Suture Anchor Fixation Has Less Gap Formation and No Difference in Complications or Revisions for Patellar Tendon Repair: A Systematic Review.

PURPOSE: To evaluate the literature on suture anchor (SA) usage for patellar tendon repair, summarize the overall biomechanical and clinical outcomes, and assess whether the cumulative research supports the adoption of this technique compared with transosseous (TO) repair. METHODS: A systematic literature review using the Preferred Reporting Items for Systematic and Meta-Analyses guidelines was performed. Multiple electronic databases were searched to identify studies focusing on surgical outcomes of patellar tendon repair with suture anchor usage. Cadaver and animal biomechanical studies, technical studies, and clinical studies were included. RESULTS: A total of 29 studies met the inclusion criteria: 6 cadaver, 3 animal, 9 technical, and 11 clinical reports. Four of the 6 cadaver studies and 1 of the 2 animal studies found significantly less gap formation from SA than from TO repair. Average gap formation in human studies ranged from 0.9 to 4.1 mm in the SA group compared with 2.9 to 10.3 mm in TO groups. Load to failure was significantly stronger in 1 of 5 cadaver studies and 2 of 3 animal studies, with human studies SA load to failure ranging from 258 to 868 N and TO load to failure ranging from 287 to 763 N. There were 11 clinical studies that included 133 knees repaired using SA. Nine studies showed no difference between complication rate or risk for reoperation, where one study reported a significantly lower re-rupture rate after SA repair compared with TO repair. CONCLUSIONS: SA repair is a viable option for patellar tendon repair and could have several advantages over TO repair. Multiple studies indicate that SA repair has less gap formation during biomechanical testing compared with TO repair in human cadaver and animal models. No differences in complications or revisions were found in the majority of clinical studies. CLINICAL RELEVANCE: Both animal and human models suggest SA fixation has potential biomechanical benefits when compared with TO tunnels for patellar tendon repair, whereas clinical studies show no difference in complications and revisions postoperatively.

Machine Learning Can Accurately Predict Overnight Stay, Readmission, and 30-Day Complications Following Anterior Cruciate Ligament Reconstruction.

PURPOSE: This study aimed to develop machine learning (ML) models to predict hospital admission (overnight stay) as well as short-term complications and readmission rates following anterior cruciate ligament reconstruction (ACLR). Furthermore, we sought to compare the ML models with logistic regression models in predicting ACLR outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent elective ACLR from 2012 to 2018. Artificial neural network ML and logistic regression models were developed to predict overnight stay, 30-day postoperative complications, and ACL-related readmission, and model performance was compared using the area under the receiver operating characteristic curve. Regression analyses were used to identify variables that were significantly associated with the predicted outcomes. RESULTS: A total of 21,636 elective ACLR cases met inclusion criteria. Variables associated with hospital admission included White race, obesity, hypertension, and American Society of Anesthesiologists classification 3 and greater, anesthesia other than general, prolonged operative time, and inpatient setting. The incidence of hospital admission (overnight stay) was 10.2%, 30-day complications was 1.3%, and 30-day readmission for ACLR-related causes was 0.9%. Compared with logistic regression models, artificial neural network models reported superior area under the receiver operating characteristic curve values in predicting overnight stay (0.835 vs 0.589), 30-day complications (0.742 vs 0.590), reoperation (0.842 vs 0.601), ACLR-related readmission (0.872 vs 0.606), deep-vein thrombosis (0.804 vs 0.608), and surgical-site infection (0.818 vs 0.596). CONCLUSIONS: The ML models developed in this study demonstrate an application of ML in which data from a national surgical patient registry was used to predict hospital admission and 30-day postoperative complications after elective ACLR. ML models developed performed well, outperforming regression models in predicting hospital admission and short-term complications following elective ACLR. ML models performed best when predicting ACLR-related readmissions and reoperations, followed by overnight stay. LEVEL OF EVIDENCE: IV, retrospective comparative prognostic trial.

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball.

