Risk Factors of Emergency Department Utilization After Outpatient Surgery for Sports-Related Injuries.

INTRODUCTION: The purpose of this study was to identify the most common reasons for and risk factors associated with postoperative emergency department (ED) utilization after orthopaedic procedures for sports-related injuries. METHODS: Using the 2014 to 2016 New York and Florida State Databases from the Healthcare Cost and Utilization Project, outpatient procedures for sports-related injuries were identified. Patient records were tracked across care settings within each state to determine the rate and reasons of postoperative ED utilization within 90 days after the index surgery. Multiple logistic regression models were used to identify risk factors associated with ED visits at 0 to 7 days, 8 to 30 days, 31 to 90 days postoperatively. RESULTS: A total of 28,192 surgery visits for sports-related injuries were identified, with knee arthroscopy with partial meniscectomy (18.48%) and arthroscopic anterior cruciate ligament reconstruction (17.04%) as the two most common procedures treating sports injuries. The overall postoperative ED utilization rates were 1.6% (0 to 7 days postoperative), 1.3% (8 to 30 days) and 2.1% (31 to 90 days). The main cause of ED visits was markedly different during each postoperative period: mainly musculoskeletal pain (36.3%) during 0 to 7 days, either musculoskeletal pain (17%) or injury (16.6%) during 8 to 30 days, and injury (24.2%) during 31 to 90 days. Sports with the highest ED utilization in descending order were basketball, football, ice/snow sports, walking/running, cycling, and soccer. Relative to open procedures, arthroscopic procedures were 0.71 times as likely to result in a postoperative ED visit. Independent predictors of ED utilization up to 90 days postoperatively included renal failure, chronic pulmonary disease, psychosis, diabetes, and alcohol abuse. DISCUSSION: Rate of ED utilization after outpatient surgery for sports-related injuries is low (<2.2%), with postoperative musculoskeletal pain and reinjury as the two most common causes, highlighting the importance of postoperative pain management and injury prevention. Arthroscopic procedures showed markedly lower ED utilization compared with open surgery, although not indicative of overall superiority. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Systematic Review and Meta-analysis of Studies Comparing Complete Capsular Closure Against Unrepaired Hip Capsules During Hip Arthroscopy.

Background: While the biomechanical importance of the hip capsule is well described, there remains controversy over the necessity of routine capsular closure after hip arthroscopy. Purpose: To perform a meta-analysis of clinical studies to compare pooled outcomes of complete hip capsular closure cohorts against unrepaired hip capsule cohorts. Study Design: Systematic review; Level of evidence, 3. Methods: The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, CINAHL/EBSCO, and Scopus were queried in February 2022 for studies that directly compared clinical outcomes for hip arthroscopy patients treated with either complete capsular closure or an unrepaired capsule. Outcomes assessed were incidence of revision hip arthroscopy, incidence of subsequent conversion to total hip arthroplasty (THA), and improvement from baseline in modified Harris Hip Score (mHHS), Hip Outcome Score (HOS) activities of daily living (ADL), HOS sports specific (SS) subscale, Copenhagen Hip and Groin Outcome Score (HAGOS) ADL, and HAGOS SS subscale. A pooled weighted mean difference (WMD) was used to compare changes in mHHS. A pooled standardized mean difference (SMD) was used to compare changes in the ADL and SS outcomes. A pooled risk ratio (RR) was used to compare the probability of revision hip arthroscopy and conversion to THA based on capsular management. For pooled outcomes where heterogeneity was regarded as potentially unimportant, a fixed-effects model was implemented. For pooled outcomes with considerable heterogeneity, a random-effects model was implemented. Results: Of the 1896 records identified in our search, 11 studies (1897 patients) were included. A significantly higher improvement in mHHS (WMD, -3.72; 95% CI, -4.95 to -2.50; P < .00001) and ADL outcomes (SMD, -0.30; 95% CI, -0.54 to -0.07; P = .01) were seen after complete capsular closure. There was a significantly lower probability of subsequent revision hip arthroscopy (RR, 1.67; 95% CI, 1.14 to 2.45; P = .008) and conversion to THA (RR, 2.01; 95% CI, 1.06 to 3.79; P = .03) after complete capsular repair. There was no difference in SS outcomes (SMD, -0.02; 95% CI, -0.16 to 0.13; P = .81) between the 2 groups. Conclusion: This meta-analysis demonstrated that routine complete capsular closure after hip arthroscopy led to superior clinical outcomes relative to unrepaired hip capsules.

Ulnar Collateral Ligament Internal Bracing Repair Technique for High-Grade Partial Proximal Tears in the Throwing Athlete.

