Decreased Hip Labral Width Measured via Preoperative Magnetic Resonance Imaging Is Associated With Inferior Outcomes for Arthroscopic Labral Repair for Femoroacetabular Impingement.

PURPOSE: To determine the association between labral width as measured on preoperative magnetic resonance imaging (MRI) and hip-specific validated patient self-reported outcomes at a minimum of 2 years' follow-up. METHODS: We performed an institutional review board-approved retrospective review of prospectively gathered hip arthroscopy patients from 2010 to 2017. The inclusion criteria were defined as patients aged 18 to 65 years with radiographic evidence of femoroacetabular impingement who underwent a primary labral repair and had a minimum of 2 years' clinical follow-up. The exclusion criteria were defined as inadequate preoperative imaging, prior hip surgery, Tönnis grade 1 or higher, or lateral center-edge angle lower than 25°. An a priori power analysis was performed. MRI measurements of labral width were conducted by 2 blinded, musculoskeletal fellowship-trained radiologists at standardized "clock-face" locations using a previously validated technique. Outcomes were assessed using the Harris Hip Score (HHS), modified Harris Hip Score (mHHS), and Non-arthritic Hip Score (NAHS). For the mHHS, scores of 8 and 74 were used to define the minimal clinically important difference and patient acceptable symptomatic state, respectively. Patients were divided into groups by a labral width less than 1 SD below the mean (hypoplastic) or widths above 1 SD below the mean. Statistical analysis was performed using linear and polynomial regression; the Mann-Whitney U, χ2, and Fisher exact tests; and intraclass correlation coefficient testing. RESULTS: A total of 103 patients (107 hips) met the inclusion criteria (mean age, 39.4 ± 17 years; body mass index, 25.0 ± 4; 51% right sided; 68% female patients; mean follow-up, 76.5 ± 19.1 months [range, 30.0-113.0 months]). Mean labral width at the 11:30 clock-face position (indirect rectus), 3-o'clock position (psoas U), and 1:30 clock-face position (point halfway between the 2 aforementioned positions) was 7.1 ± 2.2 mm, 7.0 ± 2.0 mm, and 5.5 ± 1.9 mm, respectively. Intraclass correlation coefficient agreements were good to excellent between readers at all positions (0.83-0.91, P < .001). The preoperative HHS, mHHS, and NAHS were not statistically significantly different (P > .05) between the 2 groups. Sex, laterality, and body mass index were not predictive of outcomes (P > .05). The postoperative HHS, mHHS, and NAHS were found to be significantly lower in the hypoplastic group at each location tested (P < .01), including the mHHS at the 11:30 clock-face position (69 vs 87), 3-o'clock position (70 vs 87), and 1:30 clock-face position (71 vs 87). The proportion of patients with hypoplastic labra who reached the minimal clinically important difference was significantly lower (P < .001) at the 11:30 clock-face position (50% vs 91%), 3-o'clock position (56% vs 90%), and 1:30 clock-face position (58% vs 91%) in comparison to the non-hypoplastic labrum group. The proportion of patients with hypoplastic labra above the patient acceptable symptomatic state was significantly lower (P < .001) at the 11:30 clock-face position (44% vs 83%), 3-o'clock position (37.5% vs 84%), and 1:30 clock-face position (42% vs 85%) in comparison to the non-hypoplastic labrum group. Linear regression modeling was not significant at any position (P > .05). Polynomial regression was significant at the 11:30 clock-face position (R2 = 0.23, P < .001), 3-o'clock position (R2 = 0.17, P < .001), and 1:30 clock-face position (R2 = 0.26, P < .004). CONCLUSIONS: Hip labral width less than 1 SD below the mean measured via preoperative MRI was associated with significantly worse functional outcomes after arthroscopic labral repair and treatment of femoroacetabular impingement. The negative relation between labral width and outcomes may be nonlinear. LEVEL OF EVIDENCE: Level IV, case series with subgroup analysis.

Effect of Acetaminophen on Postoperative Percocet Use In Hip Arthroscopy: A Randomized Controlled Trial.