PURPOSE: To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature. METHODS: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles. RESULTS: A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play. CONCLUSIONS: Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement. LEVEL OF EVIDENCE: Level IV, systematic review of level II-IV studies.

Machine Learning Model Identifies Preoperative Opioid Use, Male Sex, and Elevated Body Mass Index as Predictive Factors for Prolonged Opioid Consumption Following Arthroscopic Meniscal Surgery.

PURPOSE: To develop a predictive machine learning model to identify prognostic factors for continued opioid prescriptions after arthroscopic meniscus surgery. METHODS: Patients undergoing arthroscopic meniscal surgery, such as meniscus debridement, repair, or revision at a single institution from 2013 to 2017 were retrospectively followed up to 1 year postoperatively. Procedural details were recorded, including concomitant procedures, primary versus revision, and whether a partial debridement or a repair was performed. Intraoperative arthritis severity was measured using the Outerbridge Classification. The number of opioid prescriptions in each month was recorded. Primary analysis used was the multivariate Cox-Regression model. We then created a naïve Bayesian model, a machine learning classifier that uses Bayes' theorem with an assumption of independence between variables. RESULTS: A total of 581 patients were reviewed. Postoperative opioid refills occurred in 98 patients (16.9%). Multivariate logistic modeling was used; independent risk factors for opioid refills included male sex, larger body mass index, and chronic preoperative opioid use, while meniscus resection demonstrated decreased likelihood of refills. Concomitant procedures, revision procedures, and presence of arthritis graded by the Outerbridge classification were not significant predictors of postoperative opioid refills. The naïve Bayesian model for extended postoperative opioid use demonstrated good fit with our cohort with an area under the curve of 0.79, sensitivity of 94.5%, positive predictive value (PPV) of 83%, and a detection rate of 78.2%. The two most important features in the model were preoperative opioid use and male sex. CONCLUSION: After arthroscopic meniscus surgery, preoperative opioid consumption and male sex were the most significant predictors for sustained opioid use beyond 1 month postoperatively. Intraoperative arthritis was not an independent risk factor for continued refills. A machine learning algorithm performed with high accuracy, although with a high false positive rate, to function as a screening tool to identify patients filling additional narcotic prescriptions after surgery. LEVEL OF EVIDENCE: III, retrospective comparative study.

What are patients asking and reading online? An analysis of online patient searches for rotator cuff repair.

BACKGROUND: Patients undergoing rotator cuff surgery often search the internet for information regarding the procedure. One popular source, Google, compiles frequently asked questions and links to websites that may provide answers. This study provides an analysis of the most frequently searched questions associated with rotator cuff surgery. We hypothesize that there will be distinct search patterns associated with online queries about rotator cuff surgery that could provide unique insights into patient concerns. METHODS: A set of search terms were entered into Google Web Search using a clean-install Google Chrome browser. Frequently associated questions and their webpages were extracted to a database via a data mining extension. Questions were categorized by topics relevant for rotator cuff arthroscopy. Websites were categorized by source and scored for quality using the JAMA Benchmark Criteria. Pearson's χ2 tests were used to analyze nominal data. Student t tests were performed to compare JAMA Benchmark Scores. RESULTS: Of the 595 questions generated from the initial search, 372 unique questions associated with 293 websites were extracted and categorized. The most popular question topics were activities/restrictions (20.7%), pain (18.8%), and indications/management (13.2%). The 2 most common websites searched were academic (35.2%) and medical practice (27.4%). Commercial websites were significantly more likely to be associated with questions about cost (57.1% of all cost questions, P = .01), anatomy/function (62.5%, P = .001), and evaluation of surgery (47.6%, P < .001). Academic websites were more likely to be associated with questions about technical details of surgery (58.1%, P < .001). Medical practice and social media websites were more likely associated with activities/restrictions (48.1%, P < .001, and 15.6%, P < .001, respectively). Government websites were more likely associated with timeline of recovery (12.8%, P = .01). On a scale of 0-4, commercial and academic websites had the highest JAMA scores (3.06 and 2.39, respectively). CONCLUSION: Patients seeking information regarding rotator cuff repair primarily use the Google search engine to ask questions regarding postoperative activity and restrictions, followed by pain, indications, and management. Academic websites, which were associated with technical details of surgery, and medical practice websites, which were associated with activities/restrictions, were the 2 most commonly searched resources. These results emphasize the need for orthopedic surgeons to provide detailed and informative instructions to patients undergoing rotator cuff repair, especially in the postoperative setting.

