Dysplastic Hips Have Decreased Iliofemoral Ligament Thickness on Coronal Sequences in Magnetic Resonance Imaging: A Matched Cohort Analysis.

PURPOSE: To characterize hip capsule thickness on advanced imaging in patients with and without hip dysplasia and to also evaluate differences in capsular thickness between borderline and true dysplastic patients. METHODS: Patients evaluated by the senior author for concerns of hip pathology from June 2020 to June 2021 were queried and images reviewed to determine dysplasia status by lateral center edge angle (LCEA) ≤ 25 degrees. A group of non-dysplastic patients was identified and matched for age, sex, and body mass index (BMI). Hip capsular thickness was quantified using MRI. A sub-analysis was conducted to compare true dysplastic patients (LCEA < 20°) to borderline dysplastic patients (LCEAs between 20 - 25°). Analysis included independent samples t-tests, Chi-square tests, and multivariable regression. RESULTS: Eighty total patients were included, with a mean age of 31.8 ± 11.7 years, a mean BMI of 26.6 ± 6.5 points, and 70% (56) female patients. Dysplastic patients had a mean LCEA of 19.8 ± 4.3 degrees. Dysplastic individuals had decreased capsular thickness compared to their non-dysplastic controls (2.75 ± 0.96 vs 3.52 ± 1.22 mm, p = 0.003). Multivariable regression showed decreased capsular thickness associated with decreased LCEAs (ß = 2.804, R = 0.432, p<0.001) and dysplasia (ß = -0.709, R2 = 0.056, p = 0.004). Results of a sub-analysis of the dysplastic group examining differences between accepted definitions of borderline dysplasia and true dysplasia showed no significant differences in capsular thickness between the two groups (p = 0.379). CONCLUSIONS: Patients with hip dysplasia were found to have thinner iliofemoral ligaments in the coronal plane on magnetic resonance imaging on magnetic resonance imaging. Further investigation is needed to evaluate any potential implications with hip instability given the thinner hip capsule demonstrated in this study.

Common radiographic indices used to measure patellar height do not consistently identify patella alta and lack interchangeability between measurements.

PURPOSE: Abnormal patellar height has been identified as a source of aberrant mechanical functioning within the patellofemoral joint. The purpose of this study is to examine the statistical agreement among three commonly used classification methods: Blackburne-Peel (BPI), Caton-Deschamps (CDI) and Insall-Salvati (ISR), by evaluating (1) the rates of patella alta identification and (2) the ability for one index to predict another. METHODS: One hundred lateral knee radiographs were evaluated using BPI, CDI and ISR to classify each knee as patella normal, patella alta or patella baja. Linear regression analysis was performed to evaluate the relationship between each index. Conversion equations were then derived using the reported linear regression best-fit line, comparing each pair of indices. RESULTS: Patella alta was identified in 15 knees using BPI, 15 using CDI and 25 using ISR. A total of seven knees were classified as patella alta by all BPI, CDI and ISR. Statistical analysis revealed significant correlation (p ≤ 0.001) among BPI and CDI (R2 = 0.706), BPI and ISR (R2 = 0.328) and CDI and ISR (R2 = 0.288). Wilcoxon Signed-Rank test between the three indices revealed no significant difference between the means of converted and original indices. CONCLUSION: Despite their significant correlations and adequate reproducibility, variability between common patellar height indices render predictions and conversions between BPI, CDI and ISR inequivalent. Users of these indices must be aware of their incongruent properties when considering application to patients in the clinical setting. Furthermore, it remains unclear which patellar height measurement technique is the correct index to use in a given knee. This study highlights the need for further investigation to create a reliable and standardised method for identifying patella height. LEVEL OF EVIDENCE: Level IV.

Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse.

INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS: A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS: 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS: Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.

Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care.