PURPOSE: To determine whether postoperative acetaminophen reduced narcotic consumption following hip arthroscopy for femoroacetabular impingement. METHODS: This was a single-center randomized controlled trial. Opioid-naïve patients undergoing hip arthroscopy for femoroacetabular impingement were randomized into 2 groups. The control group received our institution's standard of care for postoperative pain control, 28 tablets of 5 mg/325 mg oxycodone-acetaminophen prescribed as 1 to 2 tablets every 6 hours as needed for pain, whereas the treatment group were prescribed 650 mg acetaminophen every 6 hours for pain, with 5 mg/325 mg oxycodone-acetaminophen prescribed for breakthrough pain. Patients were instructed to be mindful of taking no more than 3 g of acetaminophen in a 24-hour limit. If this limit was reached, oxycodone 5 mg would be prescribed. They were contacted daily and asked to report opioid use as well as their level of pain using the visual analog pain scale. RESULTS: Our institution enrolled 86 patients, 80 of whom completed the study (40 control, 40 treatment). There were no statistically significant differences with respect to patient demographics and patient-specific factors between groups (age at time of surgery, sex, American Society of Anesthesiologists classification, or body mass index). In addition, there was no statistically significant difference with respect to visual analog scale pain between groups preoperatively (P = .64) or at 1-week follow up (P = .39). The treatment group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (6.325 pills treatment vs 5.688 pills control, P = .237). CONCLUSIONS: The findings of this randomized controlled trial suggest that postoperative acetaminophen may have no effect on reducing the number of narcotic pills consumed by opioid-naïve patients following hip arthroscopy in the setting of reduced opioid-prescribing on the part of orthopaedic surgeons. Furthermore, the results of this study suggest surgeons may reduce postoperative narcotic prescribing without reducing patient satisfaction following hip arthroscopy. LEVEL OF EVIDENCE: II randomized control trial.

Tranexamic Acid Has No Effect on Postoperative Hemarthrosis or Pain Control After Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft: A Double-Blind, Randomized, Controlled Trial.

PURPOSE: The purpose of this double-blind, randomized, controlled trial was to evaluate the use of intravenous (IV) tranexamic acid (TXA) in patients undergoing primary bone-patellar tendon-bone (BPTB) anterior cruciate ligament reconstruction (ACLR) regarding postoperative hemarthrosis, pain, opioid consumption, and quadriceps atrophy and activation. METHODS: A controlled, randomized, double-blind trial was conducted in 110 patients who underwent ACLR with BPTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-g boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated and the volume of blood (in milliliters) was recorded. Additionally, we recorded perioperative blood loss (in milliliters); visual analog scale scores on postoperative days 1, 4, and 7 and at postoperative weeks 1, 6, and 12; postoperative opioid consumption on postoperative days 1, 4, and 7; range of motion (ROM) and ability to perform a straight leg raise at postoperative weeks 1, 6, and 12; and preoperative and postoperative thigh circumference ratio. RESULTS: There was no significant difference in perioperative blood loss between the TXA and control groups (32.5 mL vs 35.6 mL, P = .47). In the TXA group, 23 knees were aspirated; in the control group, 26 knees were aspirated (P = .56). No significant difference in postoperative hemarthrosis volume was seen in patients who received IV TXA versus those who did not (26.7 mL vs 37.3 mL, P = .12). There was no significant difference in visual analog scale scores between the 2 groups (P = .15); in addition, there was no difference in postoperative opioid consumption (P = .33). No significant difference in ROM, ability to perform a straight leg raise, or postoperative thigh circumference ratio was observed (P > .05 for all). CONCLUSIONS: IV TXA in patients who undergo ACLR with BPTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early postoperative recovery regarding ROM or quadriceps reactivation. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Clinical Outcomes of Hip Arthroscopy in Patients With Systemic Inflammatory Diseases Compared With Matched Controls at a Minimum of 2-Year Follow-Up.

PURPOSE: To evaluate postoperative outcomes and preoperative risk factors for patients with underlying systemic inflammatory disorders after hip arthroscopy. METHODS: A retrospective analysis of patients who had undergone hip arthroscopy, with a history of systemic inflammatory disease, was performed. This included patients with a diagnosis of lupus, a positive antinuclear antibody test, rheumatoid arthritis, psoriatic arthritis, sarcoidosis, inflammatory bowel disease, Reiter syndrome, and mixed connective tissue disease. These cases were 1:2 matched to a control group of patients with no history of systemic inflammatory disease based on age and sex. An a priori power analysis was conducted and A 1:2 case-control ratio was selected to increase study power. Inclusion criteria included all skeletally mature patients with hip pain refractory to nonoperative management who underwent hip arthroscopy for labral tears and femoroacetabular impingement. Skeletally immature patients, those with Tönnis grades of 2 or more (less than 2 mm of joint space), hip dysplasia, patients undergoing revision hip arthroscopy, and patients whose pain failed to improve after intra-articular injection were excluded. The primary outcome was rate of revision hip arthroscopy or total hip arthroplasty 24 months after surgery. Secondary outcomes included 2 patient-reported outcome scores, the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). RESULTS: Twenty patients (21 hip arthroscopy procedures) and 42 controls were included. There was no significant difference in proportion of patients who met failure criteria (28.6% vs 16.7%, P = .271) or 2-year survivorship (76.2% vs 83.3%, P = .496) between the systemic inflammatory disorder and control groups, respectively. Both groups had a significant improvement in mHHS and NAHS at 24 months compared with baseline; however, there was no significant difference in mHHS (P = .28) or NAHS (P = .22) at 24 months between the 2 groups. CONCLUSIONS: Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared with patients with no history of inflammatory disease. LEVEL OF EVIDENCE: III, retrospective comparative study.

