of hip PROMIS scores. Exclusion criteria consisted of arthroplasty and trauma studies. Patient demographics, PROMIS usage, and PROMIS Pearson or Spearman correlation coefficients to historic PROs were recorded for each study. RESULTS: Fifteen articles published between 2017 and 2021 were included in the analysis, with the majority (75%) published between 2020 and 2021. Studies assessing postoperative outcomes had follow-up periods ranging from 6 months to 5 years. The most common PROMIS domain reported was Physical Function (PF), and there was varying usage of other domains including Pain Intensity, Anxiety, and Depression. PROMIS validity was most often assessed in comparison to the modified Harris Hip Score (mHHS) by calculating the Pearson coefficient, which assumes normal data distribution, or Spearman coefficient, which is rank-based and does not require normal data distribution. Studies comparing PROMIS-PF with mHHS reported Pearson coefficients ranging from 0.49 to 0.72 and Spearman coefficients ranging from 0.67 to 0.71. CONCLUSIONS: There has been a chronologic increase in PROMIS usage in hip preservation literature. PROMIS demonstrates moderate-to-strong correlations with legacy PROs, but there is substantial heterogeneity in follow-up periods, PROMIS domains used, and statistical methodology. The current data show that PROMIS is not as responsive as historically used, validated PROs in quantitatively assessing function and pain in hip preservation patients. CLINICAL RELEVANCE: Surgeons using PROMIS solely should be aware that the score may not be as responsive as legacy PROs in closely assessing improvements or deterioration in patient performance after hip preservation surgery. Rather than being used alone, PROMIS may be useful as a replacement for a group of legacy PROs. Thus, when used alongside select legacy PROs, overall questionnaire burden can be reduced while maintaining a high level of accuracy in assessing health status.

Pathogenesis, Evaluation, and Management of Osteolysis After Total Shoulder Arthroplasty.

Radiographic osteolysis after total shoulder arthroplasty (TSA) remains a challenging clinical entity, as it may not initially manifest clinically apparent symptoms but can lead to clinically important complications, such as aseptic loosening. A thorough consideration of medical history and physical examination is essential to rule out other causes of symptomatic TSA-namely, periprosthetic joint infection-as symptoms often progress to vague pain or discomfort due to subtle component loosening. Once confirmed, nonoperative treatment of osteolysis should first be pursued given the potential to avoid surgery-associated risks. If needed, the current surgical options include glenoid polyethylene revision and conversion to reverse shoulder arthroplasty. The current article provides a comprehensive review of the evaluation and management of osteolysis after TSA through an evidence-based discussion of current concepts.

Intraoperative Automated Radiographic Visualization Tool Allows for Higher Accuracy of Cam Lesion Resection When Used by Novice Surgeons for Arthroscopic Femoroplasty: Lowering the Learning Curve.