The use of ulnar collateral ligament (UCL) repair with concomitant internal bracing for throwing athletes is a viable treatment option, but must take into account tear location, ligament quality, the expected length of the athlete's career, desire to advance to the next level of competition, and age. There has been increased interest in repair of UCL injuries in overhead athletes due to advancements in surgical technique, as well as improved technologies of anchor and suture material. In addition, return to sport can be accelerated compared to reconstruction. In this Technical Note, we demonstrate an ulnar collateral ligament repair technique, with internal bracing augmentation for high-grade partial proximal tears in the throwing athlete that is reliable, strong, and easily reproducible.

Total Knee Arthroplasty After Meniscectomy Is More Likely in Patients With Bicompartmental or Complex Tears.

Purpose: To determine the relationship between meniscus tear morphologies, stratified by location and pattern, and knee arthroplasty rates in a commercial insurance population. Methods: The PearlDiver database was queried for patients ≥35 years old with a meniscus tear of specified laterality and ≥2 years follow-up between 2015 and 2018. Two analyses were conducted with cohorts matched on age, sex, Charlson Comorbidity Index, obesity, osteoarthritis (OA), and treatment (meniscectomy vs conservative): one with equal-sized subgroups by tear location (medial only, lateral only, or both medial and lateral) and another by tear pattern (bucket-handle, complex, or peripheral). The rate of subsequent total knee arthroplasty (TKA) was compared between matched groups. Results: In total, 129,987 patients (mean age: 57.8 ± 10.5 years) were matched by tear location; 1,734 patients with medial-only tears (4.0%), 1,786 with lateral-only tears (4.1%), and 2,611 with medial plus lateral tears (6.0%) underwent a TKA within 5 years (P < .001). Patients with both medial and lateral tears were 1.55-fold more likely to undergo TKA. In total, 24,213 patients (mean age: 56.0 ± 10.5 years) were matched by tear pattern; 296 patients with bucket-handle tears (3.7%), 373 with complex tears (4.6%), and 336 with peripheral tears (4.2%) underwent TKA (P = .01). Patients with complex tears were 1.29-fold more likely to undergo TKA than patients with bucket-handle tears (P = .002). Conclusions: In matched cohorts of patients with degenerative meniscus tears, having both medial plus lateral tears conferred a 1.5-fold risk of TKA, whereas complex tears conferred a 1.3-fold risk within 5 years. Specific meniscal tear patterns and locations harbor varying risk in progressing to end-stage knee OA, and these data may help counsel patients about their likelihood of progressing to end-stage OA warranting an arthroplasty procedure. Level of Evidence: Level III, retrospective comparative study.

Patient-Specific Variables Associated with Failure to Achieve Clinically Significant Outcomes After Meniscal Allograft Transplantation at Minimum 5 Year Follow-Up.

PURPOSE: To determine the improvements in patient-reported outcome measures (PROMs) necessary to achieve minimal clinically important difference (MCID), patient-acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) after primary meniscal allograft transplantation (MAT) at a minimum of 5-year follow-up, while identifying variables predictive of achieving clinically significant outcomes (CSOs). METHODS: A retrospective review was performed to identify patients undergoing primary MAT at a single institution from 1999 to 2016. Lysholm, International Knee Documentation Committee (IKDC), and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were collected before surgery and at a minimum of 5-year follow-up. A distribution-based approach was used to calculate MCID, whereas an anchor-based approach was used to calculate SCB and PASS. Multivariate logistic regression was performed to determine factors associated with CSO achievement. RESULTS: A total of 202 patients undergoing MAT (56% medial, 44% lateral) were included with a mean follow-up of 9.8 ± 4.1 years, age of 29.7 ± 8.5 years, and body mass index (BMI) of 26.5 ± 4.7. Thresholds for achieving MCID, PASS, and SCB, respectively, at a minimum 5-year follow-up for Lysholm (10.3, 74.5, 32.5), IKDC (12.1, 55.6, 29.1), and KOOS subscales questionnaires (Pain [11.0, 70.7, 25.1], Symptoms [11.0, 60.8, 19.6], Activities of Daily Living [10.5, 90.3, 17.9], Sport [16.2, 47.4, 37.5], and Quality of Life [13.6, 40.5, 37.3]) were calculated. Reduced odds of achieving MCID were associated with higher preoperative PROM scores, BMI, patient age, concomitant osteotomy, male sex, and worker's compensation (WC) status. Reduced odds of achieving PASS were associated with lower preoperative PROM scores, higher BMI (particularly ≥30), patient age, and WC status. Reduced odds of achieving SCB were associated with higher preoperative PROM scores and WC status. CONCLUSIONS: This study established the MCID, PASS, and SCB at 5-year minimum follow-up for the Lysholm score, IKDC, and KOOS subscales in patients who underwent MAT. Increased BMI and patient age, male sex, performance of concomitant osteotomy, WC status, and preoperative PROM scores were associated with failure to achieve CSOs after primary MAT at a minimum of 5-year follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic study, retrospective case series.

