The Windshield Wiper Sign Is an Instability-Related Osteochondral Defect of the Anterolateral Femoral Head.

PURPOSE: To investigate a radiographic sign believed to be indicative of hip instability and acetabular suction seal disruption in the native hip, coined the "windshield wiper" (WSW) sign. METHODS: A retrospective review was performed for patients who underwent periacetabular osteotomy (PAO) with the senior author between March 2021 and September 2023. A WSW sign was identified on plain films as a concave or flat osteochondral defect on the anterolateral femoral head extending medial to the head-neck junction with resultant loss of femoral head sphericity in the native hip. Every patient underwent a standardized series of radiographs, as well as computed tomography and magnetic resonance imaging. All patients underwent arthroscopy before PAO to address intra-articular pathology and other indicated procedures. The osteochondral defect and resultant suction seal disruption were verified during arthroscopy. These patients were then compared with a control group of arthroscopically treated hips without hip instability. RESULTS: Of 250 patients reviewed, a total of 19 hips in 17 patients (prevalence of 7.6%) demonstrated radiographic evidence of the WSW sign. All patients with a WSW sign presented with symptomatic clinical hip instability requiring a PAO. The mean patient age was 31.2 years, with a mean lateral center-edge angle (LCEA) of 14.3°. There were 13 hips (68.4%) with dysplasia, 4 (21.1%) with borderline dysplasia, and 2 (10.5%) with a normal LCEA. All patients with a WSW sign and LCEA ≥ 20° displayed significant femoral antetorsion abnormalities. All arthroscopic videos and images demonstrated a compromised suction seal. Of the 50 control group hips reviewed, the WSW sign was not identified. CONCLUSIONS: The WSW sign is an uncommon radiographic finding in patients with hip instability. When identified, it can be predictive of substantial instability, especially in cases which are otherwise considered borderline dysplasia or normal based on LCEA. LEVEL OF EVIDENCE: Level III, retrospective comparative case control study.

The Everted Acetabular Labrum: Outcomes of Surgical Management.

BACKGROUND: An everted acetabular labrum (EL) is a pathologic variant in which the labrum is flipped to the capsular side of the acetabular rim. An iatrogenic EL is a known complication of a poorly executed labral repair, and a recent study described the native acetabular EL. PURPOSE: To analyze surgical outcomes after advancement or reconstruction of an EL in a native hip. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a multicenter retrospective review of prospectively collected data on primary hip arthroscopic surgeries performed between 2013 and 2023. An EL was identified arthroscopically as a labrum-femoral head gap while off traction in the native hip. All patients with EL who were analyzed in this study underwent arthroscopic labral repair and advancement or labral augmentation or reconstruction. Patients with hip dysplasia also underwent periacetabular osteotomy with or without a derotational femoral osteotomy. Patient-reported outcomes (PROs) were assessed using the 12-item International Hip Outcome Tool (iHOT-12) and the Nonarthritic Hip Score. PROs were obtained preoperatively and up to 24 months after surgery. PROs were compared with those of a case-matched control cohort in a 1:2 ratio. Only patients with PROs available at ≥1 year postoperatively were included in the outcome analysis. RESULTS: A total of 111 patients (129 hips) with EL during the study period were identified, with PROs available in 96 hips. The mean age of patients with EL was 30.5 years, and women made up 87% of the cohort. Of the 129 hips with an EL, an isolated diagnosis of an EL was present in 11.6% of hips. Deficient acetabular coverage (lateral center-edge angle <25°) was seen in 40.6% of EL hips. No difference was seen in iHOT-12 scores between EL and control groups at 12- or 24-month follow-up (P = .18 and .94, respectively). Patients with EL reported a significant improvement of PROs at latest follow-up (P < .001 for iHOT-12 and Nonarthritic Hip Score). CONCLUSION: Surgical management of a native EL with restoration of the labral seal on the femoral head and correction of concomitant pathologies resulted in significant clinical improvement, with postoperative outcome scores comparable to those of patients without an EL. These findings provide evidence supporting surgical intervention for a native EL.

