Minimal Important Clinical Difference Values Are Not Uniformly Valid in the Active Duty Military Population Recovering from Shoulder Surgery.

BACKGROUND: There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of two different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operator curve (ROC) -based MCIDs and baseline-adjusted ROC MCIDs. METHODS: All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROMs battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons score (ASES), Patient Reported Outcome Management Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and the Warfighter Readiness survey. Standard anchor-based and baseline-adjusted ROC MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval either completely negative or positive). RESULTS: There were 117 patients (136 operations) identified, comprised of 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7. CONCLUSION: When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC method was more effective at discerning changes across a battery of PROMs among the same cohort.

Leadership in Orthopaedic Surgery: Creating a Highly Effective Leader.

Strong leadership is associated with improved outcomes in multiple domains, including orthopaedic surgery. There are multiple leadership styles, including transformational, transactional, and laissez-faire leadership. An effective leader understands the importance of verbal and nonverbal communication, emotional intelligence, preparation, and mindset on team performance. Orthopaedic surgeons serve as leaders in the operating room, in the outpatient setting, and on committees. Leadership skills can be developed through leadership-specific evaluations and training.

Treatment Following a First-Time Shoulder Dislocation: What Should I Do?

A first-time shoulder dislocation is a challenging topic that requires consideration of anatomic and patient-specific factors. Initial management is predicated on determining functional demands, activity level, and expectations of the patient, in addition to assessing the risk of recurrent instability. When considering surgical indications, it is imperative to understand the biomechanical implications of injury to the glenohumeral joint complex and how specific surgical procedures can restore stability. It is important to provide an overview of the current treatment algorithm for management of first-time shoulder dislocation, with a special focus on diagnosis and intervention in the young athlete.

What to Do When It Is Anterior Cruciate Ligament Reconstruction Number Two.

Several factors contribute to the greater complexity of revision anterior cruciate ligament reconstruction compared with primary anterior cruciate ligament reconstructive surgery. Prior tunnels and hardware may compromise revision tunnel placement and secure fixation. This may necessitate two-stage revision or specific techniques to achieve anatomic revision tunnels. Prior autograft use may limit graft options. Individuals with a failed anterior cruciate ligament reconstruction are more likely to have risk factors for further failure. These may include malalignment, occult instability, knee hyperextension, or increased tibial slope. There are also higher rates of meniscus and cartilage injuries in revision anterior cruciate ligament reconstruction that may require intervention. Successful revision anterior cruciate ligament reconstruction requires thoughtful preoperative planning along with multiple potential intraoperative plans depending on the pathology encountered. It is important to provide the orthopaedic surgeon with an up-to-date, evidence-based overview of how to approach and execute a successful revision anterior cruciate ligament reconstruction.

Medial Meniscal Extrusion Evaluation With Weight-Bearing Ultrasound: Correlation With MR Imaging Findings and Reported Symptoms: Correlation With MR Imaging Findings and Reported Symptoms.

OBJECTIVES: To compare medial meniscal extrusion on weight-bearing ultrasound (US) with supine US and magnetic resonance (MR) imaging correlating with meniscal pathology and reported symptoms. METHODS: IRB approved study with informed consent. Patients obtaining routine knee MR imaging for suspected knee pathology were prospectively evaluated with supine and weight-bearing US of the medial meniscus. Meniscal extrusion was measured independently by two fellowship-trained musculoskeletal radiologists. Correlation was made to presence or absence of meniscal degeneration or tear on MR imaging, as well as reported symptoms. Statistical significance was calculated via intraclass correlation coefficient (ICC) and analysis of variance (ANOVA). RESULTS: Ninety-nine knees from 95 subjects (50 males, 45 females; mean age 45 ± 15 years) were included. Mean medial meniscal extrusion measured at US for a normal meniscus (n = 36) was 0.8 mm when supine, increasing to 1.6 mm on weight-bearing. Mean meniscal extrusion in subjects with mucoid degeneration (n = 20) and those with meniscal tears (n = 43) was 1.6 mm, increasing to 2.3 mm with weight bearing. Inter-reader reliability showed ICC values of 0.853 to 0.940. There was a significant difference in medial meniscal extrusion comparing subjects with a normal medial meniscus at magnetic resonance imaging (MRI) and subjects with either meniscal degeneration or tear. There was no significant difference in degree of meniscal extrusion between subjects with meniscal degeneration or tear. There was trend of worsening symptoms and increasing functional limitations moving from normal meniscus to meniscal degeneration to meniscal tear. CONCLUSIONS: A normal meniscus shows lesser mobility between supine and upright position, than a pathologic meniscus. Both mucoid degeneration and meniscal tear demonstrate extrusion in the supine position, which increases with weight-bearing position.

Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates.

We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient's prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient's surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen. LEVEL OF EVIDENCE: Level V, expert opinion.

Effects of Blood Flow Restriction Therapy for Muscular Strength, Hypertrophy, and Endurance in Healthy and Special Populations: A Systematic Review and Meta-Analysis.

OBJECTIVES: Blood flow restriction (BFR) training is an increasingly applied tool with potential benefits in muscular hypertrophy, strength, and endurance. This study investigates the effectiveness of BFR training relative to other forms of training on muscle strength, hypertrophy, and endurance. DATA SOURCES: We performed systematic searches of MEDLINE, Embase, and PubMed and assessed the methodological quality of included studies using the Cochrane risk of bias tool. MAIN RESULTS: We included 53 randomized controlled trials with 31 included in meta-analyses. For muscular strength comparing low-intensity BFR (LI-BFR) training with high-intensity resistance training (HIRT), the pooled mean difference (MD) for 1 repetition maximum was 5.34 kg (95% CI, 2.58-8.09; P < 0.01) favoring HIRT. When comparing LI-BFR training with HIRT for torque, the MD was 6.35 N·m (95% CI, 0.5-12.3; P = 0.04) also favoring HIRT. However, comparing LI-BFR with low-intensity resistance training (LIRT) for torque, there was a MD of 9.94 N·m (95% CI, 5.43-14.45; P < 0.01) favoring BFR training. Assessing muscle hypertrophy, the MD in cross-sectional area was 0.96 cm2 (95% CI, 0.21-1.7; P = 0.01) favoring pooled BFR training compared with nonocclusive training. Assessing endurance, V̇o2 maximum demonstrated a greater mean increase of 0.37 mL/kg/min (95% CI, -0.97 to 3.17; P = 0.64) in BFR endurance training compared with endurance training alone. CONCLUSION: Blood flow restriction training produced increases in muscular strength, hypertrophy, and endurance. Comparing LI-BFR training with HIRT, HIRT was a significantly better training modality for increasing muscle hypertrophy and strength. However, LI-BFR was superior when compared with a similar low-intensity protocol. Blood flow restriction training is potentially beneficial to those unable to tolerate the high loads of HIRT; however, better understanding of its risk to benefit ratio is needed before clinical application. LEVEL OF EVIDENCE: Level 1.

Pearls and Pitfalls in the Management of Cam-Type Femoroacetabular Impingement: Deformity and Approach.

The arthroscopic treatment of cam-type femoroacetabular impingement (FAI) is a technically demanding surgery, which has been shown to yield successful clinical outcomes, and improved hip biomechanics and range of motion and may also favorably alter the natural history of FAI-induced osteoarthritis. Assessing the presenting symptoms, clinical history, and physical examination findings can help to confirm the diagnosis of symptomatic cam-type FAI. Appropriate preoperative imaging studies are important in the characterization of cam-type deformities and often guide the decision between open and arthroscopic management. Although most cam-type FAI can be successfully managed using an arthroscopic approach, certain complex deformity patterns might best be addressed with surgical dislocation. Command of intraoperative techniques for exposure and instrumentation, as well as effective use of fluoroscopy, allows for consistent and reproducible cam deformity correction while minimizing complications.

Independent Suture Tape Reinforcement of Tripled Smaller-Diameter and Quadrupled Grafts for Anterior Cruciate Ligament Reconstruction With Tibial Screw Fixation: A Biomechanical Full Construct Model.