Prospective Randomized Trial of Biologic Augmentation With Bone Marrow Aspirate Concentrate in Patients Undergoing Arthroscopic Rotator Cuff Repair.

BACKGROUND: Although initial studies have demonstrated that concentrated bone marrow aspirate (cBMA) injections promote rotator cuff repair (RCR) healing, there are no randomized prospective studies investigating clinical efficacy. HYPOTHESIS/PURPOSE: To compare outcomes after arthroscopic RCR (aRCR) with and without cBMA augmentation. It was hypothesized that cBMA augmentation would result in statistically significant improvements in clinical outcomes and rotator cuff structural integrity. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients indicated for aRCR of isolated 1- to 3-cm supraspinatus tendon tears were randomized to receive adjunctive cBMA injection or sham incision. Bone marrow was aspirated from the iliac crest, concentrated using a commercially available system, and injected at the aRCR site after repair. Patients were assessed preoperatively and serially until 2 years postoperatively via the following functional indices: American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test, 12-Item Short Form Health Survey, and Veterans RAND 12-Item Health Survey. Magnetic resonance imaging (MRI) was performed at 1 year to assess rotator cuff structural integrity according to Sugaya classification. Treatment failure was defined as decreased 1- or 2-year ASES or SANE scores as compared with preoperative baseline, the need for revision RCR, or conversion to total shoulder arthroplasty. RESULTS: An overall 91 patients were enrolled (control, n = 45; cBMA, n = 46): 82 (90%) completed 2-year clinical follow-up and 75 (82%) completed 1-year MRI. Functional indices significantly improved in both groups by 6 months and were sustained at 1 and 2 years (all P < .05). The control group showed significantly greater evidence of rotator cuff retear according to Sugaya classification on 1-year MRI (57% vs 18%; P < .001). Treatment failed for 7 patients in each group (control, 16%; cBMA, 15%). CONCLUSION: cBMA-augmented aRCR of isolated supraspinatus tendon tears may result in a structurally superior repair but largely fails to significantly improve treatment failure rates and patient-reported clinical outcomes when compared with aRCR alone. Additional study is warranted to investigate the long-term benefits of improved repair quality on clinical outcomes and repair failure rates. REGISTRATION: NCT02484950 (ClinicalTrials.gov identifier).

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.

Staged Bilateral Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Index Surgery Patient Reported Outcome Measures Predict Contralateral Surgery Results at 2 Years.

PURPOSE: To determine whether (1) patient-reported outcome (PRO) scores after index hip arthroscopy correlate with PRO scores for the contralateral hip in patients undergoing staged bilateral hip arthroscopy and (2) patients who achieved minimal clinically important difference (MCID) or patient-acceptable symptom state (PASS) for the index hip were more likely to achieve MCID or PASS for the contralateral hip. METHODS: Patients who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome were retrospectively reviewed. PRO scores were prospectively collected at preoperative and 1- and 2-year timepoints. Odds ratios for achievement of MCID and PASS for the contralateral hip given achievement for the index hip were calculated. Improvements from before surgery to 2 years after surgery were correlated between both hips. RESULTS: A total of 143 patients (286 hips) were included in the final analysis. Average time between surgeries was 8.5 months (range, 0.7-57.2). Both hips demonstrated significant improvement (P < .05 for all) in all PROs at 2 years. Achievement of MCID in Hip Outcome Score Activities of Daily Living (HOS-ADL) at the 1-year timepoint for the index hip was predictive of achievement of MCID in HOS-ADL at 2 years for the contralateral hip. Achievement of PASS in all PROs at the 1-year timepoint for the index hip were predictive of achievement of PASS in the equivalent outcome score at the 2-year mark for the contralateral hip. Achievement of MCID or PASS at the 2-year timepoint for the index hip was predictive of achievement of the equivalent outcome at the 2-year timepoint for the contralateral hip. The strongest correlation between improvement in PRO scores for the index and contralateral hips was noted in patients who underwent staged hip arthroscopy within less than 3 months. CONCLUSION: Patients experience significant clinical benefit in both hips after staged bilateral hip arthroscopy. Results from the initial hip arthroscopy at either 1- or 2-year follow-up can be used to predict outcomes on the contralateral side; however, there is a higher degree of predictive value using 2-year results. Average correlations between 2-year PROs on the index and contralateral hips were moderate to strong, regardless of the time between surgeries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The safe zones for endoscopic proximal hamstring repair: a cadaveric assessment of standard portal placement and their relationship to major neurovascular structures.