A Modified "Shuttle" Method Technique for Arthroscopic Hip Capsular Reconstruction in Capsular Deficiency.

The hip capsule has been recognized as a vital structure in the stability and proper function of the hip. Preserving its integrity during arthroscopic surgery is one of the utmost important principles in hip preservation surgery. When capsular deficiency is present, capsular reconstruction may be indicated to restore stability and proper hip mechanics. In this technical note, we introduce a simple and reproducible shuttle method technique for hip capsular reconstruction using a dermal allograft.

Lateral Extra-articular Tenodesis: The Onlay Technique.

Tibial anterolateral rotary instability associated with anterior cruciate ligament (ACL) tears is a well-documented and difficult problem with a long history of solutions. The lateral extra-articular tenodesis (LET) has undergone multiple refinements in technique, largely focusing on the femoral site insertion using either an interference screw versus a staple for adequate fixation. In this article, we present an improved technique using a suture anchor as an alternative to a staple or an interference screw with secure fixation to insert the LET graft onto the femur. This technique diminishes the chance of ACL tunnel-LET drilling convergence, minimizes the footprint required for adequate graft fixation, and allows the surgeon to dial in the correct tension necessary for adequate augmentation of an ACL reconstruction.

Acetabular Labral Reconstruction: Review of Techniques and Outcomes.

PURPOSE OF REVIEW: To analyze advances in labral reconstruction, and to discuss the literature relating to efficacy, outcomes, and technical considerations of labral reconstruction. RECENT FINDINGS: The available evidence suggests that labral reconstruction is a safe and effective procedure that can improve pain and function in patients with severe and/or complex labral tears. The superiority of labral reconstruction over labral repair is uncertain, and it remains unclear what graft type and technique should be used in labral reconstructions. Labral reconstruction assists in restoring the function of the labrum of the hip. It consistently restores stability of the hip joint and demonstrates good clinical outcomes at follow-up. The optimal graft type, technique, and extent are still debated, and more research is needed. Ultimately, despite this uncertainty, labral reconstruction is proving to be a valuable tool for hip preservation specialists.

Left Knee Open Rectus Femoris Repair With Achilles Allograft Augmentation: A Case Report.

CASE: We present a case of a 48-year-old man with a subacute tear of his left rectus femoris, repaired using Achilles tendon allograft. After fixation distally to the patella using suture anchors and a Krackow suture technique, the allograft was fixed proximally to the remnant rectus femoris tendon with multiple sutures in a variety of stitch configurations. The patient recovered excellently, regaining near-normal flexion and an intact straight leg raise without an extensor lag. CONCLUSION: The literature regarding repair of subacute and chronic rectus femoris ruptures is limited. We provide an additional option for operative repair of subacute and chronic ruptures using Achilles tendon allograft.

A Technique for Optimizing Hip Labrum Suction Seal With a Double-Limb, Oblique Inverting Mattress Stitch: The "X" and the "M" Configurations.

Classic techniques in arthroscopic hip labral repair use circumferential or intrasubstance suture secured with anchors typically placed behind the labrum (capsular side). The primary goal of labral repair is to re-establish the hip suction seal and is often achieved via fixation techniques that invert viable labral tissue to restore or improve contact with the femoral head. Many repair techniques use only 1 suture limb either passed circumferentially around the labrum or passed in an intrasubstance manner, resulting in smaller purchase of labral tissue and lack of a strong inverting vector. In some cases, this may evert the labral tissue, compromising the suction seal. We describe a technique in which both suture limbs are passed in a mattress, figure-of-8 configuration, through the labral tissue, and tied on the capsular side to yield an inverting, double-limb repair. Therefore, each anchor results in a wider, more impactful repair footprint while reliably inverting the labral tissue.