PURPOSE: To compare the effect of independent suture tape reinforcement on the dynamic elongation and stiffness behavior as well as ultimate strength of tripled smaller-diameter and quadrupled soft-tissue grafts for anterior cruciate ligament reconstruction (ACLR) with tibial screw fixation in a biomechanical in vitro study. METHODS: Tripled smaller-diameter (8 mm) and quadrupled (9 mm) bovine tendon grafts with and without suture tape reinforcement (n = 8 in each group) were tested using femoral suspensory and tibial interference screw fixation. The suture tape was femoral sided and fixed independent from the graft by passing it through the suspensory button and securing the 2 open tibial strands with a secondary interference screw. Dynamic testing was performed in position and force control at 250 N and 400 N, followed by pull to failure with the mode of failure noted. Dynamic elongation, stiffness, and ultimate strength were analyzed. RESULTS: Tripled constructs showed a significantly worse structural performance than quadrupled constructs at higher loads. Reinforcement of tripled and quadrupled grafts substantially decreased total elongation by 56% (4.54 ± 0.75 mm vs 2.01 ± 0.50 mm, P < .001) and 39% (3.25 ± 0.49 mm vs 1.98 ± 0.51 mm, P < .001), respectively, by significantly increasing dynamic stiffness. No statistical significance was found between the reinforced groups. Failure loads of reinforced tripled (1,074 ± 148 N vs 829 ± 100 N, P = .003) and quadrupled (1,125 ± 157 N vs 939 ± 76 N, P = .023) grafts were also significantly improved. CONCLUSIONS: Independent reinforcement of soft-tissue grafts with suture tape strengthened the performance especially of tripled smaller-diameter grafts for ACLR with tibial screw fixation by significantly improving dynamic elongation at increased stiffness and ultimate strength. Quadrupled reinforced grafts showed no over-constraining and structurally behaved similarly to tripled grafts with reinforcement. CLINICAL RELEVANCE: Independent reinforcement for ACLR may provide an option for protecting autografts or allografts against irreversible lengthening during the maturation and remodeling phases of healing.

The Dancer's Hip: The Hyperflexible Athlete: Anatomy and Mean 3-Year Arthroscopic Clinical Outcomes.

PURPOSE: To report preoperative anatomy, patient-related outcomes measures, and return to dance rates in a cohort of competitive dancers undergoing an arthroscopic hip procedure. METHODS: Competitive dancers who underwent an arthroscopic hip procedure between 2008 and 2016 were included. Specific types of dance performed, morphology, and radiographic parameters were documented. Outcomes were evaluated with Modified Harris Hip Score (mHHS), the 12-Item Short Form Health Survey, visual analog scale, and Hip Disability and Osteoarthritis Outcome Scores (HOOS). RESULTS: There were 63 competitive dancers (77 hips) with a mean age 21.2 years in the current study. Specific types of dance performed included 57 studio dance and 41 high-kick dance, and 28 dancers (44%) were professional-level. Morphology included cam-type femoroacetabular impingement (95%), pincer-type femoroacetabular impingement (40%), anterior inferior iliac spine impingement (subspine) (83%), and mild (borderline) dysplasia (11%). Procedures performed included 95% labral repairs, 5% labral debridements, 99% femoral resections, 49% rim resections, 88% subspine decompressions, and 66% capsular plications. At mean 36 months' follow-up post-arthroscopy, the mean outcome improvements were 25.6 points (mHHS), 18.9 points (HOOS-activities of daily living), 29.9 points (HOOS-Sports), 8.7 points (12-Item Short Form Health Survey), and 3.7 points (visual analog scale) (P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for mHHS (60.0 vs 85.6 points), HOOS-activities of daily living (72.5 vs 91.5 points), and HOOS-Sports (49.7 vs 79.6) (P < .01). Sixty-three percent of dancers returned to their previous level of competitive dance, 21% returned to limited or modified dance, and 16% were unable to return to dance, including 1 retirement. CONCLUSIONS: A careful arthroscopic approach to address cam-type pathomorphology, highly prevalent subspine impingement, and capsular laxity in competitive dancers can achieve a modest rate of return to sport and good-to-excellent patient-reported outcomes at short- to mid-term (3-year) follow-up. Eighty-four percent of dancers ultimately returned to competitive dance, although only 63% returned to their preinjury competitive level. LEVEL OF EVIDENCE: IV, case series.

Does Bone Plug and Graft Orientation (Inferior Versus Posterior) Alter Native Femoral Footprint Coverage in Bone Patellar Tendon Bone Anterior Cruciate Ligament Reconstruction?

PURPOSE: The purpose of this study was to compare the percentage of native femoral anterior cruciate ligament (ACL) footprint covered by the 2 most clinically relevant bone plug/graft orientations used with interference screw fixation in ACL reconstruction. A secondary purpose was to assess whether a transtibial or tibia-independent drilling technique would affect this outcome. METHODS: Five matched pairs of cadaver knees were used. Each matched pair had 1 knee assigned to a 10-mm femoral socket prepared via a transtibial (TT) drilling technique and the other via an anteromedial (AM) drilling technique. The bone plug of each graft was press-fitted into the femoral socket with the graft collagen in 2 distinct clinically relevant orientations (collagen inferior or posterior). The digitized graft collagen cross-sectional area (CSA) in each orientation was overlaid onto the native femoral ACL footprint CSA to generate a percentage of native ACL footprint covered by graft collagen. RESULTS: The average native ACL femoral footprint CSA was 110.5 ± 9.1 mm2, with no difference between knees assigned to TT or AM drilling (112.6 ± 2.7 vs 108.4 ± 13.0 mm2, P = .49). The average femoral socket CSA was 95.4 ± 8.7 mm2, with no difference between TT and AM tunnels (95.5 ± 9.9 vs 95.3 ± 8.4 mm2, P = .96). There was no difference between the percentage of native footprint covered between TT and AM sockets (76.8% ± 7.8% vs 82.2% ± 13.7%, P = .47). Irrespective of drilling technique, there was significantly greater native ACL footprint covered by graft collagen when the bone plug was oriented with graft collagen inferior rather than posterior (75.6% ± 6.3% vs 65.4% ± 11.4%, P = .02). CONCLUSION: Orienting the femoral bone plug such that the graft collagen is inferior rather than posterior significantly increases native ACL femoral footprint coverage in bone-patellar tendon-bone ACL reconstruction. This effect is consistent across AM and TT drilling techniques. CLINICAL RELEVANCE: Surgeons attempting to restore an anatomic ACL footprint should consider bone plug-graft orientation when performing ACL reconstruction. STUDY DESIGN: Controlled laboratory study.

Vault perforation after eccentric glenoid reaming for deformity correction in anatomic total shoulder arthroplasty.

BACKGROUND: The management of glenoid deformity during anatomic total shoulder arthroplasty remains controversial. In this study, we evaluate variable correction of glenoid deformity by eccentric reaming. We hypothesize that partial correction of modified Walch B/C-type glenoid deformities can achieve 75% bone-implant contact area (BICA) with a reduced vault perforation risk compared with complete correction. METHODS: Fifty shoulder computed tomographic scans with glenohumeral osteoarthritis were retrospectively evaluated. The Tornier BluePrint v2.1.5 software simulated 3 eccentric reaming scenarios including no, partial, and complete deformity correction. Each scenario was evaluated at 4 BICAs and using 3 implant fixation types. Three-dimensional surface representations were used to evaluate medialization and vault perforation. RESULTS: The patients had mean glenoid retroversion and inclination of 18.5° and 8.8°, respectively, and mean posterior humeral head subluxation of 76%. With 75% BICA, the 3 fixation types had glenoid vault perforation in 6%-26% and 26%-54% of cases for partial and complete glenoid deformity correction, respectively. The central and posterior-inferior implant components were most likely to perforate across all scenarios. DISCUSSION: Eccentric reaming for glenoid deformity correction increases the risk of vault perforation. Severe glenoid deformity required increased medialization to achieve 75% BICA. Pegged implants have increased chances of perforation compared with a keeled design; the central and posterior-inferior components were most likely to perforate during deformity correction. CONCLUSION: Partial deformity correction of modified Walch B/C-type glenoid deformities can achieve 75% BICA while reducing the risk of vault perforation compared with complete correction at the time of anatomic total shoulder arthroplasty.

Editorial Commentary: What Is an Anatomic Anterior Cruciate Ligament Reconstruction, and Does It Matter? There Are Many Ways to Skin a Cat!

