Editorial Commentary: Arthroscopic Hip Labral Preservation Combined With Bony Correction and Capsular Closure Results in Improved Patient Outcomes.

Hip labral reconstruction aims to replace an irreparable or insufficient labrum with the goal of restoring the native function of the labrum and thus contribute to hip preservation. Multiple studies have reported success and improved outcomes with labral reconstruction, both in primary and revision settings. The function of the labrum includes providing additional soft-tissue coverage of the femoral head and contributing to regulation of fluid dynamics within the hip joint through the "suction seal." Labral tears and insufficiency alter hip joint biomechanics, which could result in hip microinstability and joint degeneration. Yet, although labral reconstruction is better than a labral-deficient state, labral reconstruction does not restore native hip biomechanics when compared with the native intact labrum. However, concomitant procedures to address bony morphology, hip capsule, cartilage, and adhesions in the revision setting frequently are performed at the time of labral reconstruction, making the true effect of labral reconstruction unknown. Therefore, the labrum should be considered as one of many variables when evaluating individuals with hip pain, and surgeons who perform hip arthroscopy should ensure that appropriate patient selection and additional pathology are adequately addressed in the primary and revision settings.

Magnetic Resonance Arthrogram Outperforms Standard Magnetic Resonance Imaging 2 Weeks After First Shoulder Dislocation for Labral Tear Diagnosis.

PURPOSE: To determine the comparative accuracy and precision of routine magnetic resonance imaging (MRI) versus magnetic resonance (MR) arthrogram in measuring labral tear size as a function of time from a shoulder dislocation. METHODS: We retrospectively evaluated consecutive patients who underwent primary arthroscopic stabilization between 2012 and 2021 in a single academic center. All patients completed a preoperative MRI or MR arthrogram of the shoulder within 60 days of injury and subsequently underwent arthroscopic repair within 6 months of imaging. Intraoperative labral tear size and location were used as standards for comparison. Three musculoskeletal radiologists independently interpreted tear extent using a clock-face convention. Accuracy and precision of MR labral tear measurements were defined based on location and size of the tear, respectively. Accuracy and precision were compared between MRI and MR arthrogram as a function of time from dislocation. RESULTS: In total, 32 MRIs and 65 MR arthrograms (total n = 97) were assessed. Multivariate analysis demonstrated that intraoperative tear size, early imaging, and arthrogram status were associated with increased MR accuracy and precision (P < .05). Ordering surgeons preferred arthrogram for delayed imaging (P = .018). For routine MRI, error in accuracy increased by 3.4° per day and error in precision increased by 2.3° per day (P < .001) from time of injury. MR arthrogram, however, was not temporally influenced. Significant loss of accuracy and precision of MRI compared with MR arthrogram occurred at 2 weeks after an acute shoulder dislocation. CONCLUSIONS: Compared with MR arthrogram, conventional MRI demonstrates time-dependent loss of accuracy and precision in determining shoulder labral tear extent after dislocation, with statistical divergence occurring at 2 weeks. LEVEL OF EVIDENCE: Level II, retrospective radiographic diagnostic study.

'Real world' clinical implementation of blood flow restriction therapy does not increase quadriceps strength after quadriceps tendon autograft ACL reconstruction.

