Increasing Hip Arthroscopy Case Volume Is Associated With Increased Risk for Revision Surgery but Not Conversion to Total Hip Arthroplasty or 90-Day Hospitalizations: A Cross-Sectional Analysis of 468 Surgeons.

PURPOSE: To analyze the effects of surgeon-specific factors, including case volume, career duration, fellowship training, practice type, and region of practice, on rates of 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations following hip arthroscopy. METHODS: The PearlDiver Mariner Database was used to query patients undergoing hip arthroscopy between 2015 and 2018. Surgeons performing these procedures were identified, and surgeon-specific demographics and variables were collected from publicly available data. Patients were followed for 2 years to assess for reoperations, including revision hip arthroscopy and conversion to THA, as well as 90-day hospitalizations, including emergency department visits and hospital readmissions. International Classification of Diseases, Tenth Revision codes were used to track the laterality of revision hip procedures. Associations between surgeon-specific factors and postoperative outcomes were assessed through univariate and multivariate analyses. RESULTS: In total, 20,834 patients underwent hip arthroscopy procedures by 468 surgeons. Multivariate analysis with logistic regression adjusted for patient-related factors (age, sex, obesity, Charlson Comorbidity Index, and smoking status) identified increasing surgeon case volume to be associated with increased risk for 2-year revision hip arthroscopy (P < .001), but not 2-year conversion to THA or 90-day hospitalizations. Nonsports medicine fellowship-trained surgeons were associated with greater risk for 2-year THA conversion (P < .001) and 90-day hospital readmissions (P < .01). Surgeons practicing in an academic setting demonstrated greater risk for 90-day hospital readmissions (P < .001). Surgeons practicing in the West region of the United States were more likely to incur 2-year revision hip arthroscopy procedures compared to surgeons in the South, Midwest or Northeast (P < .001). CONCLUSIONS: Increasing surgeon hip arthroscopy case volume is associated with an increased risk for 2-year revision hip arthroscopy but not conversion to THA or 90-day hospitalizations. Further, non-sports medicine fellowship-trained surgeons were associated with higher risk for 2-year THA conversion after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective cohort analysis.

Editorial Commentary: Understanding the Gap in Clinical Outcomes After Rotator Cuff Repair Based on the Influence of Social Determinants of Health.

There is growing recognition and understanding of the important role that social determinants of health and access to care play in surgical outcomes, particularly in the field of orthopaedic surgery and sports medicine. Factors including race, ethnicity, education, income, insurance status, social class, and sex have been identified as important contributors to outcomes after orthopaedic procedures, including rotator cuff repair. Disadvantaged or marginalized patients have been shown to attend fewer office visits and physical therapy sessions, are more likely to present with advanced stages of disease, have delayed surgical interventions, and have poorer patient-reported outcomes after surgery. Virtual visits and telemedicine have the great ability to improve access to medical professionals for disadvantaged patients who have poor access to transportation. However, reliance on telehealth has the potential to worsen access to care for patients with limited access to technology or language barriers. Disadvantaged populations, including those with noncommercial health care insurance, show decreased use of telemedicine.

Editorial Commentary: Interportal Capsulotomy for Hip Arthroscopy in Patients With Borderline Hip Dysplasia May Result in Inferior Outcomes: Periportal Capsulotomy May Reduce Hip Capsular Damage.

Management of the hip capsule remains an ongoing discussion in the field of hip arthroscopy. Interportal and T-capsulotomies remain the most common approaches to gain access to the hip during surgery, and biomechanical and clinical research supports repair of these types of capsulotomies. Less is known, however, about the quality of the tissue that heals at these repair sites during the postoperative period, particularly in the setting of patients with borderline hip dysplasia. The capsular tissue provides important joint stability to these patients, and disruption to the capsule can result in significant functional impairments. There is also an association between borderline hip dysplasia and joint hypermobility, which increases the risk of insufficient healing after capsular repair. Patients with borderline hip dysplasia show poor capsular healing after arthroscopy followed by interportal hip capsule repair, and incomplete healing results in inferior patient-reported outcomes. Periportal capsulotomy may limit capsular violation and improve outcomes.