Three-Dimensional Analysis Versus Two-Dimensional Slice-Based Analysis of CT for Measuring Femoral Torsion and Its Correlation to Passive Hip Range of Motion.

Introduction Femoral torsion is an important anatomical consideration of the hip that has major implications on the natural motion of the hip joint. Similarly, it affects pathologic conditions of the hip, including femoroacetabular impingement, dysplasia, and/or microinstability. Femoral torsion is typically measured on two-dimensional (2D) axial CT cuts by creating the angle between the femoral neck and the posterior aspect of the ipsilateral femoral condyles. Position of the leg during imaging may affect 2D measurements. Three-dimensional (3D) analysis of a hip CT with inclusion of femoral alignment may portray the anatomy of the hip more accurately as compared to a 2D slice-based analysis of a hip CT scan. It is thought that femoral torsion measured using this system could be a more accurate and reliable means of measurement. The primary purpose of this study is to assess the differences in measuring femoral torsion with 3D modeling and analysis compared to the standard 2D slice-based approach on a CT scan. Secondarily, we attempt to determine how the passive range of motion of the hip correlates with femoral torsion measured using the 3D model versus the 2D model. Methods In a prospective cohort study of 20 patients, femoral torsion was assessed using both 2D analysis and 3D analysis. The differences between these measurements on each of the imaging modalities were compared. Additionally, each patient had the passive range of motion of their hip measured with a goniometer. The amount of internal and external rotation was measured with the hip in a neutral position and with the hip flexed to 90°. Acetabular version, combined version, and alpha angle were added to multivariate regression analysis to evaluate their effect versus femoral torsion alone. Results Femoral antetorsion measured using the standard 2D slice-based approach on CT scan was 22.1° (SD: 11.1°), which was higher (p<0.001) than that using 3D analysis (8.25°; SD: 10.5°). There was a strong correlation between femoral torsion measurements using 3D analysis and 2D analysis (R=0.91). Based on 3D analysis, there was a moderate correlation between femoral torsion and passive hip external rotation measured with the hip flexed to 90° (R=0.65, p<0.002) and with the hip in a neutral position (R=0.58, p<0.007). Conclusion There was a significant difference between femoral torsion measurements using the 3D analysis, which showed approximately 14° of less antetorsion on average. Additionally, rotation of the hip and femoral torsion was correlated to higher levels of antetorsion associated with more internal rotation of the hip.

Return-to-Play Outcomes in Professional Baseball Players After Nonoperative Treatment of Incomplete Medial Ulnar Collateral Ligament Injuries: A Long-Term Follow-up Study.

BACKGROUND: Medial ulnar collateral ligament (UCL) injuries are common among baseball players. There is sparse literature on long-term results after nonoperative treatment of UCL injuries in professional baseball players. PURPOSE: The primary purpose was to assess long-term follow-up on reinjury rates, performance metrics, rate of return to the same level of play or higher (RTP), and ability to advance to the next level of play in professional baseball players after nonoperative treatment of incomplete UCL injuries. The secondary aim was to perform a matched-pair comparison between pitchers treated nonoperatively and a control group without a history of UCL injuries. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Twenty-eight professional baseball players (18 pitchers, 10 position players) treated nonoperatively were identified from a previous retrospective review of a single professional baseball organization between 2006 and 2011. UCL reinjury rates and player performance metrics were evaluated at long-term (minimum, 9 years) follow-up. Rates of RTP were calculated. A matched-pair comparison was made between the pitchers treated nonoperatively and pitchers without a history of UCL injuries. RESULTS: Overall, 27 players (17 pitchers, 10 position players) were available for long-term follow-up at a mean follow-up of 12 years (SD, 2 years). The overall rate of RTP was 85% (23/27), with the rate of RTP being 82% (14/17) in pitchers and 90% (9/10) in position players. Of the 23 players who did RTP, 18 (78%) reached a higher level of play and 5 (21.7%) stayed at the same level. Of the 9 position players who did RTP, the median number of seasons played after injury was 4.5 (interquartile range, 3.3). Of the 14 pitchers who did RTP, the mean number of seasons played after injury was 5.8 (SD, 3.8). In the matched-pair analysis, no significant differences were observed in any performance metrics (P > .05). The overall reinjury rate was 11.1% (3/27), with no players requiring UCL reconstruction. CONCLUSION: There was a high rate of RTP for professional baseball players treated nonoperatively for incomplete UCL injuries. Compared with a matched cohort with no history of UCL injury, professional baseball pitchers treated nonoperatively had similar performance metrics. Reinjury rates were low, and no player had reinjury requiring UCL reconstruction. Nonoperative treatment of incomplete UCL injuries in professional baseball players, specifically pitchers, is a viable treatment option in the long term.