Editorial Commentary: Surgeons Planning Hip Labral Arthroscopic Repair Should Have a Backup Plan of Labral Reconstruction or Augmentation Based on Intraoperative Labral Degeneration, Hypoplasia, or Ossification.

The arena of hip arthroscopy has seen leaps in practices over the past decade, evolving from surgical debridement of the labrum to improvements in techniques which now allow repair, augmentation, and circumferential reconstruction. But as the operating theater continues to change its act, so too must the preoperative choreography. Recent advancements in the understanding of preoperative risk factors for failure of primary labral repair have identified the diminutive or hypoplastic labra on prescreening magnetic resonance imaging as a negative predictor of success. While this quantitative assessment predicts the anatomical coverage of the labrum, we are still limited in our ability to qualify the latter's tissue substance preoperatively. Ossified or degenerative labra may not have the inherent functional capacity to restore the suction seal of the hip in a primary repair setting. If the applause from the audience fails to reach a significant threshold, we must rethink our act, and that begins with the choreography. The next step in hip arthroscopy is determining if a primary augmentation or reconstruction, in lieu of primary repair, warrants further consideration. Until we develop reliable methods of quantifying and qualifying the labral tissue, both preoperatively and optimally, we should establish backup for surprises encountered while on the "stage."

Automated Text-Messaging After Hip Arthroscopy: A Randomized-Controlled Trial of "Post-Op Buddy".

PURPOSE: To assess an automated text-messaging system for patients after hip arthroscopy and its impact at 90 days on the Hip Disability Osteoarthritis Outcome Score Physical Function Short form (HOOS-PS, HOOS-Pain), compliance with rehabilitation guidelines, and patient satisfaction. METHODS: One hundred twenty-one participants (average age 29 ± 8.7 years, 52% female) undergoing hip arthroscopy at 2 academic institutions were prospectively enrolled and randomized to receive (1) standard perioperative communication or (2) additional automated mobile phone text messages. Inclusion criteria included ability to communicate in written English and access to a mobile phone with text-messaging capability. Patients undergoing revision surgery or simultaneous femoral or acetabular osteotomy were excluded. HOOS-PS and HOOS-Pain were collected preoperatively, and after surgery an automated mobile phone robot sent participants in the therapeutic arm intermittent text messages for 90 days. At 90 days all participants again completed HOOS-PS, HOOS-Pain, and additional survey questions on satisfaction with their experience (10-point scale), communication from the surgical team (10-point scale) and adherence to physical therapy exercises, weight-bearing guidelines, and brace use, The primary outcome assessed was a statistically significant change in HOOS-PS and HOOS-Pain; secondary outcomes included change in satisfaction, communication, and adherence to physical therapy exercises, weightbearing guidelines, or brace use. Wilcoxon rank sum was used to compare HOOS-PS and HOOS-Pain scores at 0 and 90 days. Demographic characteristics and survey variables were compared using Students t test for continuous variables and χ2 or Fisher exact test for categorical variables as appropriate. RESULTS: There were statistically significant and clinically relevant improvements in HOOS-PS and HOOS-Pain in both groups (P < .05). Subjective feedback was strongly positive, with 96% of text message participants reporting they would choose automated messages if it was offered to them again in the future. CONCLUSIONS: Ninety days of automated text messaging after hip arthroscopy failed to show a significant difference in HOOS-PS (P = .09), HOOS-Pain (P = .13), patient-reported compliance with postoperative guidelines, or satisfaction with support and communication from the surgical team. LEVEL OF EVIDENCE: I, randomized control trial (RCT).