Editorial Commentary: Hip Arthroscopy in Patients With Early Degeneration Who Receive Intra-Articular Bone Marrow Aspirate Concentrate Can Achieve Outcomes Similar to Nonarthritic Patients.

The management of patients with early joint degeneration is challenging. In this setting, biologic interventions, from platelet-rich plasma to bone marrow aspirate concentrate (BMAC) to hyaluronic acid, may be beneficial. Recent research, with 2-year follow-up, shows that patients with early degenerative changes (Tönnis grade 1 or 2) who received intra-articular injection of BMAC after hip arthroscopy procedure had improvements in outcomes similar to nonarthritic patients (Tönnis 0) with symptomatic labral tears who underwent arthroscopy and did not receive BMAC. Although confirmatory investigation using patients with early degenerative changes as a control is required, it is possible that with BMAC, patients with early degenerative changes of their hip could achieve functional outcomes similar to patients with nonarthritic hips.

Hypermobile Patients With Femoroacetabular Impingement Syndrome Can Be Effectively Treated Utilizing Hip Arthroscopy With Periportal Capsulotomy Closure: A Matched Cohort Analysis Compared to Patients Without Joint Hypermobility.

PURPOSE: To assess the 2-year outcomes of arthroscopic treatment with periportal capsulotomy closure for femoroacetabular impingement syndrome (FAIS) in patients with generalized ligamentous laxity (GLL). METHODS: A retrospective analysis was performed from a prospectively collected database of FAIS patients undergoing hip arthroscopy. FAIS patients with GLL were identified as having Beighton score ≥4. FAIS patients with GLL were treated with arthroscopic labral repair, osteochondroplasty, via periportal capsulotomy with subsequent capsular closure. These patients were matched by age, sex, and body mass index (BMI) with a cohort of FAIS patients without GLL who underwent the same procedure via periportal capsulotomy without capsular closure. Preoperatively, and 2 years postoperatively, patients completed patient-reported outcomes (PRO) scores, including the Hip Disability and Osteoarthritis Outcome Score (HOOS), 12-item Short-Form survey (SF-12) and the visual analog scale (VAS). RESULTS: Forty patients (5 male, 35 female) with FAIS and GLL were included (age: 29.7 ± 9.0; BMI: 23.3 ± 4.1). FAIS patients with GLL demonstrated similar significant PRO score improvements compared to a matched cohort of FAIS patients without GLL at 2 years after surgery (VAS Pain: (-)2.5 ± 3.0, (-)2.7 ± 2.7; SF-12 PCS: 17.7 ± 14.2, 16.7 ± 15.0; HOOS-Symptoms: 26.3 ± 24.0, 20.6 ± 18.1; HOOS-Pain: 29.8 ± 20.4, 24.4 ± 9.0; HOOS-ADL: 24.9 ± 18.4, 22.0 ± 19.9; HOOS-Sports: 43.6 ± 26.1, 33.1 ± 29.8; and HOOS-QOL: 44.2 ± 27.6, 41.7 ± 27.1, respectively). Both cohorts achieved minimal clinically important differences (MCID) for each HOOS subscore at equivalent high rates (70-88%). CONCLUSIONS: Patients with GLL in the setting of FAIS can be effectively treated with arthroscopy via periportal capsulotomy and capsular closure. These patients demonstrate significant improvements in PRO scores at 2 years, similar to normal laxity FAIS patients undergoing arthroscopic treatment via periportal capsulotomy without capsular closure. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Patient-Reported Outcome Surveys for Femoroacetabular Impingement Syndrome Demonstrate Strong Correlations, High Minimum Clinically Important Difference Agreement and Large Ceiling Effects.