Biomechanical Testing of Suture Anchor Versus Transosseous Tunnel Technique for Quadriceps Tendon Repair Yields Similar Outcomes: A Systematic Review.

PURPOSE: To systematically review the literature to evaluate the biomechanical properties of the suture anchor (SA) versus transosseous tunnel (TO) techniques for quadriceps tendon (QT) repair. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase using PRISMA guidelines to identify studies that evaluated the biomechanical properties of SA and TO techniques for repair of a ruptured QT. The search phrase used was "quadriceps tendon repair biomechanics". Evaluated properties included ultimate load to failure (N), displacement (mm), stiffness (N/mm), and mode of failure. RESULTS: Five studies met inclusion criteria, including a total of 72 specimens undergoing QT repair via the SA technique and 42 via the TO technique. Three of 4 studies found QTs repaired with SA to have significantly less elongation upon initial cyclic loading when compared to QTs repaired with the TO technique (P < .05). Three of 5 studies found QTs repaired with SA to have significantly less elongation upon final cyclic loading when compared to QTs repaired with the TO technique (P < .05). The pooled analysis from 4 studies reporting on initial displacement showed a statistically significant difference in favor of the SA group compared to the TO group (P = .03). The pooled analysis from studies reporting on secondary displacement and ultimate load to failure showed no significant difference between the SA and TO groups (P > .05). The most common mode of failure in both groups was suture slippage. CONCLUSION: On the basis of the included cadaveric studies, QTs repaired via the SA technique have less initial displacement upon cyclic testing when compared to QTs repaired via the TO technique. However, final displacement and ultimate load to failure outcomes did not reveal differences between the two fixation strategies. Knot slippage remains a common failure method for both strategies.

Distal Adductor Longus Avulsion: A Technique for Successful Repair.

Strains of the adductor muscle are common among athletes, but avulsion at its insertion is rare. Likewise, the diagnosis and management of distal ruptures of the adductors are infrequently reported in the literature. Presented here are the common presenting clinical findings of chronic distal adductor longus tendon ruptures and a description of how these can be successfully treated with a previously undescribed surgical technique. Preoperative and postoperative magnetic resonance imaging can be compared for verification of successful surgical repair. Also reviewed are common sports and mechanisms that elicit this injury pattern, adductor longus muscle function, relevant surgical anatomy, and treatment strategies.

Open Repair of Acute Proximal Adductor Magnus Avulsion.

Hip adduction is accomplished through coordinated effort of the adductor magnus, brevis, and longus and the obturator externus and pectineus muscles. Each of these muscles may be injured at its proximal or distal insertion or in its midsubstance. The incidence of injuries to the adductor complex is difficult to determine in sport because of players' underreporting and playing through minor strains. The most commonly injured adductor muscle is the adductor longus muscle. The injury most frequently occurs at the proximal or distal musculotendinous junction, but several case reports of origin and insertional ruptures of the adductor longus exist in the literature. Successful outcomes have been obtained with both operative and nonoperative approaches in these cases. Reports of isolated proximal avulsion of the adductor magnus are less common. This article describes our surgical technique for management of a rare acute proximal adductor magnus avulsion.