BACKGROUND: With rising healthcare costs and campaigns aimed at avoiding low-value care, reducing cancer overtreatment has emerged as an important measure of cancer care quality. The extent to which avoidance of low-value care has been incorporated in cancer-specific quality measures is unknown. We aimed to identify and characterize cancer quality measures that promote the avoidance of low-value care, and identify gaps that may guide future measure development. METHODS: We systematically identified cancer-specific quality measures from leading quality measure organizations [e.g., National Quality Forum (NQF), National Quality Measures Clearinghouse (NQMC)]. We reviewed measures promoting the avoidance of low-value cancer care and subclassified them into disease site- or non-disease site-specific categories and the phase of care they targeted. RESULTS: We reviewed 313 quality measures from six organizations. Of these, 18% (n = 55) focused on avoidance of low-value care. Quality measures focused on end-of-life care were most likely to focus on low-value care [n = 13 (50%)], followed by breast [n = 12 (18%)], lung [n = 9 (31%)], colon [n = 8 (20%)], prostate [n = 5 (38%)], general cancer care [n = 4 (3%)], symptoms and toxicities [n = 2 (40%)], and palliative cancer care [n = 2 (11%)] measures. The phases of care quality measures targeted included low-value screening [n = 5 (9%)], diagnostic testing and staging [n = 7 (13%)], treatment [n = 19 (34%)], surveillance [n = 6 (11%)], and clinical outcomes [n = 18 (33%)]. All categories had a treatment-specific quality measure, but no category had a representative measure for every phase of care. DISCUSSION: A minority of cancer quality measures are aimed at avoiding low-value care, and multiple evidence-based recommendations targeting low-value care have not been incorporated.

Female Patients and Decreased Hip Capsular Thickness on Magnetic Resonance Imaging Associated With Increased Axial Distraction Distance on Examination Under Anesthesia: An In Vivo Study.

PURPOSE: To investigate the relation of hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and intraoperative hip joint axial distraction distance on an examination under anesthesia. METHODS: A retrospective review of primary arthroscopic hip procedures performed between November 2018 and June 2021 was conducted. The inclusion criteria included a diagnosis of femoroacetabular impingement syndrome and preoperative radiographic imaging and MRI. Fluoroscopic images were obtained at 0 lb and 100 lb of axial traction force. Total distraction distance was calculated by comparing the initial joint space with the total joint space at 100 lb. Hip capsular thickness was measured on MRI. Analysis was conducted using multiple linear regression, independent-samples t tests, and Mann-Whitney U tests. RESULTS: Eighty patients were included. Bivariable regression showed an association between an increased distraction distance and female sex (ß = 4.303, R = 0.561, P < .001), as well as decreased anterior axial (ß = -1.291, R = 0.365, P < .001) and superior coronal (ß = -1.433, R = 0.501, P < .001) capsular thickness. Multivariable regression (R = 0.645) showed an association between an increased distraction distance and female sex (ß = 3.175, P < .001), as well as decreased superior coronal capsular thickness (ß = -0.764, P = .022). Independent-samples t tests showed that female patients had significantly decreased superior coronal capsular thickness (2.92 ± 1.14 mm vs 3.99 ± 1.15 mm, P < .001). CONCLUSIONS: Female sex and decreased hip capsular thickness in the superior aspect of the coronal plane on magnetic resonance scans were found to be predictors of increased hip joint axial distraction distance on examination under anesthesia prior to hip arthroscopy, with anterior axial capsular thickness being a moderate predictor. Poor predictors of distraction distance were posterior axial and inferior coronal capsular thickness, age, body mass index, and lateral center-edge angle. Female patients were also found to have thinner hip capsules in the superior region, which may explain the association between female patients and increased distraction. These findings further characterize the relation between capsular thickness and hip laxity. LEVEL OF EVIDENCE: Level IV, case series.

Incidence of Subsequent Surgical Intervention at Short-term Follow-up in Previously Healing and Stable Juvenile Osteochondritis Dissecans of the Knee.

BACKGROUND: Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery. METHODS: A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression. RESULTS: Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery (B=-2.6, P=0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm2, respectively, though not significantly different (P=0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different (P=0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities. CONCLUSIONS: While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions. LEVEL OF EVIDENCE: Level IV-prognostic study.

Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study.

INTRODUCTION: Guidelines allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70 years of age with hormone receptor-positive (HR +) breast cancer. Despite this, national data suggest these procedures have not been widely de-implemented. OBJECTIVES: Our objectives were to evaluate trends in SLNB and post-lumpectomy radiotherapy utilization in patients who are eligible for omission, and evaluate patient preferences as a target for de-implementation of low-value care. METHODS: We performed a sequential explanatory mixed-methods study by first analyzing an institutional database of patients ≥ 70 years of age with HR + breast cancer who received surgical treatment from 2014 to 2018. Based on the quantitative data, we conducted semi-structured interviews with women identified as high or low utilizers of breast cancer treatments to elicit patient perspectives on de-implementation. RESULTS: SLNB and post-lumpectomy radiotherapy were performed in 68% and 43% of patients, respectively, who met the criteria for omission. There was a significant decrease in SLNB rates from 2014 to 2018. Forty-nine percent of patients were classified as high utilizers and 26% were classified as low utilizers. Qualitative analysis found that the most important factors influencing decision making regarding SLNB and post-lumpectomy radiotherapy omission for both high and low utilizers were trust in their provider and a desire for peace of mind. CONCLUSIONS: Despite efforts to de-implement low-value care, older women with HR + breast cancer remain at risk of overtreatment. Patient perspectives suggest that multi-level de-implementation strategies will need to target provider practice patterns and patient-provider communication to promote high-quality decision making and reduction in breast cancer overtreatment.