PURPOSE: To determine the correlation between different patient-reported outcome (PRO) measurements used to assess outcomes after arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) in a single cohort of patients. METHODS: Patients undergoing primary hip arthroscopy for FAIS (without dysplasia, arthritis, or joint hypermobility) were retrospectively analyzed from a prospectively collected cohort. PROs collected before surgery and at 2-year follow-up included the Visual Analog Scale (VAS) for pain, modified Harris Hip Score (mHHS), Hip Disability and Osteoarthritis Outcome Scores (HOOS) with subscales for symptoms, pain, activities of daily living (ADL), sport, and quality of life (QoL), and the physical and mental components of the Short Form-12 (SF-12 PCS and SF-12 MCS). RESULTS: Three hundred patients with 2 years' follow-up (mean age 35.1 ± 11.3, BMI 24.7 ± 3.8, 52.7% female, median Tönnis grade 1) were identified. All patients underwent femoroplasty and labral repair. There was a strong correlation among nearly all the PRO surveys at 2-year follow-up, with the highest correlations identified between mHHS and HOOS-Pain (r = .86, P < .001) and mHHS and HOOS-ADL (r = .85, P < .001). Preoperative scores and the change from preoperative to postoperative scores demonstrated an overall moderate correlation between surveys. There was a consistently weak correlation between the SF-12 MCS and all other PROs. There were strong agreements (67%-77%) in the patients achieving minimal clinically important differences (MCID) for each PRO survey. All surveys except the SF-12 demonstrated a ceiling effect after surgery, with 13% to 43% of patients achieving the maximum score. CONCLUSIONS: PRO surveys used for FAIS demonstrate strong correlations, especially in the evaluation of patients during the postoperative period. MCID for VAS, mHHS, and HOOS demonstrate strong agreement, whereas large ceiling effects were seen with the mHHS and HOOS. The results support a more efficient use of PRO scores while being able to accurately capture patient outcomes. LEVEL OF EVIDENCE: IV, retrospective case series.

Imbalance in Axial-plane Rotator Cuff Fatty Infiltration in Posteriorly Worn Glenoids in Primary Glenohumeral Osteoarthritis: An MRI-based Study.