Surgical Technique for Release of Anterior Interval Scarring of the Knee After Anterior Cruciate Ligament Reconstruction.

Postoperative scarring is a known complication after arthroscopic anterior ligament reconstruction of the knee. The anterior interval of the knee has been previously identified as a common location for anterior scar formation. The anterior interval is defined as the space between the infrapatellar fat pad and the anterior border of the tibia. Patients with anterior interval scarring often present with lack of terminal knee extension, anterior knee pain, decreased patellar mobility, and quadriceps atrophy. The goal of this paper is to describe the technique for anterior interval release of the knee.

Thromboembolic Events After Arthroscopic Knee Surgery: Increased Risk at High Elevation.

PURPOSE: To evaluate the incidence of thromboembolic events in patients undergoing arthroscopic surgery of the knee in centers located at elevations near sea level and compare those rates with the patients undergoing the same operations in centers at high elevation. METHODS: A retrospective review was conducted using a database of a major health care system with surgery centers located throughout the United States. More than 115 centers located in 15 different states were analyzed for any reported thromboembolic events including deep vein thromboses and pulmonary embolism (PE) in patients who had undergone knee arthroscopy over a 2-year period. The centers located at elevations lower than 1,000 ft were considered sea level centers. Centers located at elevations above 4,000 ft were considered high-elevation centers. Centers located between 1,000 ft and 4,000 ft elevation were excluded. RESULTS: A total of 35,877 patients underwent a knee arthroscopy at a low-elevation center and 10,181 patients underwent a knee arthroscopy at a high-elevation center between 2011 and 2012. During that same time period, 45 total venous thromboembolic events (VTEs) including 12 PEs occurred at centers considered low elevation, whereas 50 VTEs including 4 PEs occurred at centers considered high elevation. The incidence of VTE at low-elevation centers was 0.13%. The incidence of VTE at high-elevation centers was 0.49%. The difference was statistically significant, P < .0001. The relative risk of developing a VTE was 3.8 times higher at high elevation. There was no difference in PE incidence between high- and low-elevation centers (0.04% vs 0.03%, respectively; P = .78). CONCLUSIONS: Patients undergoing arthroscopic procedures of the knee in centers at high elevation are at 3.8 times higher risk of developing a VTE than those undergoing the same procedures in centers at low elevations. There was no observed increased risk of PE. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries: Comparison of Operative Versus Nonoperative Treatment Based on Magnetic Resonance Imaging Findings.

BACKGROUND: The medial ulnar collateral ligament (UCL) is the primary static stabilizer to valgus stress of the elbow. Injuries to the UCL are common in baseball pitchers. In the 1970s, reconstructive surgery was developed. Return-to-play (RTP) rates of 67% to 95% after reconstruction have been reported. There is a paucity of published studies among professional baseball players reporting RTP with nonoperative treatment. PURPOSE: To identify professional baseball players' ability to RTP after the nonoperative treatment of UCL injuries based on the magnetic resonance imaging (MRI) grade. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A review of elbow injuries among a professional baseball organization from 2006 to 2011 was performed. MRI was performed on all players. Forty-three UCL injuries were diagnosed. Treatment included rehabilitation, surgery, or both. Rates of RTP and return to the same level of play or higher (RTSP) were calculated and correlated with the MRI grade, location of injury, and player position. MRI grading was as follows: I, intact ligament with or without edema; IIA, partial tear; IIB, chronic healed injury; and III, complete tear. RESULTS: Forty-three UCL injuries in 43 players were diagnosed. Eight had complete tears (grade III), were treated operatively with UCL reconstruction, and had an RTP rate of 75% and RTSP rate of 63% (5/8 returned to the same level and 1 to a lower level). All 8 were pitchers. The remaining 35 players had incomplete injuries (4 grade I, 8 grade IIA, and 23 grade IIB), consisting of 24 pitchers and 11 positional players. Of these 35 players, 1 underwent surgery without attempted rehabilitation, 3 initiated rehabilitation until MRI was performed and then underwent surgery, and 3 underwent surgery after failed rehabilitation. The 7 players who underwent UCL reconstruction surgery had an RTP rate of 100% and RTSP rate of 86% (6/7 returned to the same level and 1 to a lower level). The remaining 28 with nonoperative treatment had both RTP and RTSP rates of 93% (26/28 returned to the same level and 0 to a lower level). Of these, 10 were positional players with an RTSP rate of 90%, and 18 were pitchers with an RTSP rate of 94%. Of all players with incomplete UCL injuries who completed nonoperative rehabilitative treatment (n = 31), 26 had a successful RTSP (84%). CONCLUSION: Incomplete UCL injuries in professional baseball players can be successfully treated nonoperatively in the majority of cases. Pitchers are more likely to have complete tears leading to surgery. MRI grading of UCL injuries can help predict RTP and the need for surgery.