Academic Influence as Reflected by h Index Is Not Associated With Total Industry Payments but Rather With National Institutes of Health Funding Among Academic Orthopaedic Sports Medicine Surgeons.

PURPOSE: (1) To compare the total number and dollar amount of industry funding and National Institutes of Health (NIH) funding to academic orthopaedic sports medicine surgeons and (2) to examine the impact of academic influence on industry funding and NIH funding to academic orthopaedic sports medicine surgeons. METHODS: Academic orthopaedic sports medicine surgeons were identified using faculty web pages. Academic influence was approximated by a physician's Hirsch index (h index) and number of publications and obtained from the Scopus database. Total industry payments were acquired through the Open Payments Database, and NIH funding was determined from the NIH website. Statistical analysis was performed using Mann-Whitney U test and Spearman correlations with significance set at P < .05. RESULTS: Physicians who received industry research payments and NIH funding had a significantly higher mean h index and more mean total publications than physicians who did not receive industry research payments and NIH funding. There were no significant differences in h index (P = .374) or number of publications (P = .126) between surgeons receiving industry nonresearch funding and those who did not. h Index and number of publications were both weakly correlated with the amount of industry research and nonresearch funding. CONCLUSION: Although academic influence is associated with industry research funding and NIH funding, there is no association between measures of academic influence and total industry and industry nonresearch payments. Combined with the weak associations between academic influence and the amount of industry payments, academic influence does not appear to be a major determinant of industry funding to academic orthopaedic sports medicine surgeons. CLINICAL RELEVANCE: Surgeons should be cognizant of potential conflicts with industry, but the relationship between academic sports medicine surgeons and industry may be less subject to bias than previously believed.

The Efficacy of Arthroscopic Simulation Training on Clinical Ability: A Systematic Review.

PURPOSE: To examine the effect of arthroscopic simulator training on technical performance in a human model. METHODS: A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches of PubMed, Embase, and Cochrane Library were conducted using combinations of the terms virtual, digital, computer, reality, simulation, arthroscopy, training, learning, and education. Studies were considered for inclusion if they tested the effect of arthroscopic simulator training in a randomized controlled fashion, performed testing in a cadaver or live patient, and used explicit outcome measures of technical skill. Data from studies were extracted and study characteristics and outcomes were reviewed. The primary outcome measure was the number of studies in which the simulation trained group had significantly improved performance results relative to the control group in ≥50% of all measured outcomes. Risk of bias was assessed with Cochrane's Collaboration Tool. RESULTS: Twelve studies, including 340 total study participants, were included for review. Eight studies showed improved performance of the simulation trained group relative to the control group in ≥50% of assessed outcomes. Six of ten studies reporting completion time, three of six studies reporting task checklist completion, 3 of 7 studies reporting global rating scales, and 1 of 4 studies reporting Arthroscopic Surgical Skill Evaluation Tool scores showed improved performance of the simulation group relative to the control group for the respective outcome measures. CONCLUSIONS: The literature is limited due to heterogeneity, both in type and merit, of the outcome measures that have been used to assess the transfer validity of arthroscopic simulator training to clinical performance. Despite the limitations of the literature, this review demonstrates that arthroscopic simulator training has potential to improve clinical performance. LEVEL OF EVIDENCE: II, systematic review of Level II studies.

Magnetic Resonance Imaging Predictors of Chondral Lesions in Patients With Femoroacetabular Impingement: An Analysis of 545 Cases.