BACKGROUND: Fatty infiltration of the rotator cuff evaluated with CT has been associated with asymmetric glenoid wear and humeral head subluxation in patients with glenohumeral arthritis. The relationship between rotator cuff pathologic findings and abnormal glenoid wear plays an important role in determining the optimal surgical management of advanced glenohumeral osteoarthritis. Compared with CT, MRI has increased sensitivity for identifying rotator cuff conditions; therefore, prior studies using CT may have underestimated the association between fatty infiltration of the rotator cuff and abnormal glenoid wear. QUESTIONS/PURPOSES: (1) Compared with Type A glenoids, which muscles in which Walch subtypes have a greater degree of fatty infiltration using Goutallier scores? (2) What glenoid type is associated with greater imbalance in fatty infiltration, as measured by comparing Goutallier scores between the posterior and anterior rotator cuff muscles? (3) What is the correlation between glenoid version and fatty infiltration of the rotator cuff muscles? (4) Comparing Type B2 and B3 glenoids with Type A glenoids, after accounting for age and sex, is there an increase in fatty infiltration of the infraspinatus muscle? METHODS: A total of 129 shoulders from 129 patients undergoing anatomic total shoulder arthroplasty to treat primary glenohumeral osteoarthritis were retrospectively reviewed. Patients had an average age of 66.4 ± 9.3 years and an average BMI of 30.6 ± 6.7 kg/m2, and 53% (69 of 129) were men. All patients underwent MRI within 12 months before total shoulder arthroplasty to assess glenoid morphology and rotator cuff pathologic findings. Three reviewers assessed the images, and glenoid morphology was assigned using the modified Walch classification system (Types A1, A2, B1, B2, B3, C, and D). Fatty infiltration of the rotator cuff was classified using Goutallier scores. The examiners demonstrated moderate-to-good reliability using these classification systems; the Walch classification system had interrater reliability kappa coefficients (κ) from 0.54 to 0.69 and intrarater reliability κ from 0.60 to 0.64. Goutallier scores using the simplified classification system had interrater reliability κ from 0.64 to 0.68 and intrarater reliability κ from 0.64 to 0.79. Thirty-six percent (46 of 129) of the shoulders had posterior wear patterns (18% [23] were Type B2 glenoids; 18% [23] were Type B3 glenoids). The average Goutallier scores for each rotator cuff muscle were determined, and the amount of fatty infiltration was compared between the various Walch subtypes using independent t-tests. Axial-plane imbalance in fatty infiltration of the rotator cuff was assessed by determining the difference in the average fatty infiltration of the posterior rotator cuff muscles (infraspinatus and teres minor) and anterior rotator cuff muscles (subscapularis) and comparing the differences among the Walch subtypes using independent t-tests. The association between glenoid version and fatty infiltration was assessed using Pearson correlations. Finally, a multivariate logistic regression model was used to assess fatty infiltration of the rotator cuff among the various Walch subtypes while accounting for patient age and sex. RESULTS: Compared with Type A1 glenoids, Type B2 and B3 glenoids had an increased amount of fatty infiltration of the infraspinatus (1.6 ± 0.7 versus 0.7 ± 0.4; mean difference 0.9 [95% CI 0.7-1.2]; p < 0.001 and 1.8 ± 0.4 versus 0.7 ± 0.4; mean difference 1.1 [95% CI 0.9-1.4]; p < 0.001, respectively) and teres minor (1.3 ± 0.7 versus 0.6 ± 0.5; mean difference 0.7 [95% CI 0.4-1.0]; p < 0.001 and 1.6 ± 0.6 versus 0.6 ± 0.5; mean difference 1.0 [95% CI 0.7-1.2]; p < 0.001, respectively). There was greater imbalance in fatty infiltration between the posterior and anterior rotator cuff muscles for Type B2 (0.5 ± 0.3) and B3 (0.6 ± 0.5) glenoids than for Type A1 (0.1 ± 0.3) and A2 (0.1 ± 0.6) glenoids (p < 0.001). Only the infraspinatus's fatty infiltration was strongly correlated with glenoid version (r = 0.64; p < 0.001), while fatty infiltration of the other muscles only correlated weakly or moderately. After accounting for age and sex, fatty infiltration in the infraspinatus was associated with Type B2 (OR 66.1 [95% CI 7.6-577.9]; p < 0.001) and Type B3 glenoids (OR 59.5 [95% CI 5.4-661.3]; p < 0.001) compared with Type A glenoids. CONCLUSION: Compared with concentric wear, posteriorly worn glenoids had an imbalance in axial-plane rotator cuff fatty infiltration and an increased amount of fatty infiltration of the infraspinatus and teres minor compared with the subscapularis. These imbalances may contribute to the higher rates of failure after anatomic total shoulder arthroplasty in patients with posterior wear compared with those with concentric wear. Future research should be directed toward investigating the temporal relationship of these findings, as well as understanding the clinical outcomes for patients undergoing anatomic total shoulder arthroplasty who have posteriorly worn glenoids with a high degree of fatty infiltration of the posterior rotator cuff musculature. CLINICAL RELEVANCE: Providers should consider the increased likelihood of higher-grade fatty infiltration of the posterior rotator cuff in the setting of posteriorly worn glenoids, particularly when treating patients without using MRI. These patients have higher rates of failure postoperatively and may benefit from closer monitoring and altered postoperative rehabilitation protocols that target the posterior rotator cuff.

Isolated Acetabuloplasty for Femoroacetabular Impingement: Favorable Patient-Reported Outcomes and Sustained Survivorship at Minimum 5-Year Follow-Up.