Can Robot-Assisted Unicompartmental Knee Arthroplasty Be Cost-Effective? A Markov Decision Analysis.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) is a treatment option for single-compartment knee osteoarthritis. Robotic assistance may improve survival rates of UKA, but the cost-effectiveness of robot-assisted UKA is unknown. The purpose of this study was to delineate the revision rate, hospital volume, and robotic system costs for which this technology would be cost-effective. METHODS: We created a Markov decision analysis to evaluate the costs, outcomes, and incremental cost-effectiveness of robot-assisted UKA in 64-year-old patients with end-stage unicompartmental knee osteoarthritis. RESULTS: Robot-assisted UKA was more costly than traditional UKA, but offered a slightly better outcome with 0.06 additional quality-adjusted life-years at an incremental cost of $47,180 per quality-adjusted life-years, given a case volume of 100 cases annually. The system was cost-effective when case volume exceeded 94 cases per year, 2-year failure rates were below 1.2%, and total system costs were <$1.426 million. CONCLUSION: Robot-assisted UKA is cost-effective compared with traditional UKA when annual case volume exceeds 94 cases per year. It is not cost-effective at low-volume or medium-volume arthroplasty centers.

Quadriceps tendon injuries in national football league players.

BACKGROUND: Distal quadriceps tendon tears are uncommon injuries that typically occur in patients older than 40 years of age, and they have a guarded prognosis. Predisposing factors, prodromal findings, mechanisms of injury, treatment guidelines, and recovery expectations are not well described in high-level athletes. HYPOTHESIS: Professional American football players with an isolated tear of the quadriceps tendon treated with timely surgical repair will return to their sport. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fourteen unilateral distal quadriceps tendon tears were identified in National Football League (NFL) players from 1994 to 2004. Team physicians retrospectively reviewed training room and clinic records, operative notes, and imaging studies for each of these players. Data on each player were analyzed to identify variables predicting return to play. A successful outcome was defined as returning to play in regular-season NFL games. RESULTS: Eccentric contraction of the quadriceps was the most common mechanism of injury, occurring in 10 players. Only 1 player had antecedent ipsilateral extensor mechanism symptoms. Eleven players had a complete rupture of the quadriceps tendon, and 3 had partial tears. There were no associated knee injuries. All ruptures were treated with surgical repair, 1 of which was delayed after failure of nonoperative treatment. Fifty percent of players returned to play in regular-season NFL games. There was a trend toward earlier draft status for those who returned to play compared with those who did not (draft round, 3.1 ± 2.5 vs. 6.0 ± 2.9, respectively; P = .073). For those who returned to play, the average number of games after injury was 40.9 (range, 12-92). CONCLUSION: Quadriceps tendon tears are rare in professional American football players, and they usually occur from eccentric load on the extensor mechanism. Prodromal symptoms and predisposing factors are usually absent. Even with timely surgical repair, there is a low rate of return to play in regular-season games. There is a trend toward early draft rounds for those who successfully return to play.