PURPOSE: To compare the accuracy of conventional fluoroscopy versus an intraoperative radiographic visualization tool in assisting a novice and experienced hip arthroscopist in comprehensive cam correction to a desired alpha angle (AA). METHODS: A cadaveric study was performed using 28 hemi-pelvises with cam-type deformity (AA > 55˚) measured on anteroposterior, lateral, and Dunn-view radiographs. Two fellowship-trained hip arthroscopists each performed 14 arthroscopic femoroplasties. The specimens were randomly assigned: 14 of the procedures were performed by the experienced surgeon, with 7 using the automated radiographic visualization tool (Guided Femoroplasty) and 7 using routine fluoroscopy (Control). The same number of hips was assigned to the novice surgeon, completing 7 femoroplasties with and without the visualization tool. Each hip was imaged before and after femoroplasty in 6 different positions using intraoperative fluoroscopy to evaluate head-neck offset. Femoroplasty AAs were compared between groups with and without visualization tool use, as well as between surgeons. One-way analysis of variance analysis was performed to evaluate the consistency of cam resection. RESULTS: For the experienced hip arthroscopist, comparison of Guide Femoroplasty and Control groups resulted in similar accuracy when compared to the controls, with post-femoroplasty AA averages ranging from 41.4° ± 3.8˚ to 44.8° ± 2.8˚ (P = .511) and 40.2° ± 5.3˚ to 45.6° ± 2.2˚ (P = .225), respectively. For the novice hip arthroscopist, the Guided Femoroplasty group had higher accuracy, with post-femoroplasty AA averages ranging from 42.8° ± 2.6˚ to 46.1° ± 7.2˚(P = .689) with and 39.8° ± 3.1˚ to 51.9° ± 8.1˚ (P = .001) without the visualization tool. Comparison of procedure time did not show any statistically significant difference between the use of the radiographic visualization tool and controls for either surgeon (P > .05 for all). CONCLUSIONS: Femoroplasty with and without the use of automated radiographic visualization tool results in accurate cam resection when used by both the experienced and novice surgeon. However, higher accuracy was observed when resecting to a desired AA performed by a novice surgeon using the visualization tool. Additionally, use of the visualization tool did not result in longer procedure times for either surgeon. CLINICAL RELEVANCE: The impact of incomplete cam resections and over-resection on patient outcomes in the literature has led to the recent development of automated intraoperative radiographic visualization tools that allow for assistance of cam resection accuracy for the treatment of femoroacetabular impingement syndrome. This cadaveric study demonstrates that femoroplasty with the use of an intraoperative automated radiographic visualization tool may result in more accurate cam resections.

Comparison of Long-term Radiographic Outcomes and Rate and Time for Conversion to Total Knee Arthroplasty Between Repair and Meniscectomy for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Previous meta-analyses have demonstrated superior outcomes in patients undergoing arthroscopic repair of medial meniscus posterior root tears (MMPRTs) compared with meniscectomy. However, these analyses have considered only short- or midterm outcomes and low-quality evidence. PURPOSE: To compare the mid- to long-term rates of radiographic osteoarthritis (OA) between repair and meniscectomy for MMPRT. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed, EMBASE, Ovid/MEDLINE, and Cochrane Central Register of Controlled Trials databases were queried for articles evaluating repair and meniscectomy for MMPRT. Articles were eligible if they had a minimum mean 4-year follow-up for radiographic OA or conversion to total knee arthroplasty (TKA) and were at least level 3 evidence. Radiographic OA was assessed using Kellgren-Lawrence (KL) progression. Rates of conversion to TKA and International Knee Documentation Committee (IKDC) scores were also extracted. DerSimonian-Laird binary random-effects models were created to evaluate differences in radiographic OA and TKA conversion rates, with odds ratios (ORs) representing pooled estimates. Continuous random-effects models with standardized mean differences (SMDs) were used to compare postoperative IKDC scores. RESULTS: Repair and meniscectomy cohorts were followed for a mean of 64.8 months and 62.5 months, respectively, for KL progression; and 82.8 months and 73.8 months, respectively, for TKA rates and IKDC scores. Overall, 59 of 144 (41%) patients undergoing surgical intervention for MMPRT demonstrated OA progression; 18 of 82 (22%) who underwent repair for MMPRT exhibited OA progression compared with 41 of 62 (66%) who underwent meniscectomy (OR, 0.17; 95% CI, 0.03-0.83; P = .029). Overall, 30 of 143 (21%) patients converted to TKA; 9.8% (8/82) of patients who underwent repair converted to TKA (range, 47-131 months), while 36% (22/61) who underwent meniscectomy converted to TKA (range, 17.8-101 months) (OR, 0.15; 95% CI, 0.05-0.44; P < .001). No significant differences between postoperative IKDC scores were observed (SMD, 0.51; 95% CI, -0.02 to 1.05; P = .06). CONCLUSION: Medial meniscus posterior root repair results in significantly lower rates of radiographic OA progression and conversion to TKA at >60-month follow-up. On the basis of these findings, we recommend consideration of repair of MMPRTs when degenerative changes are not severe, as it can yield improved outcomes.

Machine Learning Algorithms Predict Achievement of Clinically Significant Outcomes After Orthopaedic Surgery: A Systematic Review.

