Trunnions and Modularity in Total Hip Arthroplasty: A Historical Review With Current Clinical Implications.

Trunnion in total hip arthroplasty refers to the interface between the neck of a femoral stem and the femoral head. Clinical complications arising from damage to this junction, whether it be due to mechanical wear, corrosion, or a combination, are referred to as mechanically assisted crevice corrosion (MACC), also commonly known as trunnionosis. With the use of modular hip prostheses, which help customize offset and leg length to an individual patient's anatomy, the incidence of MACC and revision due to MACC has increased in recent years. Although the cause of MACC is multifactorial, with patient factors and technique factors contributing to this condition, taper design and geometry, metallurgical properties of implants, and size mismatch of the bearing couple are some of the implant factors that have also been implicated in this clinical phenomenon. Understanding the history of taper design and geometry, the track record of older implants, and the rationale behind the development of current prostheses can help surgeons choose the right implants for their patients and accurately assess the pros and cons of new implants being introduced to the market each year.

Socioeconomic factors affecting outcomes in total knee and hip arthroplasty: a systematic review on healthcare disparities.

BACKGROUND: Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty. METHODS: A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, "disparities", "arthroplasty", "income", "insurance", "outcomes", and "hospital volume" in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data. RESULTS: A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients. CONCLUSION: This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients' access to, utilization of, and outcomes after TJA. LEVEL OF EVIDENCE: IV.

The Role of Stability and Alignment in Improving Patient Outcomes After Total Knee Arthroplasty.

¼: Total knee arthroplasty (TKA) is an effective treatment option for many patients, but a small group of patients are dissatisfied following TKA. ¼: Alignment, in combination with balance, stability, and knee kinematics, is an important modifiable surgical factor that can affect patient outcomes. ¼: Driven by the subset of dissatisfied patients after TKA, new techniques have evolved in the search for a more anatomic reconstruction of individual knee morphology and a more accurate approximation of the individual lower-extremity alignment. ¼: There is a need to optimize 3 aspects of TKA to improve patient outcomes-mechanical tooling processes, implants that resurface the epiphysis, and techniques that respect the variable anatomy of patients.

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities.

BACKGROUND: Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States. METHODS: A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data. RESULTS: A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05). CONCLUSIONS: This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Training the New Generations of Orthopaedic Surgery Residents: Understanding Generational Differences to Maximize Educational Benefit.

ABSTRACT: Most of the current orthopaedic residents are considered Millennials (born between 1981 and 1996) and are often trained by attending surgeons who are from Generation X (born between 1965 and 1980) or the Baby Boomer generation (born between 1946 and 1964). The Generation X orthopaedic surgeons were largely trained by Baby Boomers who were very demanding of their trainees and expected excellence. The Baby Boomers had been inspired, mentored, and trained by the Greatest Generation (born between 1901 and 1927). Baby Boomers took nothing for granted and nothing was given to them on a silver platter. Generation X was trained under these premises and was expected to abide by similar values. Regarding the next generation of residents, current faculty hope to instill the same qualities that had been instilled in them during their training. This value transference sometimes presents a challenge because of the differences in attitudes and perspectives that may exist between Millennial residents and their predecessors regarding work-life balance, teaching styles, the regulation of duty hours, and feedback assessments. These differences require an evolution in the methods of surgical education to optimize the educational benefit and ensure good will and rapport between the generations. Trainees and faculty alike have a responsibility to understand each other's differences and come together to ensure that knowledge, experience, values, and skill sets are effectively passed on to a new generation of orthopaedic surgeons.

Use of continuous passive motion device after arthroscopic hip surgery decreases post-operative pain: A randomized controlled trial.

BACKGROUND: We sought to determine whether continuous passive motion (CPM) usage improves outcomes following arthroscopic hip surgery involving acetabular labral repair. Our hypothesis is that CPM usage reduces pain and pain medication use and improves quality of life in individuals who undergo hip arthroscopy. METHODS: We created a randomized controlled trial consisting of 54 patients who underwent arthroscopic acetabular labral repair. Patients were randomized to two groups, one with CPM use post-operatively and one without. Primary outcomes measured were pain level, patient satisfaction, and quality of life. Parameters used to measure these outcomes were self-reported pain scores on Likert scale, frequency of analgesic medication use, and self-reported scores on Hip Outcome Score Activity of Daily Living (HOS ADL). These parameters were compared between the two randomized groups using t-test for statistical analysis. RESULTS: There was no statistical difference between the treatment and control groups in terms of patient characteristics. There was no statistical difference between the two groups in terms of HOS ADL scores, although the patients in the control group demonstrated a trend toward higher HOS ADL scores. The patients in the CPM group had a statistically significant decrease in pain levels after surgery compared to patients in the control group. The total morphine equivalent dose consumed in the first two post-operative weeks was higher in the control group compared to the CPM group, although this difference was not statistically significant. CONCLUSIONS: Use of CPM resulted in lower pain level scores in patients after hip arthroscopy. Although there is no statistical difference in quality of life or quantity of analgesics consumed post-operatively, patients who used CPM tended to have lower HOS ADL scores (which is desirable) and less consumption of pain medication. A study with a larger sample of patients might elucidate more differences between the two groups. LEVEL OF EVIDENCE: II, therapeutic.