PURPOSE: To retrospectively compare strength outcomes of individuals undergoing postoperative rehabilitation following quadriceps tendon (QT) autograft anterior cruciate ligament reconstruction (ACLR) with and without blood flow restriction therapy. METHODS: A retrospective review of consecutive patients undergoing ACLR with QT autograft with a minimum of two quantitative postoperative isometric strength assessments via an electromechanical dynamometer (Biodex) was included. Demographics, surgical variables and strength measurement outcomes were compared between patients undergoing blood flow restriction therapy as part of postoperative rehabilitation versus those who did not. RESULTS: Eighty-one (81) patients met the inclusion criteria. No differences were found in demographic and surgical characteristics between those who received blood flow restriction compared with those who did not. While both groups had improvements in quadriceps peak torque and limb symmetry index (LSI; defined as peak torque of the operative limb divided by the peak torque of the nonoperative limb) over the study period, the blood flow restriction group had significantly lower mean peak torque of the operative limb at first Biodex strength measurement (95.6 vs. 111.2 Nm; p = 0.03). Additionally, the blood flow restriction group had a significantly lower mean LSI than those with no blood flow restriction at the second Biodex measurement timepoint (81% vs. 90%; p = 0.02). No other significant differences were found between the strength outcomes measured. CONCLUSIONS: Results of this study show that the 'real world' clinical implementation of blood flow restriction therapy to the postoperative rehabilitation protocol following QT autograft ACLR did not result in an increase in absolute or longitudinal changes in quadriceps strength measurements. A better understanding and standardisation of the use of blood flow restriction therapy in the rehabilitation setting is necessary to delineate the true effects of this modality on strength recovery after QT autograft ACLR. LEVEL OF EVIDENCE: Level III.

Anatomic Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament reconstruction (ACLR) techniques have substantially evolved over the past several decades, driven by evidence that nonanatomic techniques increase the risk for instability, loss of motion, surgical failure, and posttraumatic osteoarthritis. Early techniques used transtibial femoral tunnel drilling, although improved understanding of the anatomy and biomechanics has led to independent femoral tunnel. Anatomic ACLR requires careful consideration of the native ACL dimensions and orientation. Although there is significant variation between patients, understanding of anatomic patterns allows for reliable identification of the ACL footprints and appropriate tunnel positioning, particularly in chronic injuries where the remanent ACL stump is degraded or absent. The femoral tunnel should be placed low and posterior on the lateral femoral condyle using the lateral intercondylar and bifurcate ridges as landmarks. The center of the tibial footprint can be determined by referencing the medial tibial spine and posterior border of anterior horn of lateral meniscus. Measurement of the dimensions of the native ACL and intercondylar notch is also critical for determining graft size and minimizing the risk of impingement, with a goal of reconstructing 50% to 80% of the tibial footprint area. Clinical outcome studies have demonstrated superior anteroposterior and rotatory knee stability with low surgical revision rates (reported between 3% and 5%). By adhering to the principles of anatomic ACLR, surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function. The aim of this infographic is to highlight essential features of anatomic ACLR techniques, which a focus on the native anatomy and surgical planning to achieve an anatomic ACLR.

Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy.

INTRODUCTION: Indications for reverse total shoulder arthroplasty (RSA) have expanded to include individuals with intact rotator cuffs such as patients with severe glenoid deformity or with concern of future rotator cuff insufficiency. The purpose of this study was to compare outcomes of RSA with an intact rotator cuff to RSA for cuff arthropathy and anatomic total shoulder arthroplasty (TSA). We hypothesized that outcomes of RSA with an intact rotator cuff would be comparable to RSA for cuff arthropathy and TSA but with diminished range of motion (ROM) compared with TSA. MATERIALS AND METHODS: Patients at one institution who underwent RSA and TSA between 2015 and 2020 with minimum 12-month follow-up were identified. RSA with preservation of the rotator cuff (+rcRSA) was compared to RSA for cuff arthropathy (-rcRSA) and anatomic TSA (TSA). Demographics and glenoid version/inclination were obtained. Pre- and postoperative ROM; patient-reported outcomes including visual analog scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores; and complications were obtained. RESULTS: Twenty-four patients underwent +rcRSA, 69 underwent -rcRSA, and 93 underwent TSA. There were more women in the +rcRSA cohort (75.8%) than in the -rcRSA (37.7%, P = .001) and TSA (37.6%, P = .001) cohorts. Mean age of the +rcRSA cohort (71.1) was greater than that of TSA (66.0, P = .021) but similar to that of -rcRSA (72.4, P = .237). Glenoid retroversion was greater in +rcRSA (18.2°) compared with -rcRSA (10.5°, P = .011) but was similar to TSA (14.7°; P = .244). Postoperatively, there were no differences in VAS or ASES between +rcRSA vs. -rcRSA and +rcRSA vs. TSA. SSV was lower in +rcRSA (83.9) compared with -rcRSA (91.8, P = .021), but was similar to TSA (90.5, P = .073). Similar ROM was achieved in forward flexion, external rotation, and internal rotation at final follow-up between +rcRSA and -rcRSA, but TSA had greater external rotation (44° vs. 38°, P = .041) and internal rotation (6.5° vs. 5.0°, P = .001) compared with +rcRSA. There were no differences in complication rates. DISCUSSION: At short-term follow-up, preservation of the rotator cuff in RSA demonstrated similarly excellent outcomes and low complication rates compared with RSA with a deficient rotator cuff and TSA, except for slightly lower internal and external rotation compared with TSA. Although multiple factors deserve consideration when choosing between RSA and TSA, RSA with preservation of the posterosuperior cuff is a viable treatment option for glenohumeral osteoarthritis, particularly in patients with severe glenoid deformity or those at risk for future rotator cuff insufficiency.