PURPOSE: To determine what subspecialties have applied machine learning (ML) to predict clinically significant outcomes (CSOs) within orthopaedic surgery and to determine whether the performance of these models was acceptable through assessing discrimination and other ML metrics where reported. METHODS: The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were queried for articles that used ML to predict achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) after orthopaedic surgical procedures. Data pertaining to demographic characteristics, subspecialty, specific ML algorithms, and algorithm performance were analyzed. RESULTS: Eighteen articles met the inclusion criteria. Seventeen studies developed novel algorithms, whereas one study externally validated an established algorithm. All studies used ML to predict MCID achievement, whereas 3 (16.7%) predicted SCB achievement and none predicted PASS achievement. Of the studies, 7 (38.9%) concerned outcomes after spine surgery; 6 (33.3%), after sports medicine surgery; 3 (16.7%), after total joint arthroplasty (TJA); and 2 (11.1%), after shoulder arthroplasty. No studies were found regarding trauma, hand, elbow, pediatric, or foot and ankle surgery. In spine surgery, concordance statistics (C-statistics) ranged from 0.65 to 0.92; in hip arthroscopy, 0.51 to 0.94; in TJA, 0.63 to 0.89; and in shoulder arthroplasty, 0.70 to 0.95. Most studies reported C-statistics at the upper end of these ranges, although populations were heterogeneous. CONCLUSIONS: Currently available ML algorithms can discriminate the propensity to achieve CSOs using the MCID after spine, TJA, sports medicine, and shoulder surgery with a fair to good performance as evidenced by C-statistics ranging from 0.6 to 0.95 in most analyses. Less evidence is available on the ability of ML to predict achievement of SCB, and no evidence is available for achievement of the PASS. Such algorithms may augment shared decision-making practices and allow clinicians to provide more appropriate patient expectations using individualized risk assessments. However, these studies remain limited by variable reporting of performance metrics, CSO quantification methods, and adherence to predictive modeling guidelines, as well as limited external validation. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

Predictors of Above Average 6-Year Citation Rates in Leading Spine-Specific Medical Journals.

STUDY DESIGN: Cross-sectional. OBJECTIVE: To identify predictors of manuscripts achieving 6-year citation rates higher than the mean in spine-specific literature. SUMMARY OF BACKGROUND DATA: An article's citation rate demonstrates its contribution to academia and its quality. Predictors of citation rates have not yet been studied in spine-specific medical literature. METHODS: Three leading spine-specific journals were identified by a weighted scoring system comparing various journal metrics. Research articles published in 2014 were evaluated from the following journals: Spine, European Spine Journal, and Journal of Neurosurgery: Spine. Article features analyzed included journal of origin, number of words in article title, author count, degree of first author, conflicts of interest, quantity of contributing academic institutions, country of origin, study topic, study design, level of evidence, sample size, reference count, and citation rate. Multivariate logistic regression was used to determine predictors of above average citation rate at 6 years following publication. RESULTS: The final analysis included 1091 articles. Spine had a significantly higher citation rate than European Spine Journal (P = 0.0008); however, no significant differences were observed between Spine and Journal of Neurosurgery: Spine. Regression analysis demonstrated that studies originating in North America (OR:1.44, 95% CI:1.01-2.01, P = 0.04), those with 6 ≥ authors (OR:1.72, 95% CI:1.29-2.30, P < 0.001), sample size >100 (P < 0.001), prospective case series (OR: 2.67, 95% CI: 1.24-5.76), and retrospective case series (OR: 1.99, 95% CI: 1.07-3.73) were independent predictors of achieving above average 6-year citation rates. CONCLUSION: Spine, European Spine Journal, and Journal of Neurosurgery: Spine had the highest 6-year citation rates of the top 10 orthopedic spine journals, with Spine being significantly higher than European Spine Journal. Studies originating in North America, those with six or more authors, sample sizes > 100, and those that are retrospective or prospective case series are independent predictors of greater citation rates at 6 years in orthopedic spine-specific medical literature.Level of Evidence: 4.

Repeat Revision Hip Arthroscopy Outcomes Match That of Initial Revision But Not That of Primary Surgery for Femoroacetabular Impingement Syndrome.