PURPOSE: To define the anatomical relationship of the major neurovascular structures to the standard endoscopic portals used in endoscopic hamstring repair. A secondary outcome was to determine the safest angle of insertion from each standard portal. METHODS: Endoscopic portals were established in the 3 standard locations (lateral, medial, and inferior) and Steinmann pins inserted at various angles. Each hip was dissected and the distance between the pins and the pertinent anatomy measured. RESULTS: The lateral portal placed the sciatic and posterior femoral cutaneous (PFC) nerves at greatest risk: direct injury to the sciatic nerve was seen in 11/30 (37%) of the lateral portals sited. A lateral portal with an approach at 60° was the most dangerous orientation with a mean distance of 0.36 ± 0.49 mm and 4.30 ± 2.69 mm from the sciatic and PFC nerves, respectively (p < 0.001). The 60° medial portal was the safest of all portals measured, at a mean distance of 67.37 ± 11.06mm (range, 47-78 mm) from the sciatic nerve and 58.90 ± 10.57 mm (range 40-70 mm) from the PFC nerve. CONCLUSIONS: While currently described techniques recommend establishing the standard lateral portal first, this study shows that it carries the highest risk of injury if used blind. We recommend that the standard medial endoscopic portal is established first to identify the neurovascular structures and minimise iatrogenic neurovascular injury. The inferior and lateral portals can then be established created under direct vision. The lateral portal should be inserted in a more horizontal orientation to decrease the risk of nerve injury.

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis.

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Patients who have undergone total shoulder arthroplasty prefer greater surgeon involvement in shared decision making.

BACKGROUND: There has been a shift in medical decision making from a paternalist model to a shared decision-making (SDM) approach, described as a patient-physician relationship where both parties collaborate to arrive on an evidence-based treatment regimen that best suits the patient's needs and values. However, there is a scarcity in evidence regarding SDM in shoulder arthroplasty. The purpose of this study was to evaluate overall patient preference for SDM and determine demographic and socioeconomic factors related to SDM preference in those undergoing shoulder arthroplasty. METHODS: Patients aged 40-89 years who had undergone a total shoulder arthroplasty were enrolled. Two-part questionnaires were administered collecting patient demographic information and SDM subscale scores postoperatively. Bivariate and multivariate regression models were used to determine factors associated with SDM Total and subscale scores. RESULTS: A total of 125 patients (53 male; mean age, 69.5 ± 10.4 years) who had undergone primary total shoulder arthroplasty were included. The mean Total SDM score was -2.24 ± 1.9 and the Preoperative, Operative, and Postoperative SDM subscale scores were -1.54 ± 2.0, -2.59 ± 2.2, and -2.48 ± 2.1, respectively, indicating a preference for SDM in the Preoperative subscale and surgeon-driven decision making in the total score and other 2 subscales. Multivariate regression models demonstrated a preference for surgeon decision making at both the 4-12-week postoperative period for the Preoperative subscale (odds ratio [OR] -1.03, 95% CI -2.0, -0.1, P = .039) and the 2-4-week postoperative period for the Operative subscale (OR -1.74, 95% CI -3.4, -0.1, P = .038) when compared to patients at the 2-week postoperative period. No other variables were significantly associated with any of the SDM subscale scores or Total SDM score. CONCLUSION: Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. Patients preferred a shared decision-making approach in regard to preoperative considerations but indicated a significant preference for surgeon-led decision making regarding day of surgery decisions. There were no correlations between SDM scores and age, sex, race, income, education level, insurance type, or treating surgeon. Overall, patients demonstrated a predilection for an SDM approach for preoperative considerations, contrary to those decisions associated with the day of surgery and postoperative care.

Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study.