Remplissage reduces recurrent instability in high-risk patients with on-track Hill-Sachs lesions.

BACKGROUND: The purpose of this study was to compare recurrent instability rates between patients with on-track Hill-Sachs lesions who underwent arthroscopic labral repair (ALR) alone and those who underwent ALR with remplissage (ALR-R). Our hypothesis was that ALR-R would decrease the rate of recurrent instability, especially among patients at high risk of recurrent instability after ALR, such as contact athletes with near-track Hill-Sachs lesions. METHODS: We performed a multicenter, retrospective analysis of patients aged 14-50 years with on-track Hill-Sachs lesions who underwent ALR-R or ALR without remplissage between January 2014 and December 2019 with minimum 2-year follow-up. The exclusion criteria included prior ipsilateral shoulder surgery, >15% glenoid bone loss (GBL), off-track Hill-Sachs lesion, concomitant shoulder procedure, and connective tissue disorder. Age, sex, follow-up, and contact sports participation were recorded. GBL, Hills-Sachs interval (HSI), glenoid track, and distance to dislocation (DTD) were determined from preoperative magnetic resonance imaging scans. Affected-shoulder range of motion, Western Ontario Shoulder Instability Index scores, Subjective Shoulder Value scores, and recurrent dislocation and/or revision surgery status were also collected. A subgroup analysis was performed on "high-risk" patients (defined as participants in contact sports with DTD <10 mm) from each cohort. RESULTS: The ALR-R cohort included 56 patients, and the ALR cohort included 127. ALR-R patients had greater GBL (P = .004) and a greater HSI (P < .001). In the ALR-R cohort, only 1 patient (1.8%) had a recurrent dislocation and there were no revision operations. In comparison, in the ALR cohort, 14 patients (11.0%) had recurrent dislocations (P = .040) and 8 (6.3%) underwent revision operations (P = .11). Univariate analysis showed that remplissage protected against recurrent dislocation (P = .040) whereas younger age (P = .004), contact sports participation (P = .001), and increased GBL (P = .048) were associated with recurrent dislocation. Multivariate analysis showed that HSI (P = .001) and contact sports participation (P = .002) predicted recurrent dislocation. Among high-risk patients, only 1 patient (4.2%) in the ALR-R group had a recurrent instability event vs. 6 (66.7%) in the ALR group (P < .001). The high-risk ALR-R subgroup also had significantly better final Western Ontario Shoulder Instability Index (P = .008) and Subjective Shoulder Value (P = .001) scores than the high-risk ALR subgroup. CONCLUSIONS: Anterior shoulder instability patients with on-track Hill-Sachs lesions have lower recurrent dislocation rates after ALR plus remplissage when compared with ALR alone. This is especially true for high-risk patients, such as contact athletes with a DTD <10 mm.