PURPOSE: To (1) report on pre- and postoperative patient-reported outcome (PRO) scores for patients undergoing repeat revision surgery in short-term follow-up and (2) compare minimal clinically important difference (MCID) and patient acceptable symptomatic state achievement between primary, revision, and repeat revision hip arthroscopy cohorts. METHODS: Data from consecutive patients undergoing revision hip arthroscopy from January 2012 to February 2019 were retrospectively reviewed. Hips that underwent 2 revision hip arthroscopic surgeries were identified and matched 1:3 to patients undergoing revision surgery and 1:3 to patients undergoing primary surgery by age, sex, and body mass index. Baseline demographic data, surgical indications, and hip-specific PROs were collected were obtained preoperatively and at minimum 1-year follow-up. MCID was calculated individually for each cohort. RESULTS: Twenty patients who underwent repeat revision were matched to 60 patients who underwent revision and 60 primary patients. Patients who underwent repeat revision achieved MCID on all investigated PROs at a similar rate to patients undergoing primary surgery (90.0% vs 91.7%, P = .588) and at a greater rate than patients undergoing first-time revision surgery (90.0% vs 71.7%, P = .045). Patients who underwent repeat revision achieved patient acceptable symptomatic state on all investigated PROs at a similar rate to patients who underwent first-time revision (30.0% vs 55.0%, P = .053) but at a significantly lower rate than primary patients (30.0% vs 76.7%, P < .001). However, patients undergoing repeat revision surgery had significantly lower preoperative PROs (P < .001 for all) and no significant difference in PROs at minimum 1-year follow-up compared with patients undergoing revision (P > .05). Compared with the primary cohort, patients who underwent repeat revision had significantly lower Hip Outcome Score-Activities of Daily Living (77.3 ± 16.7 vs 86.1 ± 14.4; P = .034), Hip Outcome Score-Sports Subscale (60.6 ± 27.2 vs 76.1 ± 23.8; P < .001), and modified Harris Hip Score (69.2 ± 19.3 vs 81.7 ± 16.1; P = .048) at a minimum of 1-year follow-up. CONCLUSIONS: Second-time revision hip arthroscopy, which often requires advanced procedures, results in clinically significant improvement in PROs; however, outcomes for repeat revision cases are similar to first-time revision cases but inferior to those obtained following primary surgeries. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Comparison of Suction Seal and Contact Pressures Between 270° Labral Reconstruction, Labral Repair, and the Intact Labrum.

PURPOSE: To biomechanically compare the suction seal, contact area, contact pressures, and peak forces of the intact native labrum, torn labrum, 12- to 3-o'clock labral repair, and 270° labral reconstruction in the hip. METHODS: A cadaveric study was performed using 8 fresh-frozen hemipelvises with intact labra and without osteoarthritis. Intra-articular pressure maps were produced for each specimen using an electromechanical testing system under the following conditions: (1) intact labrum, (2) labral tear, (3) labral repair between the 12- and 3-o'clock positions, and (4) 270° labral reconstruction using iliotibial band allograft. Specimens were examined in neutral position, 20° of extension, and 60° of flexion. In each condition, contact pressure, contact area, and peak force were obtained. Repeated-measures analysis of variance was used to identify differences in biomechanical parameters among the 3 conditions. Qualitative differences in suction seal were compared between labral repair and labral reconstruction using the Fisher exact test. RESULTS: Repeated-measures analysis of variance for contact area in neutral position, extension, and flexion showed statistically significant differences between the normalized study states (P < .05). Post hoc analysis showed significantly larger contact areas measured in labral repair specimens than in labral reconstruction specimens in the extension and flexion positions. Region-of-interest analysis for the normalized contact area in the extension and flexion positions, as well as normalized contact pressures in neutral position, showed statistically significant differences between the labral states (P < .05). Finally, 8 labral repairs (100%) versus only 1 labral reconstruction (12.5%) retained the manually tested suction seal (P < .001). CONCLUSIONS: In this in vitro biomechanical model, 270° labral reconstruction resulted in decreased intra-articular contact area and loss of suction seal when compared with labral repair. Clinically, labral reconstruction may not restore the biomechanical characteristics of the native labrum as compared with labral repair. CLINICAL RELEVANCE: Labral reconstruction may result in lower intra-articular hip contact area and loss of suction seal, affecting the native biomechanical function of the acetabular labrum. Further biomechanical studies and clinical studies are necessary to determine whether there are any long-term consequences of 270° labral reconstruction.