INTRODUCTION: Successful outpatient anterior cruciate ligament (ACL) reconstruction hinges on effective analgesia. Routinely, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents have several known adverse effects and are associated with a potential for abuse. This study evaluates the efficacy of ketorolac, a nonsteroidal anti-inflammatory drug with analgesic properties, as an adjuvant agent for postoperative pain control after ACL reconstruction. METHODS: Adult patients undergoing primary ACL reconstruction were prospectively enrolled. Exclusion criteria involved patients with a history of bleeding diathesis, renal dysfunction, chronic analgesia use, or alcohol abuse. Eligible patients were randomized into one of two groups. The control group received a standard-of-care pain protocol involving oxycodone-acetaminophen 5 to 325 on discharge. The ketorolac group additionally received intravenous ketorolac postoperatively and 3 days of oral ketorolac on discharge. Pain levels and total narcotic utilization were recorded three times per day for the first 5 days after surgery. Pain and functional outcomes were obtained at 2 and 6 weeks postoperatively. RESULTS: The final analysis included 48 patients; the mean age of the cohort was 32 ± 11.6 years, and 60.4% of patients were female. No differences were observed in preoperative demographics, comorbidities, and preoperative functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 45.4% fewer narcotic pills than the control group (P < 0.001). In addition, mean postoperative pain scores were 22.36 points lower for patients in the ketorolac group (P < 0.001). There was no difference in functional outcome scores at up to 6 weeks postoperatively or adverse events between the two groups with no reported cases of gastrointestinal bleeding. DISCUSSION: The use of adjunctive intravenous and short-term oral ketorolac substantially reduces narcotic utilization and pain levels after ACL reconstruction. CLINICALTRIALGOV REGISTRATION NUMBER: NCT04246554.

Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State After Endoscopic Gluteus Medius or Minimus Repair With or Without Labral Treatment and Routine Capsular Closure at Minimum 5-Year Follow-up.

BACKGROUND: There is a paucity of information in the literature on midterm outcomes of endoscopic gluteus medius and/or minimus repair with concomitant labral treatment using only modern surgical techniques. PURPOSE: To define the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) at a minimum of 5 years postoperatively for patients undergoing endoscopic hip abductor repair with routine capsular closure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients who underwent primary endoscopic repair of gluteus medius and/or minimus tears between January 2012 and December 2015 by the senior author were eligible for inclusion. Patient-reported outcome scores were assessed preoperatively and at 5 years postoperatively: Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), 12-item International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain. The MCID was uniquely calculated using the distribution method, and the PASS was determined via the anchor-based method utilizing receiver operating characteristic curves and Youden index. RESULTS: A total of 46 patients were included in the study. The majority were female (87.0%), with a mean ± standard deviation age of 59.1 ± 8.9 years and body mass index of 27.3 ± 6.9. Significant postoperative improvements (P < .001) in each of the 5 patient-reported outcomes were observed at 5 years postoperatively. The MCID threshold values were calculated as follows: HOS-ADL, 11.5; HOS-SS, 15.1; mHHS, 13.3; iHOT-12, 11.8; and VAS, 15.8. The PASS thresholds were calculated as follows: HOS-ADL, 75.7; HOS-SS, 79.7; mHHS, 81.2; and iHOT-12, 60.8. A majority of patients achieved a clinically significant outcome, with 96.2% of patients reaching a threshold score for the MCID or PASS for at least 1 patient-reported outcome. CONCLUSION: Endoscopic hip abductor repair with concomitant arthroscopic labral treatment has a high rate of achievement of clinically significant outcomes and survivorship at a minimum 5-year follow-up. We defined the MCID for the HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcome scores to be 11.5, 15.1, 13.3, 11.8, and 15.8, respectively. The PASS threshold scores for the HOS-ADL, HOS-SS, mHHS and iHOT-12 scores of 75.7, 79.7, 81.2, and 60.8, respectively. Future researchers and clinicians can use the MCID and PASS values established in this study to better evaluate mid-term outcomes of patients undergoing hip abductor repair.

Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome in Hips With Mild Osteoarthritis (Tönnis Grade 1): A Matched Comparative Cohort Analysis at Minimum 5-Year Follow-up.