PURPOSE: To evaluate minimum 5-year outcomes and conversion rate to total hip arthroplasty (THA) for the treatment of femoroacetabular impingement (FAI) syndrome with an isolated acetabular osteoplasty. METHODS: Patients undergoing hip arthroscopy with an isolated acetabular osteoplasty from March 2009 to June 2014 for FAI syndrome with pincer and/or cam morphology and a labral tear were identified. Those who underwent femoroplasty or prior ipsilateral hip surgery or who had previous hip conditions, ipsilateral hip dysplasia, or a Tönnis grade higher than 2 were excluded. Patient-reported outcomes (PROs) collected included Patient-Reported Outcomes Measurement Information System (PROMIS) scores specific to physical functioning and pain interference, modified Harris Hip Score, International Hip Outcome Tool 12, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, and Numeric Pain Rating Scale. Patients were also queried about secondary surgical procedures and conversion to THA. RESULTS: We identified 86 patients at minimum 5-year follow-up (average, 7.4 years). The average patient age was 39.8 ± 12.3 years, 70.9% of patients were female, and 7% of patients had Tönnis grade 2. The mean PRO scores were 52.0 ± 8.9 for the PROMIS physical functioning score, 39.6 ± 7.5 for the PROMIS pain interference score, 78.7 ± 12.0 for the modified Harris Hip Score, 73.3 ± 23.1 for the International Hip Outcome Tool 12 score, 89.9 ± 12.0 for the Hip Outcome Score-Activities of Daily Living, and 81.4 ± 21.0 for the Hip Outcome Score-Sport-Specific Subscale. Of the patients, 72.1% achieved the patient acceptable symptomatic state (PASS) according to previously established PASS scores for FAI syndrome treated with hip arthroscopy at minimum 5-year follow-up. The overall rate of revision arthroscopy was 3.5%, and the rate of conversion to THA was 5.8%. CONCLUSIONS: An isolated acetabular osteoplasty can provide sustained clinical benefits for the treatment of FAI syndrome with labral tears, with good to excellent PROs and PASS rates and a low rate of conversion to THA at minimum 5-year follow-up. LEVEL OF EVIDENCE: Level IV, case series.

MAGIC biomarkers predict long-term outcomes for steroid-resistant acute GVHD.

Acute graft-versus-host disease (GVHD) is treated with systemic corticosteroid immunosuppression. Clinical response after 1 week of therapy often guides further treatment decisions, but long-term outcomes vary widely among centers, and more accurate predictive tests are urgently needed. We analyzed clinical data and blood samples taken 1 week after systemic treatment of GVHD from 507 patients from 17 centers of the Mount Sinai Acute GVHD International Consortium (MAGIC), dividing them into a test cohort (n = 236) and 2 validation cohorts separated in time (n = 142 and n = 129). Initial response to systemic steroids correlated with response at 4 weeks, 1-year nonrelapse mortality (NRM), and overall survival (OS). A previously validated algorithm of 2 MAGIC biomarkers (ST2 and REG3α) consistently separated steroid-resistant patients into 2 groups with dramatically different NRM and OS (P < .001 for all 3 cohorts). High biomarker probability, resistance to steroids, and GVHD severity (Minnesota risk) were all significant predictors of NRM in multivariate analysis. A direct comparison of receiver operating characteristic curves showed that the area under the curve for biomarker probability (0.82) was significantly greater than that for steroid response (0.68, P = .004) and for Minnesota risk (0.72, P = .005). In conclusion, MAGIC biomarker probabilities generated after 1 week of systemic treatment of GVHD predict long-term outcomes in steroid-resistant GVHD better than clinical criteria and should prove useful in developing better treatment strategies.

Editorial Commentary: Emergency Department Evaluation After Hip Arthroscopy Occurs More than Expected: Here's Where Patient Education and a Multimodal Approach to Pain Management Can Be Helpful.

Hip arthroscopy is known to be a relatively safe procedure with a limited and unique set complications and low hospital readmission rates. Many patients, however, may seek emergency department evaluation after surgery for postoperative pain or complaints unrelated to the most commonly cited complications, such as traction neuropraxia. It is important to recognize and understand the reasons why patients seek medical care after surgery because many of these encounters may be preventable with optimization of perioperative multimodal pain control regimens and proper patient education regarding their expected postoperative course. Patients with barriers to health care access, such as Medicare and Medicaid patients, may be at higher risk for emergency department evaluation of their problems after surgery and clinicians should consider providing additional counseling to these patients regarding when and how to seek medical evaluation after surgery.

Risk factors for 30-day readmission following hip arthroscopy.