Dose-Response Relationships Between Gonadal Steroids and Bone, Body Composition, and Sexual Function in Aging Men.

CONTEXT: Most labs set the lower limit of normal for testosterone at the 2.5th percentile of values in young or age-matched men, an approach that does not consider the physiologic changes associated with various testosterone concentrations. OBJECTIVE: To characterize the dose-response relationships between gonadal steroid concentrations and measures regulated by gonadal steroids in older men. DESIGN, PARTICIPANTS, AND INTERVENTION: 177 men aged 60 to 80 were randomly assigned to receive goserelin acetate plus either 0 (placebo), 1.25, 2.5, 5, or 10 grams of a 1% testosterone gel daily for 16 weeks or placebos for both medications (controls). PRIMARY OUTCOMES: Changes in serum C-telopeptide (CTX), total body fat by dual energy X-ray absorptiometry, and self-reported sexual desire. RESULTS: Clear relationships between the testosterone dosage (or the resulting testosterone levels) and a variety of outcome measures were observed. Changes in serum CTX exceeded changes in the controls in men whose testosterone levels were 0 to 99, 100 to 199, 200 to 299, or 300 to 499 ng/dL, whereas increases in total body fat, subcutaneous fat, and thigh fat exceeded controls when testosterone levels were 0 to 99 or 100 to 199 ng/dL. Sexual desire and erectile function were indistinguishable from controls until testosterone levels were <100 ng/dL. CONCLUSION: Changes in measures of bone resorption, body fat, and sexual function begin at a variety of testosterone concentrations with many outcome measures remaining stable until testosterone levels are well below the stated normal ranges. In light of this variation, novel approaches for establishing the normal range for testosterone are needed.

Efficacy and Validity of Orthopaedic Simulators in Surgical Training: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: The purpose of this study was to perform a systematic review and meta-analysis of the effects of training simulators on surgical skill measures across randomized controlled trials. The authors hypothesized that simulated training would (1) result in objective improvements in skill acquisition and (2) be heterogeneous regarding the outcomes and types of validity assessed. METHODS: The Cochrane Database of Systematic Reviews, the Central Register of Controlled Trials, PubMed, EMBASE, and MEDLINE databases were queried for Level I studies on training simulators between 2007 and 2019 in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Exclusion criteria were studies without discrete assessment of skills acquisition after surgical simulator training and level of evidence II to V. The Jadad scale was used to assess the methodological quality of all included articles. Data pertaining to patient demographics, validity measures, simulator types, and study-specific outcome measures were extracted. Meta-analyses adjusted for random effects and heterogeneity analyses (I) were used to compare pooled time-to-completion and performance outcomes among included studies. RESULTS: A total of 24 studies with 494 participants were identified. The most common simulator type involved knee arthroscopy (11 studies, 45.8%). Eight studies reporting time-to-task completion and performance scores were included in the meta-analysis. Virtual reality training was favored in time-to-task completion (mean difference = -82.25 seconds, P = 0.002) and improvement in objective performance scores (mean difference = 1.24, P = 0.02) relative to traditional training. Sensitivity analysis of time-to-task completion based on the length of training interval revealed a mean difference of -45.24 (P = 0.07) and -137.74 (P < 0.001) seconds for the short-term and immediate posttesting subgroups, respectively. CONCLUSION: Overall, improved task efficiency and performance were observed with the use of orthopaedic simulators. However, simulator type, training protocols, and outcome measures were heterogeneous. Future studies are warranted to evaluate financial cost and longitudinal training programs and to standardize outcomes regarding the use of simulators in orthopaedic education. LEVEL OF EVIDENCE: Level I.