National Football League athletes' return to play after surgical reattachment of complete proximal hamstring ruptures.

Although hamstring strains are common among professional football players, proximal tendon avulsions are relatively rare. Surgical repair is recommended, but there is no evidence on professional football players return to play (RTP). We hypothesized that surgical reattachment of complete proximal hamstring ruptures in these athletes would enable successful RTP. Ten proximal hamstring avulsions were identified in 10 National Football League (NFL) players between 1990 and 2008. Participating team physicians retrospectively reviewed each player's training room and clinical records, operative notes, and imaging studies. The ruptures were identified and confirmed with magnetic resonance imaging. Of the 10 injuries, 9 had palpable defects. Each of the ruptures was managed with surgical fixation within 10 days of injury. All of the players reported full return of strength and attempted to resume play at the beginning of the following season, with 9 of the 10 actually returning to play. However, despite having no limitations related to the surgical repair, only 5 of the 10 athletes played in more than 1 game. Most NFL players who undergo acute surgical repair of complete proximal hamstring ruptures are able to RTP, but results are mixed regarding long-term participation. This finding may indicate that this injury is a marker for elite-level physical deterioration.

Functional improvement after humeral shaft nonunion in a patient with glenohumeral ankylosis.

Functionally limiting heterotopic ossification about the shoulder represents an uncommon clinical entity, which has been most commonly reported as a consequence of prolonged immobilization in intensive care unit patients. Severe cases may result in complete glenohumeral ankylosis, with resultant upper extremity motion through the scapulothoracic joint, and significant functional consequences. We report the case of a 72-year-old male with spontaneous glenohumeral ankylosis who suffered a humeral shaft fracture with resultant painless nonunion. Motion through the nonunion site caused significant subjective functional improvements, increased range of motion, and the ability to complete his activities of daily living. Patients with limited shoulder range of motion may be at higher risk for humeral fractures and nonunion. These patients, however, may experience improved function due to increased upper extremity range of motion through the nonunion site.

The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair.

BACKGROUND: Interest in double-row techniques for arthroscopic rotator cuff repair has increased over the last several years, presumably because of a combination of literature demonstrating superior biomechanical characteristics and recent improvements in instrumentation and technique. As a result of the increasing focus on value-based health-care delivery, orthopaedic surgeons must understand the cost implications of this practice. The purpose of this study was to examine the cost-effectiveness of double-row arthroscopic rotator cuff repair compared with traditional single-row repair. METHODS: A decision-analytic model was constructed to assess the cost-effectiveness of double-row arthroscopic rotator cuff repair compared with single-row repair on the basis of the cost per quality-adjusted life year gained. Two cohorts of patients (one with a tear of <3 cm and the other with a tear of ≥3 cm) were evaluated. Probabilities for retear and persistent symptoms, health utilities for the particular health states, and the direct costs for rotator cuff repair were derived from the orthopaedic literature and institutional data. RESULTS: The incremental cost-effectiveness ratio for double-row compared with single-row arthroscopic rotator cuff repair was $571,500 for rotator cuff tears of <3 cm and $460,200 for rotator cuff tears of ≥3 cm. The rate of radiographic or symptomatic retear alone did not influence cost-effectiveness results. If the increase in the cost of double-row repair was less than $287 for small or moderate tears and less than $352 for large or massive tears compared with the cost of single-row repair, then double-row repair would represent a cost-effective surgical alternative. CONCLUSIONS: On the basis of currently available data, double-row rotator cuff repair is not cost-effective for any size rotator cuff tears. However, variability in the values for costs and probability of retear can have a profound effect on the results of the model and may create an environment in which double-row repair becomes the more cost-effective surgical option. The identification of the threshold values in this study may help surgeons to determine the most cost-effective treatment.