Rapidly destructive osteoarthritis and total hip arthroplasty: A new technique for acetabular reconstruction in the setting of extensive bone loss.

We report the case of a 58-year-old woman who presented with rapidly destructive osteoarthritis (RDO) of the hip that had been causing her severe pain and disability. By the time of presentation to our institution, she had a significant leg length discrepancy resulting from extensive destruction of the posterior acetabular wall, posterior column, and femoral head with a superiorly migrated femoral shaft. She underwent structural acetabular allograft augmentation of the pelvis re-enforced with a locking plate, concomitant total hip replacement with dual mobility implants, and extensive soft tissue releases to restore length to the extremity.

Pubic root fractures are commonly misread as anterior column fractures by radiologists: Single-institution study from a level 1 trauma center.

BACKGROUND: We sought to determine how frequently pubic root fracture is incorrectly identified as anterior column fracture by radiologists and describe differences in characteristics and outcomes between injury patterns. METHODS: We identified 155 patients who sustained pelvic or acetabular fractures at a single, level 1 trauma academic institution. Pelvis computed tomography (CT) scans were evaluated to determine whether patients sustained an anterior column fracture or pubic root fracture. Demographic and clinical factors such as mortality, ambulatory status, type of treatment (nonoperative/surgery), and mechanism of energy were assessed. RESULTS: There were a total of 83 patients in the anterior column group and 72 patients in the pubic root cohort. Eighty-five percent of pubic root fractures were read as anterior column fractures by radiologists. A total of 77.8% of pubic root fractures had posterior ring involvement. Patients with true anterior column acetabular fracture were more likely to need surgery (63.86% vs 41.70%, P = 0.01) and be discharged to skilled nursing or inpatient rehabilitation (59.04% vs 40.27%, P = 0.02) compared to patients with pubic root fracture. CONCLUSION: Pubic root fractures are frequently misread as anterior column fractures in radiology reports. Correctly diagnosing pubic root fractures and differentiating them from anterior column acetabular fractures can have significant impact on patients. LEVEL OF EVIDENCE: III, Therapeutic.

Expanding Role of Technology in Rehabilitation After Lower-Extremity Joint Replacement: A Systematic Review.

BACKGROUND: The effectiveness of telehealth programs in the administration of rehabilitation and the monitoring of postoperative progress after joint replacement is not well studied. The purpose of the present study was to systematically review the currently available evidence on the use of smart-device technology and telehealth programs to guide and monitor postoperative rehabilitation following total joint arthroplasty and to assess their impact on outcomes following surgery. METHODS: A literature search of the MEDLINE database was performed using keywords "mobile," "app," "telehealth," "virtual," "arthroplasty," "outcomes," "joint replacement," "web based," "telemedicine," "TKA," "THA," "activity tracker," "fitness tracker," "monitor," "rehab," "online," and "stepcounter" in all possible combinations. All English studies with a level of evidence of I to III that were published from January 1, 2010, to December 19, 2020 were considered for inclusion. Quantitative and qualitative analysis was performed on the data collected. RESULTS: A total of 28 articles meeting the inclusion criteria were identified and reviewed. With regard to objective functional outcome measures, such as strength, range of motion, or results of the Timed Up and Go (TUG) test, the virtual physical therapy group had equivalent or slightly superior outcomes compared with in-person physical therapy. There was similar improvement overall in patient-reported outcome measures (PROMs) and patient satisfaction between virtual and in-person physical therapy. Virtual physical therapy resulted in cost savings ranging from $206 to $4,100 per patient compared with in-person physical therapy. CONCLUSIONS: Telerehabilitation following lower-extremity joint replacement is less expensive compared with in-person physical therapy, with equivalent outcomes and patient satisfaction. Telerehabilitation and electronic health adjuncts can be used to substitute for traditional rehabilitation and augment postoperative care following total joint arthroplasty, respectively. Telerehabilitation that provides outcomes equivalent to in-person physical therapy not only increases convenience for patients but also decreases the cost burden on the health-care system. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of native ligament versus graft reconstruction on sensitivity of clinical tests used to diagnose anterior cruciate ligament tears.