Overhead athletes have comparable intraoperative injury patterns and clinical outcomes to non-overhead athletes following surgical stabilization for first-time anterior shoulder instability at average 6-year follow-up.

BACKGROUND AND HYPOTHESIS: Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes. METHODS: Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates. RESULTS: A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport. CONCLUSION: Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes.

Pitching Behaviors in Youth Fast-Pitched Softball: High Pitching Volumes With Unequal Pitch Counts Among Pitchers are Common.

BACKGROUND: Softball is a popular sport among youth female athletes. While youth baseball has well-established, evidence-based pitching guidelines, youth softball pitching guidelines lack both evidence and enforcement. Adherence to pitch count limits in youth softball is infrequent and results in pitchers with exceedingly high pitching volumes. METHODS: Pitch counts for youth fast-pitch softball teams competing for 1 consecutive year between January 2018 to December 2019 in age groups 8 and under (8U) to 14 and under (14U) were collected. Pitching volume was assessed based on individual games, single calendar days, and tournaments in which games are played on 2 or more consecutive days. Pitchers on teams were subdivided based on pitch count volumes and compared using a logarithmic transformation and geometric mean. RESULTS: Data was collected for 10 teams from each age division resulting in analysis of 538 pitchers on 70 teams. The average pitcher threw 813 pitches per year and appeared in 20.0% of games while the average highest volume pitcher threw 2500 pitches per year and appeared in 54.5% of games. On average, the highest volume pitcher on each team threw 40% of all team pitches, while the 3 highest volume pitchers combined threw 82% of all team pitches. The average and high-volume pitcher threw pitches in 2 or more games on the same day in 37.5% and 48.6% of possible games while pitching 2 or more consecutive days in 64.0% and 79.6% of possible games, respectively. CONCLUSIONS: Softball pitchers throw high volumes of pitches while also pitching multiple days consecutively. A disparity among pitchers on softball teams exists as 40% of team pitches are thrown by 1 player and over 80% of team pitches are thrown by the top 3 pitchers. These high-volume pitchers may be engaging in unsustainable pitching practices that could predispose to injury. LEVEL OF EVIDENCE: Level IV-cross-sectional.

Opioid Use in Robotic-Arm Assisted Total Knee Arthroplasty: A Comparison to Conventional Manual Total Knee Arthroplasty.

INTRODUCTION: Opioids are frequently prescribed in the postoperative management of total knee arthroplasty (TKA) with multiple factors influencing postoperative opioid use. Robotic-arm-assisted TKA (raTKA) was developed with the goal of improving alignment and outcomes while decreasing soft tissue injury. The purpose of this study was to compare postoperative opioid consumption in raTKA and conventional manual TKA (mTKA) cohorts. MATERIALS AND METHODS: A consecutive series of unilateral primary TKAs performed 1/1/16 to 12/31/17 were included. Patients with major procedures requiring opioids occurring within one year of TKA were excluded. A single-surgeon raTKA cohort of 127 patients (Group 1) was compared to a same-surgeon cohort of 119 mTKAs (Group 2) using the same cemented implant design and a two-surgeon cohort of 410 mTKA (Group 3). Groups were subdivided into opioid naïve (ON) and opioid exposed (OE). Length of hospitalization and postoperative opioid utilization up to one year were compared between groups and collectively without separating raTKA and mTKA. Statistical analysis included Chi-square, Student's t-test, and Wilcoxon rank sum tests. RESULTS: For both ON and OE patients, Group 1 demonstrated reduced inpatient mean daily oral morphine milligram equivalent (MME) compared to Group 3 (ON p=0.007; OE p=0.034), a shorter hospitalization compared to Group 2 (ON p=0.02; OE p=0.012), and fewer opioids prescribed at discharge compared to Group 2 (ON p=0.005; OE p=0.081) and Group 3 (ON p<0.001; OE p=0.036). No differences in opioid prescriptions were seen at three months or after. Regardless of surgical technique OE patients had higher inpatient opioid utilization (p<0.001) as well as cumulative outpatient prescription quantity (MME 1050 ON, 2660 OE) and duration (ON 0.5%; OE 28.3%) at one year (p<0.001). CONCLUSION: Less opioids were prescribed at discharge and used during hospitalization in raTKA compared to mTKA though no differences in opioid use were seen at further time points. Preoperative opioid use remains a dominant factor in postoperative opioid utilization regardless of TKA surgical technique.