PURPOSE: A large prospective cohort was used (1) to evaluate the overall ability of magnetic resonance imaging (MRI) to detect Outerbridge grade III and IV cartilage defects found during surgery and (2) to identify the specific MRI findings most associated with these cartilage defects so that the practicing hip arthroscopist can better predict cartilage injury before surgery. METHODS: All patients undergoing hip arthroscopy between February 2015 and May 2017 at 1 institution were enrolled in a prospective cohort. Intra-articular findings were documented at the time of surgery. MRI reports were retrospectively reviewed for radiologist-reported articular cartilage, osseous, or synovial abnormalities. Sensitivity and specificity of MRI findings were calculated; multivariate logistic regression analysis determined which findings were associated with high-grade chondral damage at the time of arthroscopy and used to create an online risk calculator, https://orthop.washington.edu/hiprisk/. RESULTS: Of 598 patients who underwent hip arthroscopy, 550 had MRI reports available for review (92%). Grade III and IV cartilage injuries were reported on arthroscopy in 70 patients (13%) of average age 33 ± 13 years. On univariate analyses, individual MRI findings were not sensitive in detection of articular cartilage injury (mean 22%; range, 1.4%-46%), but positive findings were highly specific (mean 90%,; range, 76%-99%). Multivariate analysis revealed that older age (odds ratio [OR] 1.09 [1.06-1.11], P < .001) and osseous findings such as subchondral cyst or edema (OR 4.77 [2.51-9.05], P < .001) were most predictive of grade III and IV defects (P < .001). CONCLUSION: MRI was a specific but not sensitive tool in diagnosing articular cartilage injury. Surgeons should be aware that osseous findings such as cysts or edema are highly predictive of full-thickness cartilage loss in FAI. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria (consecutive patients with consistently applied reference standard, no blinding).

The impact of age on 30-day complications following shoulder instability surgery.

HYPOTHESIS: The purpose of this study was to evaluate short-term outcomes including medical complications, overnight admission, and 30-day readmission with regard to patient age at the time of shoulder instability surgery. METHODS: Patients undergoing surgery for glenohumeral instability were collected from the National Surgical Quality Improvement Program between the years of 2005 and 2016. These patients were separated into cohorts of younger than 25 years, 25-34 years, and older than 34 years. Medical complications, hospital admission, and 30-day readmission were compared using multivariate analysis. RESULTS: Of the 5449 patients included, there were 2035 (37.0%) patients younger than 25 years, 1815 (33.0%) between 25 and 34 years, and 1649 (30.0%) 35 and older. Overall, 81.7% of patients underwent an arthroscopic Bankart repair, 12.6% of patients underwent an open Bankart repair, and 5.7% of patients underwent a Latarjet-Bristow procedure. The risk of 30-day readmission increased with age, ranging from 0.24% for <25 years old to 0.92% for 35 years and older (P = .040). Operative duration greater than 60 minutes (odds ratio [OR] 1.76; P = .001), duration greater than 90 minutes (OR 3.58; P < .001), and American Society of Anesthesiologists class III and IV (OR 1.80; P = .001) were associated with increased risk of overnight hospital stay. Compared with arthroscopic Bankart repair, the Latarjet-Bristow procedure was associated with increased total complications (OR 3.30; P = .021), overnight hospital stay (OR 4.64; P < .001), and 30-day readmission (OR 3.39; P = .013). CONCLUSION: This study demonstrates that even in the relatively young and healthy shoulder instability patient cohort, patients older than 25 years are almost 4 times more likely to experience a complication. Additionally, Latarjet-Bristow procedures are 3-4 times more likely to experience a complication or readmission than other shoulder instability procedures.

Trends in Hip Arthroscopic Labral Repair: An American Board of Orthopaedic Surgery Database Study.