PURPOSE: Although there have been multiple clinical studies evaluating the accuracy of physical examination tests used to diagnose anterior cruciate ligament (ACL) injury, there are no data to date evaluating the accuracy of these tests in diagnosing re-injury after prior ACL reconstruction. We compared the sensitivity of three clinical tests - Lachman, anterior drawer, and pivot shift - in diagnosing initial ACL tears versus graft re-tears following a prior ACL reconstruction. METHODS: Twenty consecutive adult patients who had undergone primary ACL reconstruction and 20 consecutive adult patients who had undergone revision ACL reconstruction by a single surgeon at a tertiary care center from November 2011 to December 2017 were included in this study. RESULTS: The sensitivity of the Lachman test was 95.0% in diagnosing ACL tears in patients with native ACL versus 85.0% in patients with prior ACL reconstruction with allograft or autograft. The sensitivity of the anterior drawer test was 80.0% in patients with native ACL compared to 77.8% in patients with prior ACL reconstructions. The sensitivity of the pivot shift test could not be accurately assessed because pain and swelling prevented the physician from performing this test in most patients on their initial presentation to the clinic. CONCLUSIONS: This study suggests that a clinician may need to have a lower threshold to perform advanced imaging or diagnostic arthroscopic evaluation in a patient with prior ACL reconstruction with a suspected re-injury even if the physical examination tests are not immediately positive.

Neurologic complications in primary anatomic and reverse total shoulder arthroplasty: A review.

Neurologic injury during shoulder replacement is one of the less common complications of the procedure, however the clinical implications can be significant. The purpose of this paper is to review the current literature on neurologic complications in various types of shoulder replacement and provide recommendations regarding avoidance, evaluation, and management of these complications.

Outpatient Total Shoulder Arthroplasty: A Systematic Review Evaluating Outcomes and Cost-Effectiveness.

BACKGROUND: Orthopaedic surgical procedures are increasingly being performed in outpatient settings. The drive for cost reduction without compromising patient safety and outcomes has increased interest in outpatient total shoulder arthroplasty (TSA). The primary aim of this study was to perform a review of the evidence regarding the outcomes and cost-effectiveness of outpatient TSA. METHODS: A search of the PubMed, Embase, and Cochrane Library databases was performed using several keywords: "outpatient," "shoulder replacement," "ambulatory," "day case," "day-case," "shoulder arthroplasty," "same day," and "shoulder surgery." Studies that were published from May 2010 to May 2020 in the English language were considered. Research design, questions, and outcomes were recorded for each study. Qualitative and quantitative pooled analysis was performed on the data where appropriate. RESULTS: Twenty studies met the inclusion criteria. Six retrospective studies compared complication rates between inpatient and outpatient cohorts and found no significant differences. Four studies found that the complication rate was lower in the outpatient cohort compared with the inpatient cohort. In a pooled analysis, the readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p < 0.05 for both). Four studies evaluated the cost of outpatient TSA in comparison with inpatient TSA. All of these studies found that TSA at an ambulatory surgery center was significantly less costly than TSA at an inpatient facility, both for the health-care system and for the patient. Patient selection for outpatient TSA may depend on several important factors, including the presence or absence of diabetes, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, poor functional status, higher American Society of Anesthesiologists class, chronic narcotic use, higher body mass index, and older age. CONCLUSIONS: Our results show that patient selection is the most critical factor that predicts the success of outpatient TSA. While outpatient TSA is significantly less costly than inpatient TSA, patients undergoing outpatient TSA are more likely to be healthier than patients undergoing inpatient TSA. More high-quality long-term studies are needed to add to this body of evidence. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of total joint arthroplasty in patients with depression: A systematic review.