BACKGROUND: There is a paucity of information in the literature on midterm outcomes from the arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) with concomitant labral treatment in patients with mild osteoarthritis (OA) using modern surgical techniques. PURPOSE: To compare outcomes of hip arthroscopy for the treatment of FAIS between patients with mild OA (Tönnis grade 1) and patients without OA (Tönnis grade 0) at minimum 5-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were identified who underwent primary hip arthroscopy for FAIS with routine capsular closure between January 2012 and December 2015. Patients with Tönnis grade 1 were matched 1:3 by age, sex, and body mass index to patients without OA. The Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score, and 12-item International Hip Outcome Tool were collected preoperatively and at 5 years postoperatively and compared between groups using an independent t test. Survivorship rate and percentage achievement of a Patient Acceptable Symptom State (PASS) or minimal clinically important difference (MCID) were compared using a Fisher exact test. RESULTS: A total of 50 patients (54 hips) with Tönnis grade 1 were matched to 162 patients (162 hips) with Tönnis grade 0. The mean ± SD age and body mass index of the Tönnis grade 1 group were 44.5 ± 9.6 years and 28.5 ± 5.5, respectively. Patient-reported outcome (PRO) scores improved significantly for both groups from presurgery to 5 years postoperatively for all PROs (P≤ .03). There were no significant differences in preoperative PROs between the groups. Patients with Tönnis grade 1 had significantly lower postoperative scores on the HOS-ADL (74.7 ± 22.6 vs 83.0 ± 20.1; P = .04) and HOS-SS (58.8 ± 33.7 vs 71.8 ± 29.3; P = .03) than patients with grade 0. Patients with Tönnis grade 1 also had significantly lower rates of achievement of the MCID (57.1% vs 80.2%; P < .01) and PASS (34.1% vs 53.4%; P = .03) for any PRO when compared with patients with Tönnis grade 0. Gross survivorship was significantly lower for Tönnis grade 1 versus grade 0 (77.8% vs 96.9%; P < .001). CONCLUSION: Patients with Tönnis grade 1 arthritis experienced significant improvement in PROs after hip arthroscopy for the treatment of FAIS. However, they had significantly lower postoperative HOS-ADL and HOS-SS scores with significantly lower rates of achievement on the MCID and PASS, with a significantly lower gross survivorship rate at a minimum 5 years postoperatively in comparison with those with Tönnis grade 0 changes.

Effect of Sacroiliac Joint Pain on Outcomes in Patients Undergoing Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome: A Matched Comparative Cohort Analysis at Minimum 2-Year Follow-up.

BACKGROUND: Patients with femoroacetabular impingement syndrome (FAIS) may frequently have co-existing sacroiliac joint (SIJ) pain. It is known that patients with lower back pain undergoing total hip arthroplasty (THA) have inferior outcomes; however, it is unclear what the effect of SIJ pain is on outcomes after hip arthroscopy. PURPOSE: To determine whether patients undergoing hip arthroscopy with SIJ pain either subjectively or on physical examination achieve similar postoperative improvement in patient-reported outcomes (PROs) compared with patients without SIJ pain at 2-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients with a minimum 2-year follow-up who underwent primary hip arthroscopy for FAIS with SIJ pain were matched in a 1:2 ratio to controls without SIJ pain. Baseline demographics, as well as postoperative PROs and rates of achievement of the minimal clinically important difference (MCID) or Patient Acceptable Symptom State (PASS) at 2-year follow-up were compared between the 2 groups. RESULTS: A total of 73 patients (75 hips) with SIJ pain were matched to 150 control patients (150 hips) without SIJ pain. Both groups demonstrated statistically significant improvement in all PROs at 2 years (P < .05 for all). Patients with SIJ pain had significantly lower postoperative PRO scores for the Hip Outcome Score-Activities of Daily Living (HOS-ADL) (SIJ pain: 80.4 ± 22.4 vs no SIJ pain: 88.0 ± 15.1; P = .006), modified Harris Hip Score (mHHS) (SIJ pain: 73.2 ± 22.8 vs no SIJ pain: 80.0 ± 17.3; P < .001), and International Hip Outcome Tool-12 questionnaire (iHOT-12) (SIJ pain: 61.7 ± 25.9 vs no SIJ pain: 73.7 ± 23.7; P = .008). There were no statistically significant differences in improvement (delta) in PRO scores between the 2 groups (P > .05 for all). The SIJ pain group had significantly lower achievement of MCID for the HOS-ADL (SIJ pain: 65.2% vs no SIJ pain: 80.5%; P = .044) but not HOS-SS, mHHS, or iHOT-12 (P > .05 for all). The SIJ pain group had significantly lower achievement of PASS for the mHHS (SIJ pain: 27.5% vs no SIJ pain: 45.3%; P = .030) and iHOT-12 (SIJ pain: 31.0% vs no SIJ pain: 56.0%; P = .010) but not the HOS-ADL and HOS-SS (P > .05 for both). Only 4.1% of patients with SIJ pain and 2.4% of controls required revision surgery or converted to THA at the time of final follow-up (P = .69). CONCLUSION: Patients with FAIS and SIJ pain on history or physical examination experience significant improvement in PROs at 2 years after hip arthroscopy. However, they may be less likely to achieve the MCID or PASS and have significantly lower postoperative PROs compared with a matched cohort of patients without SIJ pain. Overall rates of revision and conversion to THA were similarly low in both groups.

Ultrasound Can Determine Joint Distraction During Hip Arthroscopy but Fluoroscopic-Guided Portal Placement Is Superior.