Metal-on-Metal Total Hip Arthroplasty at Five to Twelve Years Follow-Up: A Concise Follow-Up of a Previous Report.

BACKGROUND: Concern has arisen regarding potential complications with modular metal-on-metal (MoM) acetabular components in total hip arthroplasty. The purpose of this study was to analyze longitudinally the longer term results of a previously reported cohort of patients utilizing a cementless modular acetabular component with a MoM bearing. METHODS: One hundred sixty-nine consecutive but selected total hip arthroplasties were performed in 148 patients at 2 institutions using a modular acetabular MoM component. One hundred thirty-nine patients (158 hips) were living at minimum 5 years, 1 patient (1 hip) was lost to follow-up and 8 patients (10 hips) were deceased. Patients were evaluated clinically in terms of revision as well as radiographically. Additional testing (metal ion levels, advanced imaging) was performed when concerns for adverse local tissue reaction (ALTR) arose. RESULTS: There were 6 (3.8%) additional hips revised since the prior report for a total of 7 hips (4.4%) revised at 5-12 year follow-up. All newly revised hips (3.8%) demonstrated ALTR. There were 7 (4.7%) additional cases of radiographically detected acetabular osteolysis and 7 (4.7%) cases of femoral osteolysis. CONCLUSION: Longitudinal evaluation of a modular MoM bearing surface acetabular component demonstrated increased rates of ALTR and osteolysis at longer duration follow-up. Although greater than 95% of hips in this study performed well at 5-12 years, when comparing the results to metal-on-polyethylene bearings using the same acetabular component, the results were inferior. Longitudinal surveillance is warranted with this design and this bearing surface couple as cases of ALTR and osteolysis increased with longer follow-up.

Minimum 10-Year Follow-Up of Cementless Total Hip Arthroplasty Using a Contemporary Triple-Tapered Titanium Stem.

BACKGROUND: There is extensive variation in design and insertion technique of cementless tapered femoral stems. The purpose of our study was to evaluate a consecutive series of contemporary tapered cementless femoral stems inserted with a ream-and-broach technique at a minimum 10-year follow-up in patients undergoing total hip arthroplasty (THA). METHODS: One hundred consecutive THAs (88 patients) performed by a single surgeon were followed for a minimum of 10 years. Hips were evaluated clinically for revision status, Western Ontario and McMaster Universities Osteoarthritis Index, 36-item Short Form Health Survey, Harris Hip Score, and University of California, Los Angeles, and Tegner Activity Scores. Radiographic evaluation included assessment for loosening, osteolysis, and stress shielding. Kaplan-Meier survivorship analysis included end points for revision and radiographic evidence of femoral component loosening. RESULTS: At minimum 10-year follow-up, 66 patients (74 hips) were living, 20 patients (24 hips) were deceased, and 2 patients (2 hips) were lost to follow-up. Four hips required reoperation, but no femoral components were revised for aseptic loosening. One femoral component (1%) was revised due to a postoperative periprosthetic fracture. Radiographic evaluation demonstrated bone ingrowth of all stems without evidence of component loosening and 1 case of severe stress shielding. Kaplan-Meier survivorship at 10 years was 100% for the end points of femoral revision for loosening or femoral radiographic loosening. CONCLUSION: This contemporary, cementless titanium-tapered femoral component inserted with ream-and-broach technique demonstrated excellent results in terms of outcomes and clinical durability as well as osteointegration on radiographs at minimum 10-year follow-up. This study corroborates, with level 2 and level 3 data, level 1 data reported in national registries.