PURPOSE: The purpose of this study is to evaluate the trends in labral repair in American Board of Orthopaedic Surgery Part II candidates performing hip arthroscopy. METHODS: Candidates who performed arthroscopic hip surgery between 2011 and 2015 during their American Board of Orthopaedic Surgery Part II board collection period were identified using Current Procedural Terminology codes (29860, 29861, 29862, 29863, 29914, 29915, 29916). The proportion of hip arthroscopy cases including labral repair (Current Procedural Terminology code 29916) were calculated for each year and analyzed by fellowship training experience. Trends in labral repair utilization were calculated using univariate and regression analyses, with significance set at P < .05. RESULTS: During the study period, 1,606 hip labral repair cases were performed, with a 35% increase in utilization between 2011 and 2015. Overall, labral repair was performed in 64.8% (1,606/2,480) of hip arthroscopy cases, with a significant increase between 2011 and 2015 (47.4% vs 79.2%; P < .001). Of the hip arthroscopy cases including labral repair, 80.4% (1,291/1,606) were performed by candidates with sports medicine fellowship training. The proportion of hip arthroscopy cases including labral repair was highest for surgeons with sports medicine fellowship training compared with those without sports medicine fellowship training (66.1% vs 59.8%; P = .007). Candidates with sports medicine training performing at least 1 labral repair each year increased from 68% to 89% over the study period (P = .0007). The average number of labral repairs per candidate increased significantly over the duration of the study period (P = .0072). CONCLUSIONS: Labral repair utilization during hip arthroscopy procedures nearly doubled from 2011 to 2015 for American Board of Orthopaedic Surgery Part II candidates, reflecting a significant change in practice. Current data suggest that nearly 80% of hip arthroscopy procedures include labral repair. These trends may reflect the current practice patterns at academic institutions with sports medicine fellowships.

Prescription Opioid Use Before and After Hip Arthroscopy: A Caution to Prescribers.

PURPOSE: To determine pre- and postoperative opioid utilization while identifying risk factors for prolonged postoperative opioid use following hip arthroscopy. METHODS: All patients undergoing hip arthroscopy between 2007 and the second quarter of 2016 were identified within the Humana Inc. administrative claims database. Chronic preoperative opioid utilization was defined as filling of any opioid prescription 1 to 3 months before surgery, whereas acute preoperative opioid utilization was defined as filling any opioid prescription within 1 month of surgery. Rates of pre- and postoperative opioid utilization were calculated, and patient demographic characteristics and medical conditions associated with pre- and postoperative opioid utilization were identified. RESULTS: Of the 1,208 patients undergoing hip arthroscopy, chronic and acute preoperative opioid utilization was observed in 24.9% and 17.3% of patients, respectively. Chronic preoperative opioid utilization was more frequently observed in obese (P < .001) patients, those ≥50 years of age (P = .002), and those with preexisting anxiety and/or depression (P < .001). In multivariate analysis, chronic preoperative opioid utilization was the strongest predictor of opioid prescription filling at 3, 6, 9, and 12 months postoperatively (odds ratio at 3 months, 18.60, 95% confidence interval, 12.41 to 28.55), whereas preexisting anxiety and/or depression and obesity were additionally identified as predictors of prolonged postoperative opioid utilization. CONCLUSIONS: Chronic preoperative opioid utilization before hip arthroscopy is common at 24.9%. The high rate of chronic preoperative opioid utilization is particularly important considering that chronic preoperative opioid utilization is the strongest predictor of continued postoperative opioid prescription filling out to 12 months postoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Assessing the Readability of Online Information About Hip Arthroscopy.

PURPOSE: To investigate the current readability of online information pertaining to hip arthroscopy. METHODS: The terms "hip arthroscopy" and "hip scope" were entered into the advanced search functions of Google, Yahoo!, and Bing on March 25, 2017, and results from the first 3 pages were analyzed. Results were required to be unique, accessible websites with information about hip arthroscopy conveyed primarily via analyzable text. Two reviewers applied inclusion criteria to the initial 97 results, discussing to reach consensus in cases of disagreement. Overall, 60 unique results were reviewed with 48 meeting inclusion criteria. Websites were categorized as physician-sponsored, academic, commercial, governmental and nonprofit organization (NPO), or unspecified. Readability was measured via 6 different indices: the Flesch-Kincaid grade level (FKGL), Flesch Reading Ease (FRE), Gunning Fog Score, SMOG Index, Coleman-Liau Index (CLI), and Automated Readability Index (ARI) along with an average grade level and readability classification score. RESULTS: Forty-eight unique websites were assessed for readability, with physician-sponsored webpages composing the majority (47.92%) followed by academic sources (35.42%). The webpages' average grade level, incorporating information from all 6 metrics, was 12.79 ± 1.98. CONCLUSIONS: The current readability of online information pertaining to hip arthroscopy is at an inappropriately high reading level compared with the sixth-grade level recommended by the American Medical Association and National Institutes of Health, thus introducing significant barriers to understanding for many patients. Online materials should be edited to reduce word and sentence length and complexity, use simpler terms, and minimize use of passive voice to facilitate patient knowledge acquisition and understanding of online information about hip arthroscopy. CLINICAL RELEVANCE: This study shows that the current readability of online information on hip arthroscopy exceeds the suggested sixth-grade reading level. It also emphasizes the need for simplifying written materials and offers specific suggestions on doing so to increase accessibility of information for patients.