Incorporating Biologics Into Your Practice: The New Horizon in Sports Medicine.

Orthobiologics continue to be one of the most discussed and trending topics in orthopaedic surgery today. Pathology of tendons, ligaments, bone, cartilage, and meniscal tissue are all theoretically treatable with biologics. Ultimately, the hope for biologics is to provide symptom relief and improve tissue healing with the potential to treat some conditions without the need for surgery. It is important to review the current state of biologic therapies available for musculoskeletal disease, discuss government regulations and barriers to use, and, finally, examine current research in biologics and what the future may hold.

Patient-Reported Outcome Measures are not a Valid Proxy for Patient Satisfaction in Total Joint Arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly used as quality benchmarks in total joint arthroplasty. The objective of this study is to investigate whether PROMs correlate with patient satisfaction, which is arguably the most important and desired outcome. METHODS: Our institutional joint database was queried for patients who underwent primary, elective, unilateral total joint arthroplasty. Eligible patients were asked to complete a satisfaction survey at final follow-up. Correlation coefficients (R) were calculated to quantify the relationship between patient satisfaction and prospectively collected PROMs. We explored a wide range of PROMs including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Oxford Hip Score, Knee Society Clinical Rating Score (KSCRS), Single Assessment Numerical Evaluation, and University of California Los Angeles activity level rating. RESULTS: In general, there was only weak to moderate correlation between patient satisfaction and PROMs. Querying the absolute postoperative scores had higher correlation with patient satisfaction compared to either preoperative scores or net changes in scores. The correlation was higher with disease-specific PROMs (WOMAC, Oxford Hip Score, KSCRS) compared to general health (Short Form-12), activity level (University of California Los Angeles activity level rating), or perception of normalcy (Single Assessment Numerical Evaluation). Within disease-specific PROMs, the pain domain consistently carried the highest correlation with patient satisfaction (WOMAC pain subscale, R = 0.45, P < .001; KSCRS pain subscale, R = 0.49, P < .001). CONCLUSION: There is only weak to moderate correlation between PROMs and patient satisfaction. PROMs alone are not the optimal way to evaluate patient satisfaction. We recommend directly querying patients about satisfaction and using shorter PROMs, particularly disease-specific PROMs that assess pain perception to better gauge patient satisfaction.

Editorial Commentary: Sprinkle Some Pixie Dust on It-Are We Really Any Better at Understanding the Benefits of Platelet-Rich Plasma for Rotator Cuff Pathology?

Platelet-rich plasma is used for the treatment of musculoskeletal ailments including rotator cuff pathology with mixed outcomes. Varied cytology and leukocyte counts within platelet-rich plasma may influence the results. The impact of this biological therapy on rotator cuff disease management is poorly understood.

Real-Time Assessment of Femoroacetabular Motion Using Radial Gradient Echo Magnetic Resonance Arthrography at 3 Tesla in Routine Clinical Practice: A Pilot Study.

PURPOSE: To compare femoroacetabular motion in a series of consecutive symptomatic patients with hip pain throughout the range of motion of the hip using a real-time radial gradient echo (GRE) sequence in addition to the routine hip protocol sequences for magnetic resonance (MR) arthrographic assessment of patients with and without clinical femoroacetabular impingement (FAI) syndrome. In particular, we sought to assess whether the additional dynamic sequence could differentiate between patients with and without a positive physical exam maneuver for FAI syndrome. METHODS: Patients with hip pain referred for conventional hip MR arthrogram including those with and without a positive physical exam maneuver for FAI syndrome were imaged using routine hip MR arthrogram protocol and an additional real-time radial 2-dimensional GRE acquisition at 3 Tesla in an axial oblique plane with continuous scanning of a 9 mm thick slice through the center of the femoral head-neck axis. Patients who were unable to move through the range of motion were excluded (n = 3). Patients with acetabular dysplasia (defined by a lateral center-edge angle [CEA] of 20°) were also excluded, as were patients had Kellgren and Lawrence scores of > 0. The real-time cine sequence was acquired with the patient actively moving through neutral, flexion, flexion-abduction external-rotation, and flexion-adduction internal rotation (FADIR) positions aiming for 40° of abduction, then 25° of adduction at 80° to 90° flexion. Due to the placement of the coil over the hip, a true FADIR was precluded. Images were evaluated independently by 2 musculoskeletal radiologists measuring the joint space in the anterior, central, and posterior positions at each point during range of motion for femoroacetabular cortical space (FACS). Anterior FACS narrowing was calculated as the ratio of joint space in FADIR:neutral position, with lower ratios indicating greater narrowing. Static metrics including alpha angle, CEA, grade of cartilage loss according the Outerbridge classification, and patient demographics were also recorded. RESULTS: Twenty-two painful hips in 22 patients (11 males and 11 females) with mean age 36 years (range, 15-67) were included. Twelve patients had a positive physical exam maneuver for FAI syndrome. The time to perform the dynamic sequence was 3 to 6 minutes. Interobserver agreement was strong, with intraclass correlation 0.91 and concordance correlation 0.90. According to results from both readers, patients with impingement on clinical exam had significantly lower anterior FACS ratios compared with those without clinical impingement (reader 1: 0.39 ± 0.10 vs 0.69 ± 0.20, P = .001; reader 2: 0.36 ± 0.07 vs 0.70 ± 0.17, P < .001). Decreased anterior FACS ratio was found to be significantly correlated to increased alpha angle by both readers (reader 1: R = -0.63, P = .002; reader 2: R = -0.67, P = .001) but not significantly correlated to CEA (reader 1: R = 0.13, P = .561; reader 2: R = 0.20, P = .378) or cartilage loss (reader 1: R = 0.03, P = .885; reader 2: R = -0.06, P = .784). Both readers found patients with an anterior FACS ratio of 1/2 to have significantly higher mean alpha angle (reader 1: 62.88 vs 52.79, P = .038; reader 2: 63.50 vs 50.58, P = .006); however, there were no significant differences in cartilage loss (reader 1: P = .133; reader 2: P = .882) or CEA (reader 1: P = .340; reader 2: P = .307). CONCLUSIONS: A dynamic radial 2-dimensional-GRE sequence can be added to standard hip MR arthrogram protocols in <6 minutes, allowing assessment of dynamic femoroacetabular motion with strong interreader agreement. Patients with impingement on clinical exam had significantly lower anterior FACS ratios between FADIR and neutral positions, compared with those without clinical impingement. LEVEL OF EVIDENCE: Level III, comparative diagnostic investigation.

Patient Dissatisfaction After Primary Total Joint Arthroplasty: The Patient Perspective.

BACKGROUND: Despite improvements in surgical technique and implant longevity, some patients continue to report dissatisfaction after total joint arthroplasty (TJA). As patient satisfaction is increasingly used as a quality metric, the objective of this study was to gain better understanding of satisfaction with total joint arthroplasty from the patient perspective. METHODS: Five hundred fifty-one primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a minimum of 1-year follow-up and were responsive to a satisfaction survey were analyzed. The incidence, predictive factors, and subjective reasoning for patient dissatisfaction were assessed. Univariate and multivariate logistic regression analyses were performed. RESULTS: Patient satisfaction was 89% for THA and 88% for TKA. Hispanic race was the most significant predictor of dissatisfaction (P = .037). The most common reasons for dissatisfaction after THA were persistent pain (N = 14/34, 41%), functional limitation (N = 12/34, 35%), surgical complication and reoperation (N = 4/34, 12%), staff or quality of care issues (N = 2/34, 6%), and slow recovery (N = 2/34, 6%). The most common reasons for dissatisfaction after TKA were persistent pain (N = 19/46, 41%), functional limitation (N = 12/46, 26%), surgical complication and reoperation (N = 8/46, 17%), staff or quality of care issues (N = 5/46, 11%), and unmet expectations (N = 2/46, 4%). CONCLUSION: While persistent pain and functional limitation are the 2 leading reasons for dissatisfaction in both TKA and THA, a subset of patients view satisfaction as an evaluation of the process by which care is delivered. Patient satisfaction is not solely a reflection of surgical outcome and should be interpreted with caution. Potential for incomplete pain relief or full functional recovery should be discussed during preoperative counseling. Empathic care is also important and should be encouraged to enhance the overall patient experience.

Tobacco Smoking Independently Predicts Lower Patient-Reported Outcomes: New Insights on a Forgotten Epidemic.

BACKGROUND: Although smoking is a well-accepted risk factor for surgical complications, the effect of smoking on patient-reported outcomes (PROs) has not been previously investigated. Prompted by an increasingly value-conscious healthcare environment, the purpose of this study is to investigate the association between smoking and PROs in total joint arthroplasty (TJA). METHODS: A retrospective review of 713 primary total hip and knee replacements was performed. Two cohorts were compared: (1) current smokers and (2) previous/never smokers at the time of TJA. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short Form-12 Physical Composite Summary (SF-12 PCS) and Short Form-12 Mental Composite Summary were assessed preoperatively and again at 6 and 12 months postoperatively. The primary outcomes were the net changes and absolute outcome scores at final follow-up. Postoperative patient satisfaction was also assessed as a secondary outcome. Linear mixed-effects regression analysis was performed. RESULTS: There were significant demographic and preoperative health disparities as measured by PROs among smokers. After adjusting for baseline differences, smokers achieved significantly lower improvements in WOMAC (P = .002) and SF-12 PCS (P = .03) compared to nonsmokers. For each unit increase in packs per day smoked, the WOMAC scores increased (worsened) by 7.7 points (P = .003) and SF-12 PCS decreased by 4.8 points (P = .001). At final follow up, nonsmokers had significantly better absolute scores for all outcomes (except for mental health) and were more likely to be satisfied with surgery (89% vs 82%, P = .052). CONCLUSION: Tobacco smoking is an independent predictor for lower PROs after TJA and this relationship is dose-dependent. The negative impact of smoking does not appear to be related to impaired psychological health. As we transition to value-based care delivery models, this study provides further evidence that smoking cessation should be strongly recommended as a modifiable risk factor before embarking on elective TJA. Studies are still needed to define the optimal window for smoking cessation.

Potent antitumor effects of combination therapy with IFNs and monocytes in mouse models of established human ovarian and melanoma tumors.

Interferon-activated monocytes are known to exert cytocidal activity against tumor cells in vitro. Here, we have examined whether a combination of IFN-α2a and IFN-γ and human monocytes mediate significant antitumor effects against human ovarian and melanoma tumor xenografts in mouse models. OVCAR-3 tumors were treated i.t. with monocytes alone, IFN-α2a and IFN-γ alone or combination of all three on day 0, 15 or 30 post-tumor implantation. Mice receiving combination therapy beginning day 15 showed significantly reduced tumor growth and prolonged survival including complete regression in 40% mice. Tumor volumes measured on day 80 in mice receiving combination therapy (206 mm(3)) were significantly smaller than those of mice receiving the IFNs alone (1,041 mm(3)), monocytes alone (1,111 mm(3)) or untreated controls (1,728 mm(3)). Similarly, combination therapy with monocytes and IFNs of much larger tumor also inhibited OVCAR-3 tumor growth. Immunohistochemistry studies showed a large number of activated macrophages (CD31(+)/CD68(+)) infiltrating into OVCAR-3 tumors and higher densities of IL-12, IP10 and NOS2, markers of M1 (classical) macrophages in tumors treated with combination therapy compared to the controls. Interestingly, IFNs-activated macrophages induced apoptosis of OVCAR-3 tumor cells as monocytes alone or IFNs alone did not mediate significant apoptosis. Similar antitumor activity was observed in the LOX melanoma mouse model, but not as profound as seen with the OVCAR-3 tumors. Administration of either mixture of monocytes and IFN-α2a or monocytes and IFN-γ did not inhibit Lox melanoma growth; however, a significant inhibition was observed when tumors were treated with a mixture of monocytes, IFN-α2a and IFN-γ. These results indicate that monocytes and both IFN-α2a and IFN-γ may be required to mediate profound antitumor effect against human ovarian and melanoma tumors in mouse models.

MRI of superior capsular reconstruction graft and associated short-term clinical outcomes in patients with massive irreparable rotator cuff tears.

OBJECTIVE: To assess MRI appearance of the dermal allograft and its correlation with clinical outcome following superior capsular reconstruction (SCR). MATERIALS AND METHODS: This is a retrospective study of patients who underwent SCR between 2015 and 2018. Patients with postoperative MRI and clinical follow-up were included. Exclusion criteria were preoperative shoulder instability, advanced glenohumeral arthritis, and lack of postoperative MRI or clinical follow-up. Radiographs and MRIs were evaluated for graft integrity and position, acromiohumeral interval, superior subluxation distance (SSD), and glenohumeral cartilage loss. Correlation between imaging and clinical outcome measures were assessed. RESULTS: 24 shoulders (23 patients) met the inclusion criteria at a mean clinical and MRI follow-up of 9.1 months. There were 12 intact grafts (50%) and 12 torn grafts (50%), most commonly at the glenoid attachment (8/12). Patients with graft tear had greater SSD (mean 10.5 ± 6.1 mm) than those without tear (mean 6.1 ± 3.8 mm) (p = 0.028). SSD > 7.9 mm had a 79% sensitivity and 91% specificity for graft tear. The intact grafts were more commonly covering the superior humeral head (91.7%) compared with the torn grafts (41.7%) (p = 0.027). There was improvement of clinical outcome measures including American Shoulder and Elbow Surgeons score (p = 0.005) and forward elevation (p = 0.021) although there was no correlation between clinical outcome and integrity of the graft. CONCLUSION: SCR results in significant short-term clinical improvement even in the presence of graft tear on postoperative MRIs on current study. Gap between graft and the anchors, non-superior position of the graft, and humeral head superior subluxation can be associated with tear.

There is direct relationship between bone bridge length and coracoclavicular fixation resistance to failure: Biomechanical study in a porcine model.

BACKGROUND: This study aims to evaluate the relation between coracoclavicular resistance to failure and the distance between clavicular tunnels. The hypothesis is that a greater clavicular bone bridge between tunnels achieves a stronger coracoclavicular fixation. METHODS: Descriptive Laboratory Study. Thirty-six (36) coracoclavicular models were constructed utilizing porcine metatarsals. Coracoclavicular stabilizations were performed using a subcoracoid loop fixation configuration through two clavicular tunnels, tied at the clavicle's superior cortex using a locking knot. Models were randomly assigned to 1 of 3 experimental groups of variable bone bridge length between clavicular tunnels: 5 mm, 10 mm, and 15 mm. Each group had 12 models. Fixation resistance was assessed through the ultimate failure point under an axial load to failure trial. Failure patterns were documented. A one-way ANOVA test was used, and a Tukey post hoc as needed (P < 0.05). FINDINGS: Mean strength per bone bridge length: 5 mm = 312 N (Range: 182-442 N); 10 mm = 430 N (Range: 368-595 N); 15 mm = 595 N (Range: 441-978 N). The 15 mm group had a significantly higher ultimate failure point than the other two groups: 5 mm (P < 0.001) and 10 mm (P < 0.001). All fixations systematically failed by a superior cortex clavicle fracture at the midpoint between tunnels. INTERPRETATION: A direct relationship between bone bridge length and coracoclavicular resistance to failure was demonstrated, being the 15 mm length a significantly higher strength construct in a tied loop model.

Distance of the Posterior Interosseous Nerve From the Bicipital (Radial) Tuberosity at Varying Positions of Forearm Rotation: A Magnetic Resonance Imaging Study With Clinical Implications.

BACKGROUND: The proximity of the posterior interosseous nerve (PIN) to the bicipital tuberosity is clinically important in the increasingly popular anterior single-incision technique for distal biceps tendon repair. Maximal forearm supination is recommended during tendon reinsertion from the anterior approach to ensure the maximum protective distance of the PIN from the bicipital tuberosity. PURPOSE: To compare the location of the PIN on magnetic resonance imaging (MRI) relative to bicortical drill pin instrumentation for suspensory button fixation via the anterior single-incision approach in varying positions of forearm rotation. STUDY DESIGN: Descriptive laboratory study. METHODS: Axial, non-fat suppressed, T1-weighted MRI scans of the elbow were obtained in positions of maximal supination, neutral, and maximal pronation in 13 skeletally mature individuals. Distances were measured from the PIN to (1) the simulated path of an entering guidewire (GWE-PIN) and (2) the cortical starting point of the guidewire on the bicipital tuberosity (CSP-PIN) achievable from the single-incision approach. To radiographically define the location of the nerve relative to constant landmarks, measurements were also made from the PIN to (3) the prominent-most point on the bicipital tuberosity (BTP-PIN) and (4) a perpendicular plane trajectory from the bicipital tuberosity exiting the opposing radial cortex (PPT-PIN). All measurements were subsequently compared between positions of pronation, neutral, and supination. In supination only, BTP-PIN and PPT-PIN measurements were made and compared at 3 sequential axial levels to evaluate the longitudinal course of the nerve relative to the bicipital tuberosity. RESULTS: Of the 13 study participants, mean age was 38.77 years, and mean body mass index was 25.58. Five participants were female, and 5 left and 8 right elbow MRI scans were reviewed. The GWE-PIN was significantly greater in supination (mean ± SD, 16.01 ± 2.9 mm) compared with pronation (13.66 ± 2.5 mm) (P < .005). The mean CSP-PIN was significantly greater in supination (16.20 ± 2.8 mm) compared with pronation (14.18 ± 2.4 mm) (P < .013).The mean PPT-PIN was significantly greater in supination (9.00 ± 3.0 mm) compared with both pronation (1.96 ± 1.2 mm; P < .001) and neutral (4.73 ± 2.6 mm; P < .001). The mean BTP-PIN was 20.54 ± 3.0, 20.81 ± 2.7, and 20.35 ± 2.9 mm in pronation, neutral, and supination, respectively, which did not significantly differ between positions. In supination, the proximal, midportion, and distal measurements of BTP-PIN did not significantly differ. The proximal PPT-PIN distance (9.08 ± 2.9 mm) was significantly greater than midportion PPT-PIN (5.85 ± 2.4 mm; P < .001) and distal BTP-PIN (2.27 ± 1.8 mm; P < .001). CONCLUSION: This MRI study supports existing evidence that supination protects the PIN from the entering guidewire instrumentation during anterior, single-incision biceps tendon repair using cortical button fixation. The distances between the entering guidewire trajectory and PIN show that guidewire-inflicted injury to the nerve is unlikely during the anterior single-incision approach. CLINICAL RELEVANCE: When a safe technique is used, PIN injuries during anterior repair are likely the result of aberrant retractor placement, and we recommend against the use of retractors deep to the radial neck. Guidewire placement as close as possible to the anatomic footprint of the biceps tendon is safe from the anterior approach. MRI evaluation confirms that ulnar and proximal guidewire trajectory is the safest technique when using single-incision bicortical suspensory button fixation.

Day-of-Surgery Video Calls and Phone Calls Increase Patient Satisfaction with Outpatient Surgery Experience: A Randomized Controlled Trial of Postoperative Communication Modalities.

BACKGROUND: With the increasing utilization of patient satisfaction as a metric for clinical care, there is growing interest in techniques that can be used to improve satisfaction in patients undergoing surgery. The purpose of this trial was to assess the impact of day-of-surgery video and phone calls on patient satisfaction. METHODS: We enrolled 251 patients undergoing outpatient orthopaedic surgery with 3 participating surgeons. Surgeons were randomized to 1 of 3 patient communication modalities: no contact (standard of care), phone call, or video call. Several hours following discharge on the day of surgery, the surgeons contacted patients according to their assigned treatment group. At the initial postoperative office visit, satisfaction outcomes were assessed using the Consumer Assessment of Healthcare Providers and Systems Surgical Care (S-CAHPS) survey and an additional satisfaction questionnaire. RESULTS: Fifty-nine (97%) of 61 patients in the no-contact group, 118 (99%) of 119 patients in the phone group, and 71 (100%) of 71 patients in the video group completed follow-up assessment. The S-CAHPS top-box response rate in both the video group (0.86 ± 0.14, p < 0.001) and the phone group (0.84 ± 0.17, p < 0.001) was greater than in the no-contact group (0.68 ± 0.26). When asked to rate satisfaction with overall care, a greater proportion of patients in the video group (85.9%) gave the top-box response compared with both the phone group (71.8%, p = 0.040) and the no-contact group (60.7%, p = 0.002). Among the patients in the video group, 62.0% indicated that they would prefer a video call in future encounters with their surgeon compared with 1.8% of patients in the no-contact group (p < 0.001) and 1.7% of patients in the phone group (p < 0.001). CONCLUSIONS: Phone and video calls following discharge are an effective way of enhancing patient satisfaction with the clinical care experience as measured by the S-CAHPS survey. In terms of satisfaction with overall care, video calls may be superior to phone calls. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Opioid Education has No Effect on Opioid Use in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Prospective, Randomized Clinical Trial.

OBJECTIVES: The purpose of this study was to determine whether a preoperative video-based opioid education reduced narcotics consumption after arthroscopic rotator cuff repair in opioid-naive patients. METHODS: This was a single-center randomized controlled trial. Preoperatively, the control group received our institution's standard of care for pain management education, whereas the experimental group watched an educational video on the use of opioids. Patients were discharged with 30 × 5 mg/325 mg oxycodone-acetaminophen prescribed: 1 to 2 tablets every 4 to 6 hours. They were contacted daily and asked to report opioid use and visual analog scale pain. A chart review at 3 months post-op was used to analyze for opioid refills. RESULTS: A total of 130 patients completed the study (65 control and 65 experimental). No statistically significant differences were noted in patient demographics between groups (P > 0.05). Patients in the education group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (14.0 pills experimental versus 13.7 pills control, P = 0.60). No statistically significant differences were noted between groups at follow-regarding the rate of prescription refills (P > 0.05). CONCLUSION: This study suggests that preoperative video-based opioid education may have no effect on reducing the number of narcotic pills consumed after arthroscopic rotator cuff repair. CLINICAL RELEVANCE: Data exist to suggest that preoperative video-based opioid education has an effect on postoperative consumption; however, the effect of this education in the setting of already-limited opioid-prescribing is not known. CLINICALTRIALSGOV IDENTIFIER: NCT04018768.

Characterizing cam-type hip impingement in professional women's ice hockey players.

OBJECTIVE: There is a high prevalence of femoroacetabular impingement (FAI) amongst elite men's ice hockey players, yet little is known about the hips of players in the National Women's Hockey League (NWHL). The primary purpose of this study was to determine the prevalence of radiographic cam-type FAI in women's professional ice hockey players. The secondary purpose was to analyze the relationship between the cam deformity and both menarchal age and hip range-of-motion (ROM). METHODS: Data were collected for NWHL players during pre-participation physicals. Alpha angles were measured on 45° Dunn radiographs, with alpha angles >55° defined as cam-positive. Pearson correlation coefficients (ρ) were performed to analyze the relationship between alpha angle and both ROM measurements and menarchal age, with statistical significance set at p < 0.05. RESULTS: Twenty-six athletes were included. Twenty-four (92%) had alpha angles >55°; 20 players (77%) had bilateral cam deformity. Average menarchal age was 13.8 ± 1.7 years. There was a significant association between age of menarche and alpha angle (ρ = 0.36, p < 0.02). There was no significant association between alpha angle and hip ROM (p > 0.05). CONCLUSION: Elite women's ice hockey players have a higher prevalence of cam-type morphology than the general population. The positive association between alpha angle and menarchal age lends additional support to the etiological hypothesis of the cam lesion resulting from activity-related stress at the proximal femoral physis during skeletal development. Professional women's ice hockey players have a high risk of developing cam-type morphology, although each player's menarchal age may mediate her individual risk for cam development.

Does Concomitant Lumbar Spine Disease Adversely Affect the Outcomes of Patients Undergoing Hip Arthroscopy?

BACKGROUND: The practice of hip arthroscopy is increasing in popularity, which has highlighted the importance of identifying risk factors that predict hip arthroscopy outcomes. The literature suggests that lumbar spine disease is an independent risk factor for poorer outcomes following total hip arthroplasty; however, the effect of lumbar spine disease on hip arthroscopy outcomes has not been fully investigated. At present, there is a paucity of literature investigating the effect of coexisting hip and lumbar spine disease on outcomes after hip arthroscopy. PURPOSE: To evaluate the outcomes of hip arthroscopy in patients with concomitant lumbar spine disease compared with those without a history of lumbar spine disease. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of a prospectively collected, single-surgeon database was performed to identify patients who underwent hip arthroscopy with subjective and objective evidence of lumbar disease. Patients were included if they were skeletally mature; had hip disease that failed nonoperative treatment; had symptoms of low back pain, lumbar radiculopathy, or lumbar stenosis at the time of surgery; and had advanced imaging of the lumbar spine (computed tomography or magnetic resonance imaging) confirming lumbar spine disease. Patients were excluded if they had any previous hip surgery or evidence of osteoarthritis of Tönnis grade 2 or higher. The hip-spine cohort was matched by age, sex, and body mass index in a 1:3 fashion to a control cohort consisting of patients without symptoms of low back pain, lumbar radiculopathy, or lumbar stenosis at the time of surgery or a history of lumbar spine disease who underwent hip arthroscopy over the same time period. Baseline preoperative modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were compared with scores at 3-, 6-, 12-, and 24-month follow-up, and rates of revision arthroscopy or total hip arthroplasty were assessed. Statistical analysis was performed with the Student t test. RESULTS: A total of 38 patients with radiographically confirmed lumbar disease were matched with 111 control patients. Preoperative mHHS and NAHS were significantly lower in the hip-spine cohort (P = .01 and P = .02, respectively); however, no significant differences were found in mHHS or NAHS between the cohorts at 3, 6, 12, and 24 months postoperatively. A 89.8% increase in mHHS was found in the hip-spine cohort, compared with a 74.4% increase in the control cohort (P = .0475). No significant differences in the rates of revision or total hip arthroplasty conversion were identified between the hip-spine and control cohorts (23.7% vs 18.0%, respectively; P = .44). CONCLUSION: Patients with known lumbar spine disease who underwent hip arthroscopy had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, and outcomes were ultimately not significantly different. No increased risk of reoperation was noted in patients with concomitant lumbar spine disease.

Clinical and Biomechanical Outcomes following Knee Extensor Mechanism Reconstruction.

PURPOSE: To evaluate clinical and biomechanical outcomes after knee extensor mechanism reconstruction (KEMR). METHODS: Patients who underwent KEMR at our institution from 2011 to 2018 were identified. Patient-reported outcomes (Kujala, Lysholm, Tegner Activity Scale) were compiled at clinical follow-up. Isokinetic testing was conducted using the BioDex system 4 pro dynamometer at slow (60°/s), intermediate (180°/s), and fast (300°/s) speeds in a 9-patient subset. RESULTS: From 2011 to 2018, 12 patients (12 knees, 10 male, 5 right, mean age: 54.3 ± standard deviation: 15.2 years) with KEM injuries requiring tendon reconstruction with a 1-year minimum follow up were identified. Postoperative follow-up was 42.6 months (range: 12.0-93.0 months). Procedures included patellar (7) and quadriceps tendon reconstruction (5). Postoperative versus preoperative Tegner Activity Scale scores demonstrated significant improvement (3.5 ± 2.5 vs 1.5 ± 1.2, n = 8, P = .05). Postoperative versus preoperative Kujala scores significantly improved (70.3 ± 11.7 vs 43.6 ± 15.7, n = 8, P = .010). There was significant improvement in preoperative to postoperative KEMR extension lag (29.4 ± 22.2° vs 0.83 ± 1.9°, P = .002). Clinically, there was no difference in passive range of motion between the operative and contralateral knee. BioDex testing demonstrated decreased maximum work generated from the operative versus contralateral knee at slow (70.4 ± 30.4 Joules vs 101.9 ± 40.6 J; P = .028), intermediate (52.0 ± 45.4 J vs 69.8 ± 63.7 J; P = .038), and fast (43.8 ± 41.7 J vs 57.5 ± 53.8 J; P = .050) speeds. Range of motion was less in the operative versus contralateral knee at all speeds: P = .011, .038, and .024. The average peak torque generated per body weight was smaller in the operative versus contralateral knee at slow speed (P = .038). CONCLUSIONS: Patients undergoing KEMR in this study have significantly improved clinical outcomes despite having strength deficits that persist postoperatively. LEVEL OF EVIDENCE: Therapeutic Case Series, Level IV.