Fixation and Wear With Contemporary Acetabular Components and Cross-Linked Polyethylene at 10-Years in Patients Aged 50 and Under.

We evaluated the mid-term performance of a moderately cross-linked polyethylene THA bearing in younger patients. One hundred consecutive THAs performed in patients 50 years of age and under using the same cementless acetabular component and moderately cross-linked polyethylene were evaluated at minimum 10 year follow-up. At final follow-up 75 patients (89 hips) were living, 7 patients (7 hips) were deceased and 4 patients (4 hips) were lost to follow-up. Average Tegner and UCLA scores were 3.7 and 5.8, respectively. Average steps per year were 1.84 million. The average linear wear rate was 0.05 mm/y and steady state wear rate was 0.033 mm/y. There was no detectable osteolysis. Minimum 10 year follow-up demonstrated durable fixation and reduced wear (P<0.001) when compared to our historical controls.

Factors Associated With Knee Extension Strength Symmetry After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft.

Background: Diminished postoperative knee extension strength may occur after anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) autograft. Factors influencing the restoration of knee extensor strength after ACLR with QT autograft remain undefined. Purpose: To identify factors that influence knee extensor strength after ACLR with QT autograft. Study Design: Case-control study; Level of evidence, 3. Methods: The authors performed a retrospective review of patients who underwent primary ACLR with QT autograft at a single institution between 2010 and 2021. Patients were included if they completed electromechanical dynamometer testing at least 6 months after surgery. Exclusion criteria consisted of revision ACLR, <6 months of follow-up, concomitant procedure (osteotomy, cartilage restoration), and concomitant ligamentous injury requiring surgery. Knee extension limb symmetry index (LSI) was obtained by comparing the peak torque of the operated and nonoperated extremities. Univariable and multivariable analyses were performed to identify factors associated with knee extension LSI in the patient, injury, rehabilitation, and preoperative patient-reported outcomes score domains. Results: A total of 107 patients (58 male; mean age, 22.8 years) were included. Mean knee extension LSI of the overall cohort was 0.82 ± 0.18 at 7.5 ± 2.0 months; 35 patients (33%) had a value of ≥0.90. Multivariable analysis demonstrated significant negative associations between knee extension LSI and female sex (-0.12; P < .001), increased age at the time of surgery (-0.01; P = .018), and larger QT graft width (-0.049; P = .053). Conclusion: Factors influencing knee extensor LSI after ACLR with QT autograft in this study population spanned patient and surgical factors, including female sex, older age at the time of surgery, and wider graft harvest. Surgeons should consider the association between these factors and lower postoperative knee extensor LSI to optimize patient outcomes.

Cementless THA for the treatment of osteonecrosis at 10-year follow-up: have we improved compared to cemented THA?

Results of cementless THA for osteonecrosis were evaluated at a minimum of 10-year follow-up and compared to our previous report of cemented THA for osteonecrosis. Eighty cementless THAs in 66 patients with osteonecrosis were followed for a minimum of 10 years. Evaluation consisted of need for revision; radiographic evidence of loosening, wear and osteolysis; activity monitoring with an accelerometer; UCLA, Tegner, WOMAC, and Harris hip scores. Results were compared to 48 cemented THAs performed for osteonecrosis with comparable follow-up. At a minimum of 10 years, 10 hips required reoperation. Loosening and revision for loosening were significantly lower in the cementless group compared to the cemented historical control. Cementless fixation in THAs for osteonecrosis demonstrated durable results with bearing surface wear being the major long-term problem.

Total hip arthroplasty in Down syndrome patients: an improvement in quality of life: replacement arthroplasty in Down syndrome (RADS) study group.

The purpose this study was to assess survival rates, clinical outcomes, and radiographic outcomes of total hip arthroplasty in Down syndrome patients. We reviewed 26 total hip arthroplasties (21 patients) performed by four experienced hip surgeons. These patients had a mean age of 35 years and a mean follow-up of 106months. Clinical outcomes were assessed using Harris Hip scores, and radiographic evaluation for component fixation and migration was performed. The overall survival with aseptic failure as an endpoint was 85%. The mean Harris Hip score improved to 84 points at final follow-up. While these patients can be challenging to treat, excellent surgical technique and selective use of acetabular constraint can reliably provide patients with excellent pain-relief and improved function.

Arthroscopic all-inside repair of challenging meniscus tears.

Meniscus tears are prevalent in isolation and in combination with anterior cruciate ligament (ACL) injury. Meniscus lesions can be difficult to access and often display complex tear patterns, which result in technical challenges for the operating surgeon during surgical treatment. The aim of this video article is to demonstrate technical tips and tricks for performing all-inside repair of challenging meniscus tears. The presented techniques are indicated in young, physically active patients with symptomatic tears of the lateral and medial menisci, with or without concomitant ACL injury. The procedure is performed using standard anterolateral and anteromedial arthroscopic portals for direct visualization of complex meniscus tear patterns and all-inside instrument access. A suture passing device is used for the placement of suture loops for meniscus root repair. All-inside repair devices are used to repair the radial meniscal tears along the native circumferential fibers using a horizontal mattress suture configuration, with curved devices to achieve optimal access to challenging tears affecting the anterior and posterior aspects at the mid-body of the meniscus. Repair of radial tears at the avascular zone of the meniscus may be augmented with an autologous fibrin clot delivered using an arthroscopic cannula.

Quantitative and qualitative disparities exist between baseball and softball peer-reviewed pitching-related literature: a systematic review from 1990 to 2020.

Background: Baseball and softball are popular sports with similar rates of injury, especially among pitchers. However, parity between the two sports is lacking, as baseball receives greater research attention than softball. The purpose of this study was to describe the discrepancy between baseball and softball in terms of quantity and quality of research. We hypothesized baseball literature would outnumber softball literature, be published in higher-impact journals, and be of higher quality. Methods: A systematic review was performed to identify original research articles related to baseball and softball from 1990 to 2020. Articles pertaining to pitching were identified via literature searches of PubMed, the Physiotherapy Evidence Database, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials and further screened by two independent reviewers. Age group studied, journal impact factor, type of research, and level of evidence were compared between pitching-related baseball and softball articles. Injury-related studies were also subanalyzed, and a meta-analysis was performed to assess rates of shoulder and elbow injuries between baseball and softball pitchers. Results: There were 813 baseball publications and 158 softball publications that met our inclusion criteria. More baseball articles were published per year than softball (5:1, P < .001). Baseball had 368 articles related to pitching, while softball had significantly fewer at 49, and there were more baseball pitching articles published per year than softball pitching articles (7.5:1, P < .001). Pitching-related baseball articles were published in journals with a higher mean impact factor than softball pitching articles (3.1 vs. 2.0, P = .049). There was no difference in methodological index for non-randomized studies criteria for rigorous reporting (P = .678), and among all groups, most articles were level III evidence. Baseball pitching articles included more clinical articles than softball pitching articles (63% vs. 43%, P = .004). Despite the fact that softball pitchers have an odds ratio of shoulder and elbow injury slightly higher than baseball (4.02 vs. 3.60), injury-related studies focused on baseball outnumbered softball studies 7 to 1. Conclusion: Softball is under-represented in the literature when compared to baseball with over 5 times fewer peer-reviewed research articles, despite having slightly higher shoulder and elbow injury rates than baseball. Pitching-related softball articles are nearly 8 times less frequent compared to baseball pitching articles and published in journals with a lower impact factor. Further research directed at softball is important to provide evidence-based injury prevention, practice guidelines, and treatment decisions.

Self-Reported Outcomes in Early Postoperative Management After Shoulder Surgery Using a Home-Based Strengthening and Stabilization System With Telehealth.