Incorporating Hip Arthroscopy Into A Practice.

Hip arthroscopy is one of the most rapidly growing areas in orthopaedic surgery because of increased awareness of nonarthritic hip pathologies, advanced imaging modalities, and advanced techniques to reproducibly manage nonarthritic hip pathologies within a deep soft-tissue envelope and a constrained joint. In addition, more academic medical centers are providing residents with education on hip arthroscopy, and many hip preservation fellowships and courses are helping increase awareness of nonarthritic hip pathologies. Nonarthritic hip pathologies currently managed via hip arthroscopy include nonrepairable labral lesions, femoroacetabular impingement, hip instability, and hip fractures. Periarticular hip pathologies currently managed via endoscopy include greater trochanteric pain syndrome, tendinopathy and tears of the gluteus medius and minimus, partial and complete hamstring avulsions, and sciatic nerve entrapment. Ischiofemoral impingement may be addressed endoscopically via the deep gluteal space. Orthopaedic surgeons should understand the role and safety of hip arthroscopy in the pediatric population, specifically in the management of slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and septic arthritis of the hip. The efficacy of hip arthroscopy is limited, and hip arthroscopy is relatively contraindicated in patients with osteoarthritis and hip dysplasia. Complications can occur and likely are underreported in patients who undergo hip arthroscopy. Orthopaedic surgeons should understand practical issues associated with incorporating hip arthroscopy into a practice, including the difficult learning curve associated with hip arthroscopy and the reluctance of some payors to reimburse procedures performed arthroscopically because hip arthroscopy is a relatively new technology.

Throwing-related injuries of the subscapularis in professional baseball players.

OBJECTIVE: To describe the MR appearance of a series of throwing-related injuries to the subscapularis muscle-tendon complex among baseball players. MATERIALS AND METHODS: A retrospective review of MR scans of the shoulder in players from 1 professional baseball organization over the course of 5 years was performed to identify cases with findings suggestive of subscapularis injury. These findings were graded and the medical record was reviewed to assess clinical findings, treatment, and follow-up. Preinjury baseline measurements of arm external rotation at 90° of abduction were compared to measurements from a noninjured cohort to evaluate whether this measure is a risk factor for injury. RESULTS: A total of 133 MR scans of the shoulder were evaluated. Eleven of the scans demonstrated signal changes suggesting subscapularis injury; 10 of these 11 patients had clinical findings supporting a diagnosis of throwing-related subscapularis strain. There were four grade 1, four grade 2, and two grade 3 injuries. All injuries occurred in the inferior half of the subscapularis at the myotendinous junction. Risk of subscapularis injury increased with lower levels of dominant arm external rotation (odds ratio, 1.12; 95% CI, 1.07-1.21; p < 0.001). A threshold of dominant arm external rotation of <106° demonstrated sensitivity of 0.700 (95% CI, 0.392-0.897) and specificity of 0.951 (95% CI, 0.888-0.982) for subscapularis injury. CONCLUSION: Throwing-related subscapularis injuries occur in the inferior half of the muscle at the myotendinous junction. Our data suggest that there is an increased risk of these injuries with lower levels of dominant arm external rotation.