Preoperative Hip Extension Strength Is an Independent Predictor of Achieving Clinically Significant Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: The effect of preoperative hip strength on outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is unclear. The purpose of this study was to determine whether preoperative isometric hip strength is associated with outcome scores at 6 months as well as achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients undergoing hip arthroscopy for FAIS. HYPOTHESIS: Increased preoperative isometric strength will be correlated with short-term postoperative outcomes and will be predictive of achieving higher functional status. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: Data from 92 consecutive patients undergoing primary hip arthroscopy for treatment of FAIS from March through August 2018 were analyzed. All patients included in the analysis had preoperative measures of isometric hip strength on both affected and unaffected limbs, as well as preoperative and 6-month patient-reported outcome (PRO) scores. Analysis was performed to determine correlations between normalized isometric hip strength measurements and PROs and whether strength measurements were predictive of achieving MCID or PASS. RESULTS: A total of 74 (80.4%) patients had 6-month PROs and were included in the final analysis. Hip extension strength on both sides was correlated with all postoperative PROs (all P > 0.05). Abduction strength on both sides was correlated with postoperative Hip Outcome Score-Activities of Daily Living subscale score, achieving MCID on at least 1 score threshold, and reaching the international Hip Outcome Tool-12 threshold score for achieving PASS (all P < 0.05). Regression analysis showed that extension strength on the affected side was the only strength measurement predictor of achieving PASS (1.043; P = 0.049). CONCLUSION: Preoperative isometric hip extension and abduction strength are correlated with 6-month postoperative PRO scores. Furthermore, hip extension strength is a predictor of achieving clinically meaningful outcomes. CLINICAL RELEVANCE: This study highlights the possible importance of preoperative optimization of hip function to maximize outcomes in patients undergoing hip arthroscopy for FAIS.

A Cadaveric Study of Cam-Type Femoroacetabular Impingement: Biomechanical Comparison of Contact Pressures Between Cam Morphology, Partial Femoral Osteoplasty, and Complete Femoral Osteoplasty.

PURPOSE: To compare the biomechanical properties of the hip joint with an intact femoral cam lesion, partial cam resection, and complete cam resection. METHODS: A cadaveric study was performed using 8 hemipelvises with cam-type morphology (alpha angle > 55°) and intact labra. Intra-articular pressure maps were produced for each specimen under the following conditions: (1) native cam morphology (intact), (2) cam morphology with incomplete resection (partial), and (3) cam morphology with complete resection (complete). By use of an open technique, resection of the superior portion of the cam morphology was performed with a 5.5-mm burr to create the partial resection, followed by the inferior portion to create the complete resection. In each condition, 3 biomechanical parameters were obtained: contact pressure, contact area, and peak force within a region of interest. Measurements were performed 3 times in each condition, and the average value was used for statistical analysis. Analysis of variance was used to compare biomechanical parameters between conditions. RESULTS: A statistically significant difference was found between the pre- and post-resection alpha angles (62.2° ± 3.9° vs 40.9° ± 1.4°, P < .001). Repeated-measures analysis of variance showed that the normalized average pressure values of hips with complete resection of cam lesions were significantly lower than those of hips with incomplete femoral cam lesions and hips with intact cam morphology (100% vs 93.6% ± 8.3% and 82.6% ± 16.2%, respectively; P < .0001). The percentage reduction of contact pressure in the complete and partial groups was 17.4% and 6.4%, respectively, compared with the intact group. Contact area and peak force showed no statistically significant differences across the 3 conditions (P > .05). CONCLUSIONS: Complete cam resection results in significantly lower intra-articular hip contact pressures than incomplete cam resection and native cam morphology in a cadaveric hip model. These observations underscore the importance of ensuring complete resection of femoral cam lesions in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. CLINICAL RELEVANCE: Previous studies have shown that the most common reason for revision hip arthroscopy in patients with femoroacetabular impingement syndrome is incomplete femoral cam resection during the index operation. This study shows biomechanical differences associated with partial cam resection compared with the complete cam resection state that may translate to persistent symptoms.

The Effect of Postoperative Opioid Prescription Refills on Achieving Meaningful Clinical Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To determine whether requiring postoperative opioid refills has an effect on both baseline and postoperative functional scores, as well as rates of achieving clinical success 2 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 were analyzed. Patients with at least 1 postoperative opioid refill were matched 1:2 by age and body mass index to patients not requiring refills. Preoperative and postoperative patient-reported outcomes including the Hip Outcome Score-Activities of Daily Living Subscale, HOS-Sports Subscale, and modified Hip Harris Score, as well as visual analog scale (VAS) pain and satisfaction surveys, were compared between the 2 groups, as well as between patients who requested 1 refill versus those requiring 2 or more refills. The minimal clinically important difference and patient acceptable symptomatic state (PASS) were calculated for the study group and compared between patient groups. RESULTS: A total of 128 patients (14.5%) requesting at least 1 postoperative opioid refill and 256 with no refills were included in the study. Analysis showed that the refill group had lower patient-reported outcomes (P < .05 for all), a lower VAS satisfaction score average (73.2 ± 30.7 vs 80.1 ± 25.9, P = .029), and a higher VAS pain score average (27.2 ± 26.1 vs 19.9 ± 22.7, P = .007). Similar trends were seen when patients with 1 refill were compared with those with 2 or more refills. Analysis of meaningful clinical outcomes showed that patients in the refill group had lower rates of achieving the PASS (68.3% vs 77.2%, P = .006). However, there were no statistically significant differences in achieving the minimal clinically important difference between the 2 groups (P > .05 for all). CONCLUSIONS: Patients undergoing hip arthroscopy for FAIS who require 1 or more opioid refills postoperatively are likely to have lower baseline and postoperative functional scores, as well as to achieve the PASS at lower rates, compared with patients who do not require an additional opioid prescription to what is routinely given after surgery. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Quality of Online Video Resources Concerning Patient Education for the Meniscus: A YouTube-Based Quality-Control Study.

PURPOSE: To evaluate the reliability and educational content of YouTube videos concerning the menisci. METHODS: YouTube was queried using the keyword "meniscus." The first 50 videos were evaluated. Eleven video characteristics were extracted, and videos were categorized by source and content. Video reliability was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-5). Video educational content was assessed using the Global Quality Score (GQS; score range, 0-4) and a meniscus-specific score (MSS; score range, 0-20). RESULTS: The mean video duration was 551.44 ± 1,046.04 seconds (range, 75-7,282 seconds). The mean number of views was 288,597.7 ± 735,275.9. Collectively, the 50 videos accrued 14,141,285 views. The mean JAMA score, GQS, and MSS were 1.55, 2.12, and 3.67, respectively. The video source was predominately non-physician based (24.49% of source uploaders), whereas video content was predominately concerned with disease information (37.50% of content). Significant between-group effects were observed for the JAMA score and video content (P = .0155), with videos concerning disease information, exercise training, and nonsurgical intervention having the highest mean JAMA scores. Significant between-group effects were also observed for the JAMA score based on video upload source (P < .001), with videos uploaded by physicians receiving the highest mean JAMA scores. The mean GQS and MSS were significantly greater for videos categorized as having disease-specific content (P = .0377 and P = .0404, respectively) and for physician video uploaders (P = .0133 and P = .0100, respectively). The number of video dislikes was a negative independent predictor of the JAMA score (ß = -0.007, P = .003). Disease-specific content was a positive independent predictor of the GQS (ß = 1.13, P = .042). There were no independent predictors of the MSS. CONCLUSIONS: Information on the meniscus found in YouTube videos is of low quality and reliability. CLINICAL RELEVANCE: Orthopaedic health practitioners should caution patients about the inaccuracy of YouTube videos regarding the meniscus given the low quality of content. These health care providers should make efforts to provide patients with higher-quality alternatives.

Radiographic Prevalence of Sacroiliac Joint Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome.

PURPOSE: To quantify the prevalence of sacroiliac joint (SIJ) abnormalities in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) by use of various imaging modalities and to compare outcomes based on SIJ abnormalities. METHODS: Plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. The exclusion criteria included patients undergoing bilateral or revision surgery, those with a history of dysplasia, and those with less than 2 years' follow-up. On radiographs, the SIJs were graded using modified New York criteria for spondyloarthropathy. CT and MRI scans were reviewed for joint surface erosion, subchondral sclerosis, joint space narrowing, pseudo-widening, bone marrow edema, and ankylosis. Patients with SIJ abnormalities were matched to patients without SIJ abnormalities in a 1:2 ratio by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain, and VAS for satisfaction. RESULTS: Of 1,009 consecutive patients, 743 (73.6%) were included; 187 (25.2%) showed SIJ changes. Of these 187 patients, 164 (87.7%) had changes on plain radiographs, 88 (47.1%) had changes on CT, and 125 (66.8%) had changes on MRI. SIJ changes on any imaging modality were weakly correlated with pain to palpation of the SIJ (r = 0.11, P = .004) on physical examination. Pain to palpation of the SIJ on physical examination (odds ratio [OR], 1.12; P = .031) and a history of SIJ pain (OR, 1.93; P = .018) increased the odds of having an SIJ abnormality on any imaging modality. After matching, patients without SIJ abnormalities had a significantly greater HOS-ADL (95.4 vs 90.6, P = .001), HOS-SS (91.1 vs 77.5, P < .001), and mHHS (91.3 vs 84.5, P < .001) and a significantly lower VAS pain score (10.9 vs 25.7, P < .001) than patients with abnormalities at a mean follow-up of 34.1 ± 9.7 months (range, 24-54 months). Patients without SIJ abnormalities had greater odds of achieving the minimal clinically important difference for the HOS-ADL (OR, 2.91; P = .001) and for the HOS-SS (OR, 2.83; P < .001) but not for the mHHS (OR, 1.73; P = .081). CONCLUSIONS: A high prevalence of SIJ abnormalities (25.2%) is seen on imaging in FAIS patients. These patients may show significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment. The results of this study may allow treating orthopaedic surgeons to better inform patients with SIJ abnormalities that they may not achieve clinically significant outcome improvement after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Mirror Image Modeling of Acetabular Rim Thickness Differences in Patients With Unilateral Femoroacetabular Impingement Syndrome.

PURPOSE: To use mirror imaging to identify the location and magnitude of difference in acetabular rim morphology between the symptomatic and unaffected acetabula in patients with symptomatic unilateral pincer-type or mixed femoroacetabular impingement syndrome (FAIS) using 1-dimensional models created with computed tomography (CT). METHODS: CT scans of bilateral hips in 33 patients diagnosed with unilateral pincer-type or mixed FAIS were obtained. Three-dimensional bilateral hip models were constructed, and the unaffected hemipelvis was superimposed onto the symptomatic side to compare acetabular thickness. Protrusion of the symptomatic side was recorded, and rim morphology was divided into clock face quadrants to analyze the location of greatest magnitude of difference between affected and unaffected acetabula. Analysis of the quadrants was performed using analysis of variance with post hoc Bonferroni correction. RESULTS: The study group consisted of more females (51.6%) than males, with an average age of 35.72 ± 7.8 years and an average body mass index of 24.3 ± 4.1 kg/m2. Of the 33 hips included, 14 were isolated pincer-type FAIS and 19 were mixed. The average preoperative symptomatic side lateral center edge angle was 37.5° ± 7.2° compared with 29° ± 5.1° on the asymptomatic side (P = .001). The symptomatic acetabular rim was on average 0.43 ± 0.18 mm thicker than the corresponding location on the unaffected rim. When the acetabulum was divided into clock face quadrants, the 12 to 3 o'clock position showed the greatest difference between symptomatic and unaffected sides (0.55 ± 0.18 mm) compared with the 3 to 6 o'clock position (0.4 ± 0.28 mm; P = .006), 6 to 9 o'clock (0.34 ± 0.07 mm; P < .001), and 9 to 12 o'clock (0.38 ± 0.03; P = .001). CONCLUSIONS: Patients with unilateral, symptomatic pincer-type or mixed FAIS show statistical differences in rim thickness between the affected and unaffected acetabula. Small changes in acetabular rim morphology on the order of ≤0.5 mm may be the difference between symptomatic FAIS and the unaffected hip. LEVEL OF EVIDENCE: IV, case series.