Purpose: To compare joint distraction measured on ultrasound (US) with joint space width (JSW) measured on fluoroscopy in hip arthroscopy and to determine whether ultrasound guidance is as safe and effective as fluoroscopy, the current gold standard, for establishing arthroscopic portals. Methods: Cadaveric whole-body specimens were positioned supine and subjected to 60 lbs. of unilateral axial traction using a distal femoral Steinman pin. Joint distraction was measured via JSW on fluoroscopic and ultrasound images. A single, fellowship-trained orthopaedic surgeon established anterolateral arthroscopy portals via ultrasound or fluoroscopic guidance in a randomized sequence. Total procedure time, number of times the spinal needle pierced the capsule, and iatrogenic chondral or labral injury were recorded. Results: Twelve full-body specimens (20 hips) underwent distraction, and 17 hips underwent portal placement with fluoroscopic (n = 8) or ultrasound (n = 9) guidance. JSW measured on ultrasound was significantly less laterally (13.0 vs 9.2 mm, P < .001), apically (16.7 vs 9.2 mm, P < .001), and medially (17.9 vs 9.2 mm, P < .001). Successful portal entry was achieved in every specimen. Average procedure time was 133 ± 51 seconds for the fluoroscopy group and 371 ± 260 seconds for the ultrasound group (P = .026). Fluoroscopic guidance required significantly less needle insertion attempts at 1.13 compared with 3.33 attempts for ultrasound (P = .022). Labral damage was greater in the ultrasound group at 66.67% compared with 12.50% for fluoroscopy (P = .0497). Conclusions: Joint distraction measured on ultrasound can be used to subjectively determine if the joint is adequately distracted in hip arthroscopy. Ultrasound-guided portal placement was associated with more needle insertion attempts, iatrogenic injury of the labrum, and overall procedure time in comparison to fluoroscopic guidance. Clinical Relevance: Fluoroscopy is the gold standard to confirm adequate joint distraction, aid in establishing arthroscopy portals, and evaluate resection of the femoral head during hip arthroscopy but exposes the patient to ionizing radiation, requires additional operators in the operating room, and involves the need for a heavy lead shield. Alternatives to fluoroscopy are needed, but ultrasound has not proven superior in our cadaveric model.

Meniscal ramp lesions - Skillful neglect or routine repair?

Background: Meniscal ramp lesions are injuries of the posterior horn of the medial meniscus at the meniscocapsular junction or the meniscotibial ligament and are frequently associated with concomitant anterior cruciate ligament (ACL) injury. Objective: To review the current literature on meniscal ramp lesion management to better define the indications for and outcomes of repair. Methods: A narrative literature review was performed using PubMed, Embase, and Scopus databases. Studies of all evidence levels (I-V) pertaining to meniscal ramp lesions were reviewed and included. Results: The incidence of ramp lesions has been reported between 16% and 42%. Arthroscopy remains the diagnostic gold standard as magnetic resonance imaging has limited sensitivity. Biomechanically, ramp lesions are known to increase anterior tibial translation and rotational laxity. Clinical investigations regarding optimal management are largely limited to studies of low evidence levels. While case series have demonstrated that repair is safe and efficacious, comparative studies have failed to suggest that repair of stable lesions results in superior outcomes when compared to conservative treatment approaches. However, repair may be warranted in unstable ramp lesion injuries despite the increased risk for revision surgery. Conclusion: While there is evidence to suggest that ramp lesion repair can restore joint kinematics, the current body of clinical literature fails to suggest that outcomes following repair are superior to injuries managed conservatively. The current body of clinical literature is limited, and further robust, long-term study is warranted to better guide injury diagnosis and management protocol.

Outcomes for the Arthroscopic Treatment of Femoroacetabular Impingement Syndrome With Acetabular Retroversion: A 3D Computed Tomography Analysis.

BACKGROUND: Increased attention has been directed toward the acetabular morphology in the management of patients with femoroacetabular impingement syndrome (FAIS). Whether acetabular version influences patient-reported outcomes remains poorly understood. PURPOSE: To use computed tomography (CT)-based 3-dimensional (3D) bone models to (1) quantify acetabular version in patients with FAIS, (2) compare acetabular version on 3D bone models with current plain radiographic parameters, and (3) explore the relationship between the magnitude of acetabular version and minimum 2-year clinical outcomes after hip arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Three-dimensional models of the pelvis and femur were generated by semiautomated segmentation and aligned to a standard coordinate system. Acetabular version was quantified at the 3-o'clock position, and 3 groups were identified: acetabular retroversion (AR; <15°), normal acetabular version (NV; 15°-25°), and acetabular anteversion (AA; >25°). Patient demographic characteristics, plain radiographic parameters, and clinical outcomes were analyzed, including the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction. RESULTS: Preoperative CT scans were acquired in 105 consecutive patients before hip arthroscopy for FAIS, of which 84 (80.0%) completed minimum 2-year patient-reported outcomes. The mean ± SD age and body mass index of patients were 33.9 ± 12.6 years and 26.0 ± 5.4, respectively; 70.2% were female. The number of patients and the mean central acetabular version within each group were as follows: AR (n = 12; 11.3°± 2.7°), NV (n = 56; 20.7°± 2.9°), and AA (n = 16; 28.5°± 2.7°). Posterior wall sign was the only plain radiographic parameter that was significantly more observed in the AR group than in the other 2 groups. At minimum 2-year follow-up, significant between-group differences in the mHHS, iHOT-12, and VAS for pain and satisfaction (P < .05) were appreciated, while post hoc analysis with Bonferroni correction (P < .0167) found lower scores on the mHHS, iHOT-12, and VAS for pain and satisfaction in patients with AR as compared with NV. Lower scores on the VAS for satisfaction were reported in patients with AR when compared with AA (P = .006) but not on the mHHS (P = .023), iHOT-12 (P = .032), or VAS for pain (P = .072). CONCLUSION: Traditional plain radiographic indices to describe AR, including crossover sign and ischial spine sign, were not reliable in defining AR according to 3D models derived from CT scans. Only the posterior wall sign was observed in a higher proportion in the AR group. Patients with AR demonstrated inferior outcomes when compared with patients with NV and AA after hip arthroscopy for FAIS.

Presence of a Posterior Wall Sign in the Treatment of Femoroacetabular Impingement Syndrome: A Matched Comparative Cohort Analysis at Minimum 2-Year Follow-Up.

BACKGROUND: Acetabular retroversion may predispose to more severe femoroacetabular impingement syndrome (FAIS) and early labral damage given impaction of the femoral head-neck junction on the retroverted acetabular rim. The cross-over sign (COS), posterior wall sign (PWS), and ischial spine sign (ISS) are markers of acetabular retroversion (AR) on plain radiographs. METHODS: Patients who underwent primary hip arthroscopy for FAIS from January 2012 to December 2018 with a positive PWS were matched in a 1:1 ratio by age, gender, and body mass index (BMI) to controls with a negative PWS. Preoperative and postoperative patient-reported outcomes (PROs; HOS-ADL, HOS-SS, mHHS, and iHOT-12) were compared using independent t-tests. Achievement of a Patient Acceptable Symptom State (PASS) or Minimal Clinically Important Difference (MCID) was compared using Fisher's exact test. RESULTS: Two hundred and seventy five patients with a positive PWS and 275 controls were included in the final analysis. Most patients (64%) were female, with average age, and BMI of 37.6 (SD 8.6) and 25.1 (SD 4.4), respectively. PROs improved significantly for both groups from preoperatively to 2 years postoperatively. There were no statistically significant differences (P ≥ .05) in PROs or achievement of MCID or PASS. On a subgroup analysis, patients with all three positive signs had significantly lower postoperative PROs and lower rates of achievement of MCID and PASS. CONCLUSION: Patients with an isolated PWS achieve similar outcomes following hip arthroscopy at 2 years. However, patients with a concomitant PWS, ISS, and COS demonstrate less favorable outcomes, suggesting the need for increased perioperative counseling and potential evaluation for planned concurrent or serial open procedures such as periacetabular osteotomy.

Interobserver and Intraobserver Reliability of the Sirveaux Classification of Scapular Notching After Reverse Total Shoulder Arthroplasty.

The Sirveaux classification characterizes the severity of scapular notching after reverse total shoulder arthroplasty (rTSA). However, its reliability has not been validated. The goal of the current study was to determine the interobserver and intraobserver reliability of the Sirveaux classification. An online survey was sent to the American Shoulder and Elbow Surgeons (ASES), containing 10 radiographs showing a range of scapular notching. Members were asked to grade the degree of scapular notching with the Sirveaux classification system. Then ASES members from our institution regraded the images a second time after a minimum of 6 weeks. Fleiss' and Cohen kappa coefficients were calculated to determine the degree of interobserver and intraobserver reliability, respectively. A total of 50 ASES members graded the radiographs and 3 regraded images after more than 6 weeks. Fleiss' kappa coefficient was 0.2437, indicating fair interobserver agreement. Surgeons who perform more than 20 rTSA procedures per year (n=34) had a Fleiss' kappa of 0.2864. The mean Cohen kappa coefficient was 0.4763, indicating moderate intraobserver reliability. The Sirveaux classification system has fair interobserver and moderate intraobserver reliability. Surgeons should use additional means to describe the severity of notching, particularly when communicating with other physicians or publishing research. [Orthopedics. 2022;45(4):239-243.].