BACKGROUND: Depression has been implicated as a poor predictor of outcomes after total joint arthroplasty (TJA) of the lower extremity in some studies. We aimed to determine whether depression as a comorbidity affects the TJA outcomes and whether pain reduction associated with successful TJA alters depressive symptoms. METHODS: A search of PUBMED was performed using keywords "depression", "arthroplasty", "depressive disorder", and "outcomes." All English studies published over the last ten years were considered for inclusion. Quantitative and qualitative analysis was then performed on the data. RESULTS: Thirty articles met inclusion criteria (16 retrospective, 14 prospective). Three showed that depressed patients were at higher risk for readmission. Two reported that depressed patients had higher likelihood of non-home discharge after TJA compared to non-depressed patients. Four noted that depressed patients incur higher hospitalization costs than non-depressed patients. Ten suggest depression is a predictor of poor patient-reported outcome measures, pain, and satisfaction after TJA. Five suggested the gains depressed patients experience in functional outcome scores after TJA are similar to gains experienced by patients without depression. Another eight suggested that TJA improves not only function and pain but also depressive symptoms in patients with depression. CONCLUSION: The results of this review show that depression increases the risk of persistent pain, dissatisfaction, and complications after TJA. Additionally, depressed patients may incur higher costs than non-depressed patients undergoing TJA and may have worse preoperative and postoperative patient reported outcome measures (PROMs). However, the gains in function that depressed patients experience after TJA are equivalent to gains experienced by non-depressed patients and depressed patients may experience improvement in their depressive symptoms after TJA. Patient selection for TJA is critical and counseling regarding increased risk for complications is crucial in depressed patients undergoing TJA.

Occupational hazards of orthopaedic surgery and adult reconstruction: A cross-sectional study.

BACKGROUND: Occupational injuries and hazards related to orthopaedic surgery are not well studied, and what is published on this topic is largely based on in vitro or in vivo animal studies. OBJECTIVES: To evaluate the self-reported prevalence of musculoskeletal (MSK) overuse disorders and other conditions among orthopaedic surgeons, especially those performing total hip (THA) or total knee arthroplasty (TKA), and report the factors placing these surgeons at higher risk for occupational health hazards. METHODS: This was a cross-sectional study of 66 currently practicing orthopaedic surgeons in the Midwestern United States. An online survey was sent to the participants, and all responses were collected anonymously. The survey consisted of 18 multiple-choice questions. RESULTS: Almost 82% of surgeons surveyed had either a musculoskeletal (MSK) overuse disorder, kidney stones, cataracts, infertility, deafness, or a combination of the above. Fifty-three percent of these respondents believed their medical conditions arose due to their job demands or exposure. A majority of the orthopaedic surgeons surveyed wanted to retire at either 60-65 years of age (31.8%) or 66-70 years of age (47%). Nearly 88% of the survey respondents believed they will be able to meet the demands of their job until their intended retirement age. The prevalence of an overuse disorder was highest for those who have been in practice for 21-30 years (100%). There was a trend toward higher rate of surgery for overuse condition in Adult Reconstruction (AR) surgeons. Rotator cuff disease was the most common MSK disorder affecting AR surgeons. CONCLUSION: A majority (>80%) of orthopaedic surgeons suffer from a musculoskeletal overuse disorder, kidney stones, cataracts, infertility, deafness, or a combination of these. A significant proportion (53%) of surgeons believe one or more of their medical conditions developed due to occupational exposure.

No differences in short-term outcomes between patients with anaerobic and aerobic culture positive prosthetic joint infection.

BACKGROUND: Prosthetic joint infection (PJI) is a devastation complication of total joint arthroplasty that can result in poor patient outcomes. Anaerobic organisms make up a small proportion of PJI cases and are much less studied. Studies comparing patient outcomes in anaerobic PJI to outcomes in aerobic PJI are sparse. The purpose of this study was to compare the clinical presentation, duration of antibiotics, type of treatment provided, and final outcome between PJI patients with anaerobic infection and those with aerobic infection. METHODS: This was a retrospective study of 26 patients who underwent treatment for PJI at a tertiary referral center. Eight patients with anaerobic PJI were compared to 18 patients with aerobic PJI in terms of clinical presentation, laboratory values, treatment duration, and functional outcome. Statistical analysis was performed on continuous variables of interest. RESULTS: The results of our study showed that there are no differences in short term clinical outcomes between PJI patients with cultures positive for anaerobic vs aerobic organisms (38.9% vs 50% successfully treated). Inflammatory markers were higher in the aerobic group and patients in the anaerobic group tended to have fewer medical comorbidities. CONCLUSION: PJI caused by anaerobic organisms results in poor patient outcomes similar to infection caused by aerobic organisms. There are some differences in clinical presentation between the two groups that can be explained by the fact that anaerobic organisms are of low virulence and result in indolent infections causing longstanding symptoms.

Medial Osteoarthritis in an ACL-Deficient Knee: A Critical Analysis Review.

¼: In anterior cruciate ligament (ACL)-deficient knees, treatment of medial compartment osteoarthritis (OA) that is refractory to nonoperative modalities is a controversial subject. ¼: Currently available treatment options include unicompartmental knee arthroplasty (UKA) with or without ACL reconstruction (ACLR), high tibial osteotomy (HTO) with or without ACLR, and total knee arthroplasty (TKA). ¼: Each treatment option has its own risks and benefits, and the evidence that is reviewed in this article suggests that patient characteristics guide treatment selection. ¼: Future high-quality prospective studies that directly compare all 3 of the modalities are necessary to determine the best treatment option for different patient populations.

Symptom Chronicity and Tobacco Use: Differences in Athletic and Nonathletic Candidates for Cartilage Surgery.

OBJECTIVE: To determine whether there are differences in symptomatic knee cartilage defects and rates of tobacco use among age-matched athletes versus nonathletes undergoing initial arthroscopic knee surgery who meet demographic and radiographic criteria for cartilage restoration surgery. DESIGN: Age-matched athletes (n = 186) and nonathletes (n = 159) age 40 or less with a body mass index (BMI) of 35 kg/m2 or less (mean 26.8 SD 4.1) and <50% joint space narrowing on weight-bearing radiographs were included. All patients had a symptomatic Outerbridge grade 2 or higher cartilage defect visualized during knee arthroscopy. Relationship between athletic status and chronicity of knee symptoms prior to surgery and tobacco use status, cartilage defect Outerbridge grade, size, and location at time of surgery were characterized. RESULTS: Nonathletes were more likely to smoke (P < 0.001) and had higher BMI (P = 0.005). Duration of symptoms prior to surgery was shorter among athletes (P < 0.001). Grade 4 defects were equally prevalent (P = 0.96) as were multicompartment grade 3-4 lesions (P = 0.12). Mean grade 3-4 defect size was similar in lateral (P = 0.96) and medial compartments (P = 0.82). There was a trend toward larger anterior compartment defects in nonathletes (P = 0.07). CONCLUSIONS: Among age-matched athletes and nonathletes with symptomatic cartilage defects who meet demographic criteria for cartilage restoration, nonathletes were more likely to smoke and have a longer duration of symptoms prior to treatment. Athletes tended to present earlier but with similar size defects compared to nonathletes, supporting accelerated treatment of defects in athletes and caution toward allowing continued athletic participation in patients with known cartilage defects.

Bearing failure in a mobile bearing unicompartmental knee arthroplasty: an uncommon presentation of an implant-specific complication.

BACKGROUND: We present two cases of unicompartmental knee arthroplasty (UKA) bearing failure in this report-one case of bearing dislocation and one case of bearing fracture. The causes of failure in both cases are evaluated in depth and recommendations are provided regarding intraoperative technique to reduce risk of bearing failure in mobile bearing UKAs. CASE PRESENTATION: In the first case, intraoperative evidence of metallosis and chronic pain preceding the traumatic event may indicate that the patient had attenuation of her collateral ligaments that precipitated the instability event. In the second case, the relatively atraumatic nature of the bearing fracture-dislocation and intraoperative evidence of extensive poly wear suggest that the bearing fracture was likely due to a 3-mm bearing selection in the initial surgery. CONCLUSIONS: This case report shows that late bearing in mobile bearing unicompartmental knee arthroplasty can often be a multifactorial event and treatment must address all the risk factors that led to bearing dislocation. Bearing fracture is a very rare complication associated with mobile bearing UKA and patients with thin polyethylene inserts are at risk for bearing fracture even in the absence of poly wear.

Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review.

CONTEXT: Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results. OBJECTIVE: To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure. DATA SOURCES: PubMed, MEDLINE, EMBASE, and Google Scholar. STUDY SELECTION: The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected. RESULTS: There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking. CONCLUSION: PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.

Use of dual mobility components in total hip arthroplasty: Indications and outcomes.

Instability after total hip arthroplasty (THA) can be a problematic complication and remains one of the leading causes of revision surgery in the early post-operative period. Dual mobility (DM) implants decrease dislocation risk after THA but they come with their own set of complications. Selective use of DM implants for THA in high risk groups can confer the advantages of this construct while mitigating the risks. In this paper, we review the current literature to examine the evidence for or against use of DM implants in various clinical scenarios and provide an algorithm for when to consider using DM design construct in THA.