PURPOSE: Hip arthroscopy is known to be safe with low rates of postoperative complications. The purpose of this study is to evaluate hip arthroscopy cases in a national surgical database to identify risk factors associated with readmission. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2012 to 2016 for current procedural terminology billing codes related to hip arthroscopy. International Classification of Diseases diagnostic codes were used to exclude cases involving infection, fracture, or open procedures. Univariate and multivariate analyses were performed to identify risk factors associated with 30-day readmission. RESULTS: 1493 patients were identified who had undergone hip arthroscopy. The most common procedures were labral resection or chondroplasty (n = 589, 39.5%) and femoroplasty (n = 527, 35.3%). The 30-day complication rate was 1.7% and the most common complications following the procedure were bleeding (n = 12, 0.8%) superficial infections (n = 5, 0.3%), and returning to the operating room (n = 4, 0.3%). The 30-day readmission rate was 1.3%. On multivariate analysis, hypertension requiring anti-hypertensive medication (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.4-8.7) and chronic corticosteroid or immunosuppressant use (OR 7.2; 95% CI 1.9-26.7) were identified as independent risk factors for readmission. There was no difference in complication rates when hip arthroscopy was performed with isolated femoroplasty (n = 340), isolated acetabuloplasty (n = 103), both (n = 187) or neither (n = 863). CONCLUSION: These findings confirm that the 30-day readmission (1.3%) and complication rate (1.7%) are low for isolated hip arthroscopy procedures; however, hypertension and chronic steroid use are independent risk factors for readmission. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Risk Factors for Greater Than 24-Hour Length of Stay After Primary Total Knee Arthroplasty.

BACKGROUND: Recently, the Center for Medicare Services removed total knee arthroplasty (TKA) from the inpatient-only procedure list. The purpose of this study is to assess the role of demographics, medical comorbidities, and postsurgical complications in predicting safe discharge to home within 24 hours after TKA. METHODS: Patients undergoing primary TKA between 2011 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped into those whose length of stay (LOS) was less than 24 hours after surgery vs those greater than 24 hours. Demographics, preoperative comorbidities, operative variables, and postoperative adverse events were studied as risk factors for LOS greater than 24 hours. RESULTS: A total of 210,075 patients undergoing primary TKA met the inclusion criteria, and of those, 18,134 (8.6%) patients were discharged within 24 hours postoperatively. In a risk-adjusted multivariate analysis, patients with increasing age, obesity, preoperative comorbidities of smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, hypertension, bleeding disorder, corticosteroid use preoperatively, and dependent functional status conferred a greater risk for discharge greater than 24 hours. Male gender, spinal anesthesia, and monitored anesthesia care were protective against LOS greater than 24 hours. CONCLUSION: This study suggests that dependent functional status, preoperative comorbidities, and postoperative complications are all associated with a LOS greater than 24 hours after TKA. Surgeons and patients should be aware of the clinical and demographic variables associated with risk for LOS greater than 24 hours when considering outpatient status for patients undergoing TKA.

Which Postoperative Day After Total Joint Arthroplasty Are Catastrophic Events Most Likely to Occur?

BACKGROUND: Despite lacking granularity, large database registries can help provide important information on rare outcomes following total joint arthroplasty (TJA). In an era of short stay and outpatient arthroplasty, an awareness of the timeframe for most common catastrophic complications can help providers maintain an appropriate degree of suspicion for these significant events. METHODS: Patients undergoing primary TJA between 2011 and 2016 were identified in the National Surgical Quality Improvement Program and queried for 4 adverse postoperative outcomes: pulmonary embolism (PE), myocardial infarction or cardiac arrest, cerebrovascular accident, and death. The timing of postoperative events was compared, and also their association with medical comorbidities and timing in inpatient vs outpatient arthroplasty. RESULTS: A total of 341,601 patients met inclusion criteria. Of them, 1631 (0.48%) patients sustained a postoperative PE, 1033 (0.3%) patients had a cardiac event, 304 patients had a cerebrovascular accident (0.09%), and 608 (0.18%) patients expired. Greater than 60% of all these complications occurred between postoperative days 0 and 5, including 65% of PE. On postoperative day 0, a catastrophic event is 13 times more likely to be a cardiac event (80.7%) compared to a PE (6%). However, by postoperative day 1, a cardiac event (41.2%) is only 1.03 times more likely than a PE (40%) and by postoperative day 2, a PE (62%) is twice as likely as a cardiac event (30%). CONCLUSION: Risk assessment for catastrophic event and timeliness of occurrence may guide providers to recommend enhanced observation for specific patients undergoing TJA.

Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty.

BACKGROUND: The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. METHODS: This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. RESULTS: We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. DISCUSSION/CONCLUSION: Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

Evaluation of Spin Bias in Systematic Reviews and Meta-analyses of Rotator Cuff Repair With Platelet-Rich Plasma.

BACKGROUND: The use of platelet-rich plasma (PRP) in orthopaedics continues to increase. One common use of PRP is as an adjunct in rotator cuff repair surgery. Multiple systematic reviews and meta-analyses have summarized the data on PRP use in rotator cuff repair surgery. However, systematic reviews and meta-analyses are subject to spin bias, where authors' interpretations of results influence readers' interpretations. PURPOSE: To evaluate spin in the abstracts of systematic reviews and meta-analyses of PRP with rotator cuff repair surgery. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A PubMed and Embase search was conducted using the terms rotator cuff repair and PRP and systematic review or meta-analysis. After review of 74 initial studies, 25 studies met the inclusion criteria. Study characteristics were documented, and each study was evaluated for the 15 most common forms of spin and using the AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews, Version 2) rating system. Correlations between spin types and study characteristics were evaluated using binary logistic regression for continuous independent variables and a chi-square test or Fisher exact test for categorical variables. RESULTS: At least 1 form of spin was found in 56% (14/25) of the included studies. In regard to the 3 different categories of spin, a form of misleading interpretation was found in 56% (14/25) of the studies. A form of misleading reporting was found in 48% (12/25) of the studies. A form of inappropriate extrapolation was found in 16% (4/25) of the studies. A significant association was found between misleading interpretation and publication year (odds ratio [OR], 1.41 per year increase in publication; 95% CI, 1.04-1.92; P = .029) and misleading reporting and publication year (OR, 1.41 per year increase in publication; 95% CI, 1.02-1.95; P = .037). An association was found between inappropriate extrapolation and journal impact factor (OR, 0.21 per unit increase in impact factor; 95% CI, 0.044-0.99; P = .048). CONCLUSION: A significant amount of spin was found in the abstracts of systematic reviews and meta-analyses of PRP use in rotator cuff repair surgery. Given the increasing use of PRP by clinicians and interest among patients, spin found in these studies may have a significant effect on clinical practice.

Minimally Invasive Medial Patellofemoral Ligament Reconstruction With Patellar-Sided Tensioning Using All-Suture Anchors.

Medial patellofemoral ligament (MPFL) reconstruction is a commonly performed procedure to reestablish the checkrein to the lateral patellar translation in patients with recurrent patellofemoral instability. Graft tensioning is one of the most critical aspects of the procedure. Most surgical methods for MPFL reconstruction involve tensioning and securing the graft on the femoral side. In this article, we describe a technique for patellar-sided tensioning of the graft using all-suture anchors, which provides the surgeon with the ability to finely control graft tension with two independent graft limbs, while preserving patellar bone stock.

Ultrasound Evaluation of the Hip.

PURPOSE OF REVIEW: Non-arthritic hip pain is a common presentation among the general population, with many possible contributing etiologies. While radiographs, computed tomography, and magnetic resonance imaging are all within the standard diagnostic workup, ultrasonography has emerged as a facile tool given its low cost, lack of radiation, and dynamic application. This article reviews the utility of ultrasound (US) in evaluation of non-arthritic hip pain and its ability to detect pathology both statically and dynamically in comparison and as an adjunct to standard imaging modalities. RECENT FINDINGS: Current research highlights applications of US to commonly treated hip pathologies including femoroacetabular impingement, labral tears, hip microinstability, and various other extra-articular phenomena. While static evaluation seems to add similar value to that of radiography, several novel protocols have been developed that allow for dynamic evaluation of joint biomechanics, including extent and onset of impingement and femoral head translation, that cannot be assessed with more standard imaging modalities.

Management of patellar and trochlear cartilage lesions with matrix-induced autologous chondrocyte implantation in conjunction with patellofemoral realignment procedures improves patient-reported outcomes and magnetic resonance image appearance.

OBJECTIVES: The aim of this study is to evaluate the relationship between the achievement of clinically significant improvement in patient-reported outcome measures (PROMs) and the postoperative magnetic resonance image (MRI) appearance of matrix-associated chondrocyte implantation (MACI), in conjunction with patellofemoral realignment procedures, for the treatment of grade-IV chondral defects about the patellofemoral joint. METHODS: A retrospective review of patients undergoing MACI for grade-IV chondral defects of the patella or trochlea by a single sports-medicine-fellowship-trained surgeon from 2017 to 2020 was performed. Concomitant realignment procedures, including tibial tubercle osteotomy and medial patellofemoral ligament reconstruction, were also performed as needed. Patients with preoperative and minimum 1-year postoperative PROMs and postoperative knee MRI were included. MRI scans were obtained at 6.3 (interquartile range: 5.8, 7.5) months postoperatively. A fellowship-trained musculoskeletal radiologist assigned a Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score (range: 0-100, with 100 equating to complete graft healing) to each MRI. Achievement of the minimal clinically important difference (MCID) for International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Score-Quality of Life, and Kujala scores were determined for each patient. Paired t-tests or Wilcoxon rank-sum tests were used to evaluate for an association between achievement of the MCID for each PROM and MOCART score. The average follow-up time and time from surgery to PROMs were 2.7 â€‹± â€‹1.5 years and 1.7 â€‹± â€‹0.66 years, respectively. RESULTS: Thirty patients were included. There was a significant improvement in all PROMs from preoperative to postoperative (p â€‹< â€‹0.001). More than two-thirds of patients achieved the MCID for each PROM. Patients who achieved the MCID for IKDC had significantly higher MOCART scores (66.5 â€‹± â€‹16.2) than those who did not meet the MCID for IKDC (50.6 â€‹± â€‹23.6, p â€‹= â€‹0.043). CONCLUSION: MACI for the treatment of patellofemoral chondral injuries is associated with clinically significant improvement in PROMs at short-term follow-up. Clinically significant improvements in IKDC scores are associated with a more mature MRI appearance of the autologous chondrocyte implantation graft on postoperative MRI, as indicated by higher MOCART scores. LEVEL OF EVIDENCE: IV-Case Series.

Capsular Management During Hip Arthroscopy.

PURPOSE OF REVIEW: Hip arthroscopy is widely used for the management of intra-articular pathology and there has been growing interest in strategies for management of the hip capsule during surgery. The hip capsule is an essential structure that provides stability to the joint and it is necessarily violated during procedures that address intra-articular pathology. This article reviews different approaches to capsular management during hip arthroscopy including anatomical considerations for capsulotomy, techniques, clinical outcomes, and the role of routine capsular repair. This article also reviews the concept of hip microinstability and its potential impact on capsular management options as well as iatrogenic complications that can occur as a result of poor capsular management. RECENT FINDINGS: Current research highlights the key functional role of the hip capsule and the importance of preserving its anatomy during surgery. Capsulotomies that involve less tissue violation (periportal and puncture-type approaches) do not appear to require routine capsular repair to achieve good outcomes. Many studies have investigated the role of capsular repair following more extensive capsulotomy types (interportal and T-type), with most authors reporting superior outcomes with routine capsular repair. Strategies for capsular management during hip arthroscopy range from conservative capsulotomy techniques aimed to minimize capsular violation to more extensive capsulotomies with routine capsule closure, all of which have good short- to mid-term outcomes. There is a growing trend towards decreasing iatrogenic capsular tissue injury when possible and fully repairing the capsule when larger capsulotomies are utilized. Future research may reveal that patients with microinstability may require a more specific approach to capsular management.

Postless Tape Augmentation for Posterior Cruciate Ligament Reconstruction.

Many techniques have been described for posterior cruciate ligament (PCL) reconstruction, but residual laxity remains an ongoing challenge. Suture or tape augmentation during ligament reconstruction has become a popular option to prevent graft elongation but comes at the expense of additional costs due to implants for augment fixation, and concern for stress shielding of the graft if the augment and graft are not equally tensioned. We introduce a technique for postless tape augmentation during allograft PCL reconstruction that allows for equal tensioning of graft and augment through the use of a sheath and screw construct without the need for additional implants for augment fixation.