BACKGROUND: Multiple rehabilitation protocols after shoulder surgery have been proposed. The coronavirus pandemic adds an extra layer of complexity to postoperative rehabilitation after shoulder surgery. HYPOTHESIS: The combined use of a home-based rehabilitation system, the Shoulder Strengthening and Stabilization System (SSS), and telehealth visits will lead to acceptable patient self-reported outcomes and satisfaction after shoulder surgery. STUDY DESIGN: Prospective observational cohort. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 132 patients were prescribed SSS after shoulder surgery. A virtual clinical specialist monitored patients through telehealth visits as prescribed by the treating physician. Data were collected prospectively during each telehealth visit. Patients completed an exit survey during their last telehealth visit. RESULTS: The use of SSS with telehealth revealed a positive impact on postoperative shoulder rehabilitation (96%), pain (71%), and stiffness (92%) as reported by patients. Both pain scores and pain medication use decreased from the 1st to 8th postoperative telehealth session (P < 0.01). Nearly all (93%) patients recommended SSS after shoulder surgery upon completing the SSS protocol. CONCLUSION: Postoperative management of shoulder surgery with SSS combined with telehealth results in a reduction in patient pain levels in the early postoperative period. Patients reported high levels of improvement with SSS in shoulder rehabilitation, pain, and stiffness. The overwhelming majority (93%) of patients recommended SSS for postoperative shoulder rehabilitation and SSS yielded high patient satisfaction scores. Elucidating the impact of SSS on clinical outcomes and function in comparison with traditional rehabilitation protocols is warranted. CLINICAL RELEVANCE: SSS in combination with telehealth was tolerated well by patients and may represent an alternative or adjunct to traditional rehabilitation protocols.

Depressive and Anxiety Disorders Increase Risk for Recurrent Anterior Shoulder Pain Following Arthroscopic Suprapectoral Biceps Tenodesis.

Purpose: To evaluate factors associated with postoperative anterior shoulder pain following arthroscopic suprapectoral biceps tenodesis (ABT) and to determine the clinical impact of postoperative anterior shoulder pain. Methods: A retrospective study of patients that underwent ABT between 2016 and 2020 was conducted. Groups were categorized by the presence (ASP+) or absence (ASP-) of postoperative anterior shoulder pain. Patient-reported outcomes (American Shoulder and Elbow score [ASES], visual analog scale [VAS] for pain, subjective shoulder value [SSV]), strength, range of motion, and complication rates were analyzed. Differences between continuous and categorical variables were tested with two-sample t-tests and chi-squared or Fisher's exact tests, respectively. Variables collected at different postoperative timepoints were analyzed using mixed models with post hoc comparisons when significant interactions were detected. Results: A total of 461 (47 ASP+, 414 ASP-) patients were included. A statistically significant lower mean age was observed in the ASP+ group (P < .001). A statistically significant higher prevalence of major depressive disorder (MDD) (P = .03) or any anxiety disorder (P = .002) was observed in the ASP+ group. Prescription medication with psychotropic medications (P = .01) was significantly more prevalent in the ASP+ group. No significant differences were observed in the proportion of individuals reaching the minimal clinical important difference (MCID) for ASES, VAS, or SSV between groups. Conclusions: A pre-existing diagnosis of major depressive disorder or any anxiety disorder, as well as the use of psychotropic medications was associated with postoperative anterior shoulder pain following ABT. Other factors associated with anterior shoulder pain included younger age, participation in physical therapy before surgery, and lower rate of concomitant rotator cuff repair or subacromial decompression. Although the proportion of individuals reaching MCID did not differ between groups, the presence of anterior shoulder pain after ABT resulted in prolonged recovery, inferior PROs, and a higher incidence of repeat surgical procedures. The decision to perform ABT in patients diagnosed with MDD or anxiety should be carefully considered, given the correlation to postoperative anterior shoulder pain and inferior outcomes. Level of Evidence: Level III, retrospective case-control study.