Editorial Commentary: Not Yet Convinced That the Femoroacetabular Impingement Resection (Fair) Arc Measurement Provides a "Fair" Assessment of Cam Resection Principles.

Hip arthroscopy has proven to be an effective surgical approach for the treatment of femoroacetabular impingement (FAI) syndrome. Studies have shown that patients typically have improved functional outcomes and high rates of return to activity following cam lesion resection and reshaping of the femoral head-neck junction. However, despite these favorable outcomes, there is still a steep and well-recognized learning curve in FAI hip arthroscopy. Although it is common dogma to consider an ideal reshaping of the femoral head-neck junction as being perfectly spherical, the ability to achieve this intraoperatively can be quite challenging. A new tool is the "femoroacetabular impingement resection (FAIR) arc," measured on a 45° Dunn lateral radiograph where a best-fit circle incorporates the region immediately inferior to the anteroinferior iliac spine, the subspine region, and lateral femoral neck base. The maximal radial distance height is then measured from the circumference of this circle to the apex of the cam lesion. This radiographic aid may assist with intraoperative estimate of appropriate cam lesion resection depth. While I tend to utilize preoperative radiographs and intra-operative neck sclerosis to determine cam resection depth, I continue to seek out other ways to effectively perform a femoral osteoplasty. While my initial attempt to utilize the FAIR index in my practice did not seem effective, I will continue to test this measurement in my patients.

Acute experimental venous thrombosis impairs venous relaxation but not contraction.

OBJECTIVE: Venous thrombosis (VT) damages the vein wall, both physically by prolonged distension and from inflammation. These factors contribute to post-thrombotic syndrome (PTS). Interleukin (IL)-6 might play a role in experimental PTS and vein wall responses. Previous assessments of post-thrombotic vein wall injury used static measures such as histologic examination and immunologic assays. The purpose of the present study was to use myography to quantify the changes in contraction and relaxation of murine vessels exposed to an acute VT. METHODS: Wild-type (WT) C57BL/6 mice were used to determine the baseline vein wall passive tension on a DMT 610m myograph (DMT-USA, Inc., Ann Arbor, Mich), including dosing concentrations of phenylephrine (Phe) and acetylcholine (Ach). WT and IL-6-/- mice underwent VT using inferior vena cava (IVC) ligation (complete stasis) and stenosis (partial stasis), with no-surgery mice used as controls. The mice were harvested at 2 days (2D) and analyzed using a myograph. The vessels were stimulated with Phe and Ach to stimulate a contraction and relaxation response. The endothelial responses to VT were quantified by CD31 immunohistochemistry, Greiss assay, polymerase chain reaction, and Evans blue assay. RESULTS: Optimal passive tension was determined to be 2 mN, with an optimal concentration of Phe and Ach of 7E-3M and 1E-5M, respectively. No significant differences were found in the contractions when exposed to Phe between the WT control, WT 2D ligation, and WT 2D stenosis IVC segments and the IL-6-/- mice with and without thrombus (P > .05 for all). When treated with Ach, significantly more relaxation was found in the nonthrombosed control IVC segments than in those IVC segments that had had a 2D thrombus from either ligation- or stenosis-derived thrombotic mechanisms in both WT and IL-6-/- mice. CD31 staining showed ∼20% less luminal endothelium after stasis thrombosis (P ≤ .01) but no loss in the controls (P > .05). Evans blue staining showed a trend toward increased leakiness in post-thrombotic vein walls. No significant difference in the endothelial gene markers or nitric oxide production was found. CONCLUSIONS: Compared with the controls, acute thrombosis in the total or partial stasis models did not impair IVC contractile responses, suggesting no effect on the medial vascular smooth muscle response. The relaxation response was significantly reduced in the post-thrombotic groups, likely from direct endothelial injury. These findings suggest, at acute points, that VT impairs the endothelial function of a vein wall while retaining the vascular smooth muscle cell function and might be a mechanism that promotes PTS.

Mid-term outcomes of temporary medial distal femoral hemiepiphysiodesis with and without medial patellofemoral ligament repair for recurrent patellar instability in skeletally immature patients with genu valgum.

Genu valgum contributes to patellar instability, though outcomes following temporary hemiepiphysiodesis via eight plating are less understood. The purpose of this study was to evaluate the outcomes and need for additional procedures following temporary hemiepiphysiodesis for the treatment of pediatric genu valgum and patellar instability, as well as evaluating the utility of a concurrent medial patellofemoral ligament (MPFL) repair. Patients who underwent medial distal femoral epiphysiodesis for the treatment of genu valgum and recurrent patellar instability were identified. Inclusion criteria were minimum 1-year follow-up and lack of concurrent ligamentous reconstruction. Patients were contacted to complete a questionnaire which included the International Knee Documentation Committee (IKDC) form and questions pertaining to knee function and patient satisfaction. Thirty-one patients aged 12.0 ± 1.9 years underwent 47 guided growth procedures and were included in final analysis. Seventeen knees (36%) required subsequent surgery for patellar instability. All patients requiring subsequent surgery were female, compared with 70% of patients not requiring subsequent surgery ( P  = 0.017). The MPFL repair group underwent fewer subsequent procedures to address instability, though this difference was NS (17 vs. 46%, P  = 0.318). Mean IKDC score at 5.3 years follow-up among 18 survey respondents was 78.6. Medial distal femoral hemiepiphysiodesis may partially address recurrent patellar instability in skeletally immature patients with genu valgum. Concurrent MPFL repair may minimize the need for subsequent procedures to address recurrent instability. While correcting alignment may be helpful, patients should be aware of the potential need for further patellar instability surgery. Level of evidence: IV, case series.

Relationship Between Hip Capsular Thickness and Instability After Previous Hip Arthroscopic Surgery: A Matched-Cohort Analysis.

Background: Thinner anterior hip capsules are associated with hip laxity, but there is little known about the impact of capsular thickness on the development of instability after primary hip arthroscopic surgery. Purpose: To investigate the relationship between hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and the development of hip instability after hip arthroscopic surgery for femoroacetabular impingement. Study Design: Case-control study; Level of evidence, 3. Methods: We reviewed revision hip arthroscopic procedures performed between January 1, 2019, and May 1, 2021, at a single institution. Inclusion criteria were preoperative MRI/magnetic resonance arthrography, completion of the study traction protocol, and asymmetric distraction between the hips of ≥3 mm on examination under anesthesia. A comparison group of patients treated for femoroacetabular impingement with primary hip arthroscopic surgery who did not develop capsular instability were matched 1:1 to the patients with instability. Superolateral hip capsular thickness was measured on MRI before index surgery. Analysis was conducted using independent-samples t tests and multivariable linear regression. Results: A total of 44 patients were included, with 22 patients each in the instability and no-instability groups. The mean capsular thickness was lower in the patients with hip instability than in those without (1.9 ± 0.6 vs 3.4 ± 1.1 mm, respectively; P < .001). Decreased capsular thickness was significantly associated with hips with instability versus no-instability (ß = -1.468 [95% CI, -2.049 to -0.887]; P < .001). Conclusion: Thinner preoperative hip capsules in the region of the iliofemoral ligament were seen in patients who subsequently underwent revision arthroscopic surgery for hip instability compared to patients who underwent primary hip arthroscopic surgery without subsequent revision. Patients at a higher risk for the development of postoperative hip instability had a superolateral hip capsular thickness of <2 mm.

Association of Relative Skeletal Immaturity of the Triradiate Cartilage with Increased Proximal Femoral Deformity in Prophylactic Fixation for Slipped Capital Femoral Epiphysis: A Radiographic Study.

INTRODUCTION: The purpose of this study was to describe proximal femoral deformity after contralateral hip prophylactic fixation of slipped capital femoral epiphysis (SCFE) in patients and the association of relative skeletal immaturity with this deformity. METHODS: A retrospective review of patients presenting with a SCFE was conducted from 2009 to 2015. Inclusion criteria were (1) radiographic evidence of a unilateral SCFE treated with in situ fixation, (2) contralateral prophylactic fixation of an unslipped hip, and (3) at least 3 years of follow-up. Measurements were made on radiographs and included greater trochanter height relative to the center of the femoral head, femoral head-neck offset, and femoral neck length. Skeletal maturity was evaluated by assessing the status of the proximal femoral physis and triradiate cartilage (TRC) of the hip, in addition to the length of time to closure of these physes. Values were compared from initial presentation to final follow-up. Statistical analysis included descriptive statistics and linear regression. RESULTS: Twenty-seven patients were included. Bivariable linear regression demonstrated that an increased relative trochanteric overgrowth was associated with TRC width (ß = 3.048, R = 0.585, P = 0.001) and an open TRC (ß = -11.400, R = 0.227, P = 0.012). Time to proximal femoral physis closure (ß = 1.963, R = 0.444, P = 0.020) and TRC closure (ß = 1.983, R = 0.486, P = 0.010) were predictive of increased deformity. In addition, multivariable elimination linear regression demonstrated that TRC width (ß = 3.048, R = 0.585, P = 0.001) was predictive of an increased relative trochanteric overgrowth. DISCUSSION: Patients with an open TRC and increased TRC width are associated with increased relative trochanteric overgrowth when undergoing prophylactic fixation for a unilateral SCFE. Increased caution should be exercised when considering contralateral hip prophylactic fixation in skeletally immature patients presenting with a unilateral SCFE. LEVEL OF EVIDENCE: Level IV, case series.

Physeal Location on the Distal Femoral Cortical Surface Is Consistently Proximal to Apparent Location on the Perfect Lateral Radiograph: A 3-Dimensional Digitally Reconstructed Radiograph Study.

INTRODUCTION: The perfect knee lateral radiograph visualizes anatomic landmarks on the distal femur for clinical and scientific purposes. However, radiographic imaging is a two-dimensional (2D) representation of a three-dimensional (3D) physis. The aim of this study was to characterize the perceived radiographic projection of the femoral physis using perfect lateral digitally reconstructed radiographs (DRRs) and to evaluate discrepancies from this projection to the physis at the lateral and medial cortices. METHODS: Pediatric patients from a cohort of CT scans were analyzed. Inclusion criteria were an open physis; exclusion criteria were any implant or pathology affecting the physis. CT scans were imported into 3D imaging software and transformed into lateral DRRs and 3D renderings of the femur. The physis was divided into four equal segments, with fiducial markers placed at the "anterior," "midpoint," and "posterior" points. Lines extended from these points in the lateral and medial direction. The vertical distance from these lines, representing the radiographic projection of the physis, was measured relative to the physis at the lateral and medial cortex of the femur on coronal CT slices. RESULTS: Thirty-one patients were included. On the perfect lateral radiograph DRR, the physis on the medial cortex was located proximal to the visualized physis by 6.64 ± 1.74 mm, 11.95 ± 1.67 mm, and 14.30 ± 1.75 mm at the anterior (25%), midpoint (50%), and posterior (75%) locations, respectively. On the lateral side, the physis on the lateral cortex was proximal to the visualized physis by 2.19 ± 1.13 mm, 3.71 ± 1.19 mm, and 6.74 ± 1.25 mm at the anterior, midpoint, and posterior locations, respectively. DISCUSSION: In this cohort of pediatric patients, the location of the cortical physis was, in all areas measured, proximal to the projection of the visualized physis as seen on the perfect knee lateral DRR. The distance from radiographic physis to cortical physis was greater at the medial cortex compared with the lateral cortex. STUDY DESIGN: Descriptive laboratory study. LEVEL OF EVIDENCE: III, observational radiographic anatomic study.

Magnetic Resonance Imaging and Magnetic Resonance Arthrography Are Both Reliable and Similar When Measuring Hip Capsule Thickness in Patients With Femoroacetabular Impingement Syndrome.

Purpose: To propose an accurate method of measuring hip capsular thickness in patients with femoroacetabular impingement syndrome and to compare the reliability of these measurements between magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). Methods: A previously established database of patients with femoroacetabular impingement syndrome (FAIS) was used to identify candidates with preoperative MRI or MRA from November 2018 to June 2021. Two reviewers independently examined preoperative imaging for 85 patients. Capsular thickness was measured in 12 standardized locations. Intraclass correlation coefficients (ICCs) were calculated using an absolute-agreement, 2-way random-effects model. Using the same method, 30 patients were randomly selected for repeat measurements by 1 reviewer following a washout period. Ten additional patients with preoperative MRI and MRA of the same hip were identified to compare measurements between modalities using paired samples t test. Results: ICCs for measurements on MRIs and MRAs using these proposed measurements to compare inter-rater reliability were 0.981 and 0.985. ICCs calculated using measurements by a single reviewer following a washout period for intrarater reliability were 0.998 and 0.991. When comparing MRI and MRA measurements in the same patient, t test for all pooled measurements found no difference between modality (P = .283), and breakdown of measurements by quadrant found no difference in measurements (P > .05), with the exception of the inferior aspect of the capsule on coronal sequences (P = .023). Conclusions: In patients with FAIS, both MRI and MRA have excellent reliability for quantifying hip capsular thickness. A difference in capsular thickness was found only when comparing MRI and MRA on inferior coronal aspects of the hip capsule, indicating interchangeability of these imaging modalities when measuring the clinically important aspects of the hip capsule. Level of Evidence: Level IV, diagnostic case series.

Correlation of Tibial Tubercle Overgrowth With Increased Posterior Tibial Slope: A Novel Radiographic Assessment.

Background: An elevated posterior tibial slope (PTS) is associated with an increased risk for anterior cruciate ligament and meniscal injury. Recent evidence suggests that the PTS is elevated in patients with Osgood-Schlatter disease. Purpose: To determine whether there is an association between objective measures of anterior tibial tubercle growth and PTS. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 100 radiographs were randomly selected from a sample of patients who had received a lateral knee radiograph that captured at least 15 cm of the tibia distal to the knee joint line at a single institution between December 2020 and March 2022. The PTS was measured, and tibial tubercle growth was quantified with 2 novel measurements. For these measurements, a line was drawn on the radiograph from the most anterosuperior point on the tibia to the point on the anterior cortex of the tibia 10 cm distal from the starting point. The tibial tubercle height (TTH) was measured as the perpendicular distance from this line to the most prominent portion of the anterior tibia. The anterior tibial tubercle angle (TTA) was measured as the angle between the endpoints of the line made previously and the most prominent portion of the tibial tubercle, with a more acute angle indicating a more prominent tibial tubercle. The relationship between TTA, TTH, and PTS was evaluated using a univariate linear regression model. Results: The mean patient age was 33.1 ± 14.1 years. The mean TTA was 158.6°± 4.7°, the mean TTH was 8.8 ± 2.0 mm, and the mean PTS was 9.7°± 2.6°. A significant correlation was found between PTS and TTA (r = -0.46; ß = -0.46; P < .001) as well as TTH (r = 0.43; ß = 0.43; P < .001). Conclusion: Objective measures of anterior tibial tubercle overgrowth correlated with an elevated PTS. Every 2.2° of anterior TTA deviation from the mean and every 2.3 mm in TTH deviation from the mean correlated with a 1° difference in the PTS. This suggests a link between the development of the tibial tubercle and PTS, and it potentially helps to explain why the PTS is elevated in certain patients.

Short-term Outcomes After Hip Arthroscopic Surgery in Patients Participating in Formal Physical Therapy Versus a Home Exercise Program: A Prospectively Enrolled Cohort Analysis.

BACKGROUND: Physical therapy is frequently utilized in the postoperative care of femoroacetabular impingement syndrome (FAIS). There has been limited research into the efficacy of a structured home exercise program (HEP) compared with formal physical therapy (FPT) in this patient population. PURPOSE/HYPOTHESIS: The purpose was to evaluate the short-term outcomes of patients utilizing FPT versus an HEP after hip arthroscopic surgery for FAIS. It was hypothesized that both groups would show similar improvements regarding outcome scores, which would improve significantly compared with their preoperative scores. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing hip arthroscopic surgery for FAIS at a single center between October 2020 and October 2021 were prospectively enrolled. Patients were allowed to self-select FPT or an HEP and were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. The survey included the Single Assessment Numeric Evaluation, visual analog scale for pain, 12-item International Hip Outcome Tool, Patient-Reported Outcomes Measurement Information System Physical Function, and patient satisfaction with physical therapy and overall care. Statistical analysis was conducted between the 2 groups and within groups to compare preoperative and postoperative scores. RESULTS: The patients' mean age was 32.6 ± 10.4 years, with 47.2% being female and 57.4% choosing the HEP. At 12 months postoperatively, no significant differences were reported between the FPT and HEP groups regarding the Single Assessment Numeric Evaluation score (P = .795), visual analog scale for pain score (P > .05), Patient-Reported Outcomes Measurement Information System Physical Function T-score (P = .699), 12-item International Hip Outcome Tool score (P = .582), and patient satisfaction (P > .05). Outcome scores at 12 months postoperatively were significantly improved from the preoperative scores across all measures in both groups (P < .001). CONCLUSION: There were no significant differences regarding patient outcomes between FPT and the HEP at 1-year follow-up after hip arthroscopic surgery for FAIS when patients selected their own treatment, with both groups demonstrating significant improvements in their outcome scores from their preoperative values. These findings suggest that a structured HEP may be a viable alternative to FPT after hip arthroscopic surgery in patients who prefer a self-directed rehabilitation program.

The Role of the Hip Capsule in Restoring Stability in the Initial Phase of Hip Distraction: An In Vivo Analysis.

Background: The labral suction seal has been shown to provide the majority of resistance in the initial phase of hip distraction. However, the effect of an unrepaired interportal capsulotomy and capsular repair on the initial phase of hip distractive stability in vivo is not well understood. Purpose: To investigate the effect of capsular repair on the initial phase of distractive stability of hip joints in patients with femoroacetabular impingement (FAI) syndrome. Study Design: Controlled laboratory study. Methods: Patients undergoing primary hip arthroscopy for FAI between March and August 2020 were prospectively enrolled. Total joint space was measured on fluoroscopic images at the medial and lateral edges of the sourcil at 12.5-lb (5.7-kg) axial traction intervals (up to 100 lb [45.4 kg]) in 3 capsular states: (1) native capsule, (2) interportal capsulotomy, and (3) capsular repair. Distraction on anteroposterior radiographs was calculated as the difference between total joint space at each traction interval and baseline joint space at 0 lb, normalized to millimeters. The native, capsulotomy, and capsular repair states were compared using Wilcoxon signed-rank and McNemar tests. Results: Included were 36 hips in 35 patients. The median force required to distract ≥3 mm was 75 lb (34.0 kg; 95% CI, 70-80 lb [31.8-36.3 kg]) in both the native and capsular repair states (P = .629), which was significantly greater than the median force required to distract ≥3 mm in the capsulotomy state (50 lb [22.7 kg]; 95% CI, 45-55 lb [20.4-24.9 kg]) (P < .001). The most rapid rates of change in joint space were observed at the traction interval at which hips first achieved ≥3 mm of distraction (n = 33 hips; 92%). Conclusion: The traction force at which hips distracted ≥3 mm was 75 lb (34.0 kg) in both the native capsular and capsular repair states. Significantly less traction force (50 lb [22.7 kg]) distracted hips ≥3 mm in the capsulotomy state. Complete capsular closure after interportal capsulotomy resulted in restoration of initial distractive stability relative to the unrepaired capsulotomy state at time zero after primary hip arthroscopy. Clinical Relevance: This study provides surgeons with an improved understanding of the additional stability to the hip joint from capsular repair after hip arthroscopy for FAI syndrome.

Hip Joint Venting Decreases the Traction Force Required to Access the Central Compartment During Hip Arthroscopy.

Purpose: To investigate the effect of hip joint venting on the magnitude of traction force required to arthroscopically access the central compartment of the hip. Methods: Patients who underwent hip arthroscopy for femoroacetabular impingement syndrome prospectively underwent an intraoperative traction protocol. Joint space was measured on fluoroscopic images obtained at 50 and 100 lbs of axial traction in the prevented and vented state, and joint space values were normalized to millimetric values using preoperative anteroposterior pelvis radiographs. Venting was performed by inserting a large gauge spinal needle into the hip joint through the hip capsule and removing the stylet. Joint space differences were compared with paired t-tests, Wilcoxon signed-rank tests, and McNemar tests. Results: Fifty hips in 46 patients were included. Mean joint space before venting was 7.4 ± 2.6 mm and 13.3 ± 2.8 mm at 50 and 100 lbs of traction, respectively. Mean joint space after venting was 13.9 ± 2.3 mm and 15.5 ± 2.4 mm at 50 and 100 lbs of traction, respectively. Mean differences in joint space at 50 and 100 lbs were 6.5 mm (P < .001) and 2.2 mm (P < .001), respectively. Mean joint space at 50 lbs in the vented state was significantly greater than in the pre-vented state at 100 lbs (13.9 mm vs. 13.3 mm; P = .002). The increase in joint space between 50 and 100 lbs of traction was significantly greater in the prevented state than in the vented state (5.9 mm vs 1.6 mm; P = .021). Conclusions: Venting the hip reduces the traction force necessary to arthroscopically visualize and instrument the central compartment of the hip by at least 50%. Further, residual negative pressurization of the hip joint remains after breaking the labral suction seal and venting effectively eliminates this phenomenon to aid in hip joint distraction at lower traction force. Level of Evidence: Level IV, case series.

Rates and reasons for reoperation within 30 and 90 days following cervical spine surgery: a retrospective cohort analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry.

BACKGROUND CONTEXT: Reoperation following cervical spinal surgery negatively impacts patient outcomes and increases health care system burden. To date, most studies have evaluated reoperations within 30 days after spine surgery and have been limited in scope and focus. Evaluation within the 90-day period, however, allows a more comprehensive assessment of factors associated with reoperation. PURPOSE: The purpose of this study is to assess the rates and reasons for reoperations after cervical spine surgery within 30 and 90 days. DESIGN: We performed a retrospective analysis of a state-wide prospective, multi-center, spine-specific database of patients surgically treated for degenerative disease. PATIENT SAMPLE: Patients 18 years of age or older who underwent cervical spine surgery for degenerative pathologies from February 2014 to May 2019. Operative criteria included all degenerative cervical spine procedures, including those with cervical fusions with contiguous extension down to T3. OUTCOME MEASURES: We determined causes for reoperation and independent surgical and demographic risk factors impacting reoperation. METHODS: Patient-specific and surgery-specific data was extracted from the registry using ICD-10-DM codes. Reoperations data was obtained through abstraction of medical records through 90 days. Univariate analysis was done using chi-square tests for categorical variables, t-tests for normally distributed variables, and Wilcoxon rank-sum tests for variables with skewed distributions. Odds ratios for return to the operating room (OR) were evaluated in multivariate analysis. RESULTS: A total of 13,435 and 13,440 patients underwent cervical spine surgery and were included in the 30 and 90-day analysis, respectively. The overall reoperation rate was 1.24% and 3.30% within 30 and 90 days, respectively. Multivariate analysis showed within 30 days, procedures involving four or more levels, posterior only approach, and longer length of stay had increased odds of returning to the OR (p<.05), whereas private insurance had a decreased odds of return to OR (p<.05). Within 90 days, male sex, coronary artery disease (CAD), previous spine surgery, procedures with 4 or more levels, and longer length of stay had significantly increased odds of returning to the OR (p<.05). Non-white race, independent ambulatory status pre-operatively, and having private insurance had decreased odds of return to the OR (p<.05). The most common specified reasons for return to the OR within 30 days was hematoma (19%), infection (17%), and wound dehiscence (11%). Within 90 days, reoperation reasons were pain (10%), infection (9%), and hematoma (8%). CONCLUSION: Reoperation rates after elective cervical spine surgery are 1.24% and 3.30% within 30 and 90 days, respectively. Within 30 days, four or more levels, posterior approach, and longer length of stay were risk factors for reoperation. Within 90 days, male sex, CAD, four or more levels, and longer length of hospital stay were risk factors for reoperation. Non-white demographic and independent preoperative ambulatory status were associated with decreased reoperation rates.

Hardware Impingement Is Associated With Shorter Screw Length in Patients Treated With In Situ Screw Fixation for Slipped Capital Femoral Epiphysis: An In Vivo Arthroscopic Evaluation.

Purpose: To determine the incidence of screw impingement on dynamic exam during hip arthroscopy in patients undergoing treatment for femoroacetabular impingement after previous slipped capital femoral epiphysis fixation and to evaluate screw characteristics with hardware impingement. Methods: A retrospective review from 2008 to 2020 was performed of slipped capital femoral epiphysis (SCFE) patients that underwent arthroscopy for symptoms of hip impingement. Patients underwent a dynamic exam under direct arthroscopic visualization to assess for sources of impingement, including bony anatomy and fixation hardware. Slip angle was calculated on lateral radiographs prior to arthroscopy, and screw length was noted in the initial operative reports at treatment of SCFE and reported in millimeters. Normality of data was assessed using Shapiro-Wilk tests, with statistical analysis performed using independent sample t-tests, Mann-Whitney U-nonparametric tests, and multivariable logistic regression. An alpha level of <0.05 was used to indicate statistical significance. Results: Thirty-nine hips were included, with 13 (33.3%) having screw impingement on dynamic exam. Slip angle was found to be increased in the screw impingement group (42.4° vs 35.5°; P = .11). Screw length was noted to be significantly shorter in the screw impingement group (53.1 vs 61.6 mm; P = .021). The presence of screw impingement was found to be associated with shorter screw length (ß = -0.172, R 2 = 0.329; P = .036). Conclusions: Shorter screws (55 mm or less) are at greater risk of causing hardware hip impingement after in situ SCFE fixation. When considering hip arthroscopy for the treatment of femoroacetabular impingement in patients with a previous SCFE, hardware impingement and subsequent hardware removal should be considered in hips with shorter screws and in hips that show objective hardware impingement on dynamic exam. Level of Evidence: Level IV, therapeutic case series.