The concept of an "anatomic" anterior cruciate ligament (ACL) reconstruction remains a major focus of active research in the literature, but the true definition remains elusive. Although most authors have defined this by a tunnel position contained within the native ligament footprint, it is clear that such a description is grossly inadequate to recapitulate the form and function of the native ACL: Aperture surface area, geometry, graft bundles, collagen fiber tension, and isometry, as well as incorporation and maturation, are all critical factors that affect the final outcome. It is clear that no single- or double-bundle ACL reconstruction in 2019 is in fact anatomic; rather, it is guided by the native anatomic landmarks to more appropriately place the new graft.

Arthroscopic Superior Capsular Reconstruction for Massive, Irreparable Rotator Cuff Tears: A Systematic Review of Modern Literature.

PURPOSE: To systematically review and evaluate the efficacy and complication profile of superior capsular reconstruction (SCR) as a technique to address massive, irreparable rotator cuff tears (MIRCTs). METHODS: Searches of the Cochrane Database of Systematic Reviews, Embase, MEDLINE, PubMed, and conference abstracts of 4 major conferences identified clinical studies addressing SCR for MIRCTs. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. RESULTS: A total of 10 studies, 7 full texts and 3 conference abstracts, satisfied the inclusion criteria. The included studies examined a total of 350 shoulders with a mean patient age of 60.6 years and mean follow-up period of 20.6 months postoperatively. Only 4 studies had a minimum of 24-month follow-up data. Statistically significant improvements in pain and function were noted in all studies reporting results, with mean improvement ranging from 29.4 to 68.5 and from 2.5 to 5.9 points across the American Shoulder and Elbow Surgeons score and visual analog scale score, respectively. Mean improvement in range of motion ranged from 21.7° to 64.0° in elevation and from 9.0° to 15.0° in external rotation. Statistically significant improvements in the postoperative acromiohumeral distance were noted in 4 of 5 reporting studies, with a mean increase ranging from 2.2 to 5.0 mm. The combined clinical and radiographic failure and/or retear rate ranged from 3.4% to 36.1%. Complications for all studies included deep infection (0%-2%), symptomatic suture anchor loosening (0%-4%), and severe shoulder contracture (0%-2%). CONCLUSIONS: Arthroscopic SCR represents an accepted surgical option for patients with MIRCTs, with short-term improvements shown in pain, range of motion, and function. Although early results are promising, further studies are necessary to determine the long-term success of this technique and to better delineate the clinical indications, survivorship, and risk factors for failure in this population. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Arthroscopic Surgery for Femoroacetabular Impingement in Skeletally Immature Athletes: Radiographic and Clinical Analysis.

PURPOSE: To evaluate radiographic and clinical outcomes after arthroscopic femoroacetabular impingement (FAI) correction in symptomatic adolescent athletes with open physes. METHODS: We retrospectively reviewed radiographic and clinical outcomes in patients treated with a non-physeal-sparing arthroscopic approach for symptomatic FAI with open physes and a minimum 1-year follow-up. Specific plain radiographic and computed tomography parameters were determined, and preoperative and postoperative outcomes were prospectively evaluated with modified Harris Hip Score (mHHS), 12-Item Veterans-Rand, and pain on a visual analog scale. RESULTS: Thirty-seven hips (28 patients; 75% male) with a mean age of 15.9 years (range, 12.8-18.3 years) had imaging studies consistent with open femoral neck and iliac crest physes. The ischial tuberosity and greater trochanteric physes were open in 95% and 54% of the hips, respectively. All patients participated in organized athletics, and 50% were in multiple sports year-round. Mean follow-up was 39.8 months post-arthroscopic FAI correction. There was a mean 27.7-point improvement in the mHHS (P < .001), a 4.8-point decrease in the visual analog scale for pain (P < .001), and a 15.2-point improvement in the 12-Item Veterans-Rand physical component (P < .001). Ninety-three percent of patients returned to their preinjury level of sports participation without limitations. Thirty (81.1%) patients demonstrated improvements in mHHS greater than the minimally clinically important difference (of mHHS 8 points). Two patients could not reach minimally clinically important difference because of a preoperative mHHS of > 92. There were no postoperative physeal growth arrests, growth disturbances, physeal instability, or avascular necrosis. CONCLUSIONS: A non-physeal-sparing arthroscopic approach for FAI in adolescents with open physes is safe and effective with no evidence of clinically relevant complication of growth arrest-related deformity or physeal instability in patients with a minimum of 1 year (mean, 39.8 months) of follow-up after surgery. Young, highly athletic adolescent patients with larger FAI deformities demonstrated greater outcomes improvement after arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Low-Dose Computed Tomography Reduces Radiation Exposure by 90% Compared With Traditional Computed Tomography Among Patients Undergoing Hip-Preservation Surgery.

PURPOSE: To compare the delivered radiation dose between a low-dose hip computed tomography (CT) scan protocol and traditional hip CT scan protocols (i.e., "traditional CT"). METHODS: This was a retrospective comparative cohort study. Patients who underwent hip-preservation surgery (including arthroscopy, surgical hip dislocation, or periacetabular osteotomy procedures) at our institution between 2016 and 2017 were identified. Patients were excluded if they had a body mass index (BMI) greater than 35, they underwent previous surgery, or a radiation dose report was absent. The low-dose group included patients who underwent hip CT at our institution using a standardized protocol of 100 kV (peak), 100 milliampere-seconds (mAs), and a limited scanning field. The traditional CT group included patients who had hip CT scans performed at outside institutions. The total effective dose (Ehip), effective dose per millimeter of body length scanned, patients' age, and patients' BMI were compared by univariate analysis. The correlation of Ehip to BMI was assessed. RESULTS: The study included 41 consecutive patients in the low-dose group and 18 consecutive patients in the traditional CT group. Low-dose CT resulted in a 90% reduction in radiation exposure compared with traditional CT (Ehip, 0.97 ± 0.28 mSv vs 9.68 ± 6.67 mSv; P < .0001). Age (28 ± 11 years vs 26 ± 10 years, P = .42), sex (83% female patients vs 76% female patients, P = .74), and BMI (24 ± 3 vs 24 ± 3, P = .75) were not different between the 2 groups. Ehip had a poor but significant correlation to BMI in the low-dose CT group (R2 = 0.14, slope = 0.03, P = .02) and did not correlate to BMI in the traditional CT group (R2 = 0.13, P = .14). CONCLUSIONS: A low-dose hip CT protocol for the purpose of hip-preservation surgical planning resulted in a 90% reduction in radiation exposure compared with traditional CT. LEVEL OF EVIDENCE: Level II, diagnostic study.

Outcomes of hyaluronic acid injections for glenohumeral osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: Hyaluronic acid (HA) is an analgesic and chondroprotective agent often used for the nonoperative treatment of osteoarthritis (OA). The effects of HA injections are well studied in the treatment of knee OA, but the effects in glenohumeral OA remain unclear. This study evaluated the efficacy of HA to reduce pain in patients with glenohumeral OA. METHODS: PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through January 16, 2018. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of risk of bias. The primary outcome was change in visual analog scale for pain. The secondary outcomes were functional outcome and adverse events. RESULTS: In the HA arm, the reduction of visual analog scale pain score at 3 months was 26.2 mm (95% confidence interval, 22.0-30.3 mm; I2 = 31%) and at 6 months was 29.5 mm (95% confidence interval, 25.5-33.4 mm; I2 = 19%). All studies reported an improvement in functional outcome. Similar clinical improvements were reported in the intervention and control groups, suggesting that these improvements may not be directly related to HA. Commonly reported adverse events were rare and included swelling and mild pain at the injection site, local effusion, lethargy, and face rash. CONCLUSION: Intra-articular HA injection is safe and improves pain for patients with glenohumeral OA. Pain improvements also reported in the control group suggest that a significant placebo effect may be present with respect to intra-articular shoulder injection. Further randomized controlled trials are necessary to evaluate the efficacy of HA and identify optimal dosing and route of administration.

The Effects of Delays in Diagnosis and Surgical Reconstruction of ACL Tears in Skeletally Immature Individuals on Subsequent Meniscal and Chondral Injury.

BACKGROUND: Although studies have shown increased rates of chondral injury with delayed surgical treatment of pediatric anterior cruciate ligament (ACL) injuries, it is unknown if this is related to a delay in diagnosis and appropriate activity restrictions. The purpose of this study was to determine if the time from injury to diagnosis, time from diagnosis to reconstruction, and preoperative activity level correlate with the degree of cartilage injury seen intraoperatively. METHODS: A retrospective review of skeletally immature patients who underwent ACL reconstruction was performed. Patients were stratified based on the time from injury to diagnosis (≤6 vs. >6 wk), diagnosis to surgery (≤6 vs. >6 wk), and injury to surgery (≤12 vs. >12 wk). Weight-bearing status, brace usage, athletic participation, and meniscus tears were characterized as binary variables. Articular cartilage injury was graded on a scale of 0 to 3. Differences between groups were analyzed using the χ test. RESULTS: In total, 91 subjects with mean age of 13 years (range, 9 to 16 y) were included. In total, 71% were diagnosed within 6 weeks of injury and 40% underwent surgery within 6 weeks of diagnosis. No differences were found in the presence of medial or lateral meniscus tears or the grade of articular cartilage damage when groups were analyzed by time from injury to diagnosis, diagnosis to surgery, and injury to surgery (P>0.05 in all cases). When stratified by weight-bearing status, brace status, and athletic activity, there were no significant differences between groups for meniscal tears or cartilage injury in any compartment (P>0.05). CONCLUSIONS: Diagnosis of ACL rupture within 6 weeks of injury and surgical reconstruction within 6 weeks of diagnosis or 12 weeks of injury do not appear to affect the rate of cartilage injury in skeletally immature patients. Weight-bearing status, brace use, and participation in athletic activities between the time of injury and diagnosis also did not impact the rate of intra-articular injury following ACL tear. LEVEL OF EVIDENCE: Level IV.

Anterior cruciate ligament tear induces a sustained loss of muscle fiber force production.

INTRODUCTION: Patients with anterior cruciate ligament (ACL) tears have persistent quadriceps strength deficits that are thought to be due to altered neurophysiological function. Our goal was to determine the changes in muscle fiber contractility independent of the ability of motor neurons to activate fibers. METHODS: We obtained quadriceps biopsies of patients undergoing ACL reconstruction, and additional biopsies 1, 2, and 6 months after surgery. Muscles fiber contractility was assessed in vitro, along with whole muscle strength testing. RESULTS: Compared with controls, patients had a 30% reduction in normalized muscle fiber force at the time of surgery. One month later, the force deficit was 41%, and at 6 months the deficit was 23%. Whole muscle strength testing demonstrated similar trends. DISCUSSION: While neurophysiological dysfunction contributes to whole muscle weakness, there is also a reduction in the force generating capacity of individual muscle cells independent of alpha motor neuron activation. Muscle Nerve, 2018.

Open versus arthroscopic Latarjet procedures for the treatment of shoulder instability: a systematic review of comparative studies.

BACKGROUND: The arthroscopic and open Latarjet procedures are both known to successfully treat shoulder instability with high success rates. The objective of this study was to compare the clinical outcomes and positioning of the coracoid graft and screws between the arthroscopic and open Latarjet procedures. METHODS: The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies between database creation and 2018. Only studies directly comparing open and arthroscopic Latarjet procedures were included. RESULTS: There were 8 included studies, with a total of 580 patients treated arthroscopically and 362 patients treated with an open Latarjet procedure. Several papers found significantly better standardized outcome scores for either the open or arthroscopic procedure but these findings were not consistent across papers. Patients treated with arthroscopic Latarjet procedures had significantly lower initial post-operative pain, however pain scores became equivalent by one month post-operatively. Three of the five included studies found no significant difference in the coracoid graft positioning and two of three included studies found no significant difference in screw divergence angles between the two techniques. Arthroscopic procedures (112.2 min) appear to take, on average, longer than open procedures (93.3 min). However, operative times and complication rates decrease with surgeon experience with the arthroscopic procedure. Overall 3.8% of the patients treated arthroscopically and 6.4% of the patients treated with the open procedure went on to have post-operative complications. CONCLUSIONS: Both open and arthroscopic Latarjet procedures can be used to effectively treat shoulder instability with similarly low rates of complications, recurrent instability and need for revision surgery. Arthroscopic Latarjet procedures are associated with less early post-operative pain but require increased operative time. The evidence does not support there being any significant difference in graft or screw positioning between the two techniques. At this time neither procedure shows clear superiority over the other.