Outcomes After Diagnostic Hip Injection.

PURPOSE: To provide a comprehensive review of outcomes associated with local anesthetic (LA) or LA and corticosteroid (CS) diagnostic hip injections, and how well response predicts subsequent operative success. METHODS: A systematic review from database (PubMed, Medline, Scopus, Embase) inception to January 2015 for English-language articles reporting primary patient outcomes data was performed, excluding studies with >50% underlying osteoarthritis. Studies were assessed by 2 reviewers who collected pertinent data. RESULTS: Seven studies were included, reporting on a total 337 patients undergoing diagnostic hip injection. The mean age was 34.4 years, with 5 studies reporting 94 (35.2%) males and 173 (64.8%) females. One study examined the rate of pain relief with LA (92.5%); 2 CS studies reported relief on a scale from 0% to 100% (no to complete relief), ranging from 61% to 82.3%; and 3 studies used 10-point pain scales, with a CS study noting a pain score of 1.0, an LA study with a score of 3.03, and 1 study using either CS or LA scores of 3 to 5.6. Duration of pain relief was 9.8 (CS) and 2.35 days (LA). By pathology, greatest relief was achieved in acetabular chondral injury (93.3%) and least in cam impingement (81.6%), with clinical and imaging findings being unreliable predictors of relief. One study showed nonresponse to be a strong predictor of negative surgical outcome for femoroacetabular impingement. CONCLUSIONS: Diagnostic hip injections provide substantial pain relief for patients with various hip pathologies, with limited data to suggest greatest relief for those with chondral injury. Clinical and imaging findings are unreliable predictors of injection response, and nonresponse to injection is a strong negative predictor of surgical outcome. Future research should focus on elucidating differences by underlying pathology and predicting future operative success. LEVEL OF EVIDENCE: Level IV, systematic review.

Adolescent Femoroacetabular Impingement: Gender Differences in Hip Morphology.

PURPOSE: To compare the hip morphology of adolescent male patients and female patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) and determine if gender differences exist. METHODS: We retrospectively reviewed the records of 177 adolescents, aged 13 to 18 years, who were treated for FAI with hip arthroscopy. We examined and analyzed preoperative magnetic resonance imaging (MRI) scans and plain radiographs, measuring the lateral center-edge angle, Tönnis angle, and alpha angle. The intraclass correlation coefficient between readers was calculated. We created multiple linear regression models incorporating age, gender, and body mass index (BMI) with the radiographic measurements. Intraoperative findings using the Outerbridge grading system, as well as procedure performed, were documented. We compared these findings with our preoperative imaging measurements using the χ2 test and the Wilcoxon rank sum test. RESULTS: The intraclass correlation coefficient showed moderate to strong agreement between the 3 image readers. The BMI- and age-adjusted mean alpha angle was higher in male patients than female patients on both plain radiographs (55.9° vs 45.2°, P < .0001) and axial oblique MRI scans (54.1° vs 42.5°, P < .0001). An alpha angle greater than 55° was found in 38.9% of male patients compared with only 1% of female patients (P < .0001). The lateral center-edge angle and Tönnis angle on MRI scans and plain radiographs displayed no statistically significant differences between genders after we controlled for BMI and age. Male patients were more likely to have chondral damage intraoperatively than female patients (56.3% vs 32.5%, P = .0041). CONCLUSIONS: Distinct differences between genders were seen both on preoperative imaging and at the time of hip arthroscopy. We found that male patients with FAI displayed a larger mean alpha angle, and therefore a more severe cam-type deformity, than female patients. Our study also found that male patients were more likely to show evidence of chondral damage than female patients at the time of surgery. LEVEL OF EVIDENCE: Level IV.

The Impact of the Multicenter Orthopaedic Outcomes Network (MOON) Research on Anterior Cruciate Ligament Reconstruction and Orthopaedic Practice.

With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction.