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.

Median Time to Return to Sports After Concussion Is Within 21 Days in 80% of Published Studies.

PURPOSE: To perform a systematic review of the literature and evaluate the return to play (RTP) time frame after a concussion diagnosis. Our secondary purpose was to analyze and compare different prognostic variables affecting concussions, time to return to school, time to symptom resolution of concussive symptoms, and time each patient spent in the RTP protocol. METHODS: A PubMed, Scopus, Medline, Embase, and Cochrane Library database literature review was performed in August 2022. The studies needed to report, in days, the length of time a patient/athlete was removed from play due to concussion management. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for risk of bias for each study, and Methodological Index for Non-Randomized Studies criteria were used for quality assessment. RESULTS: There were 65 studies included in the systematic review and a total of 21,966 patients evaluated. The RTP time intervals ranged from 1 to 1,820 days, with 80.7% of the median RTP time frames for each study within 21 days. Preconcussion risk factors for prolonged RTP included female sex, younger age, presence of psychiatric disorders, and history of previous concussion. Postconcussion risk factors included severe symptom scores at initial clinic visit, loss of consciousness, nonelite athletes, and delayed removal from competition. The most common sports resulting in concussion were contact sports, most commonly football and soccer. Median time to return to school was 3 to 23 days. Median time to symptom resolution ranged from 2 to 11 days. Median time in RTP protocol was 1 to 6 days. CONCLUSIONS: Median time to return to sports after concussion is within 21 days in 80% of published studies. LEVEL OF EVIDENCE: IV, systematic review of Level I to IV studies.

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.

Complete Isolated Ruptures of the Distal Biceps Brachii During Athletic Activity: A Systematic Review.

Complete, isolated ruptures of the distal biceps brachii sustained during athletic activities are uncommon. A systematic review of the literature was performed to identify complete distal biceps brachii tears experienced during athletic activities to determine injury prevalence, athletic activities/mechanisms responsible for injury and return to activity timing following operative management. A total of 10 studies, comprising 16 athletes undergoing surgery for 18 cases, were identified. Injuries were predominately associated with weightlifting. Injuries were treated utilizing a single incision in 56% of cases and primary repair performed in 89% of cases. Mean time to return to activity was 4.86 ± 1.14months. Athletes undergoing surgery ≤ 10 days following injury and those undergoing primary repair returned to activity significantly quicker. Isolated tears of the distal biceps remain uncommon during athletic activities, occurring primarily during weightlifting. Return to activity timing was not significantly delayed based on surgical approach, steroid use, or athlete age.

Predictors of Occult Chondral Injury Sustained After a Primary Patellar Dislocation.

Background and objective Primary patellar dislocations can concomitantly involve osteochondral injuries for which prompt recognition is paramount for joint preservation. These injuries can be missed on radiographs, necessitating MRI examinations. In this study, we aimed to identify patient parameters that correlate with occult osteochondral injuries. Methods Patients were retrospectively identified between 2015 and 2020 through a chart review. The inclusion criteria were as follows: patients diagnosed with a primary patellar dislocation with three radiographic views and an MRI of the injured knee. Demographic and radiographic data were evaluated. Results A total of 61 patients met the inclusion criteria. There were no statistically significant demographic differences between patients with osteochondral injuries and those without (p>0.05). Seven knees (88%) with an osteochondral lesion and 20 (38%) without had an effusion (p=0.02). There was no association in terms of ligamentous laxity (p=0.49), Caton-Deschamps index (CDI) (p=0.68), sulcus angle (SA) (p=0.68), congruence angle (CA) (p=0.56), and lateral patellofemoral angle (LPFA) (p=0.25) between patients with and without an occult osteochondral injury. Conclusion Among the parameter examined, the presence of an effusion was the only one that correlated with the presence of occult osteochondral injury in our cohort.

Immunologic Contributions Following Rotator Cuff Injury and Development of Cuff Tear Arthropathy.

¼: Rotator cuff tear arthropathy (RCTA) describes a pattern of glenohumeral degenerative changes following chronic rotator cuff tears that is characterized by superior humeral head migration, erosion of the greater tuberosity of the humeral head, contouring of the coracoacromial arch to create a socket for the humeral head, and eventual glenohumeral arthritis. ¼: Acute and chronic inflammatory changes following rotator cuff tears are thought to contribute to cartilage damage, muscle fibrosis, and fatty infiltration in the glenohumeral joint. ¼: In vitro animal studies targeting various inflammatory modulators, including macrophages, insulin-like growth factor-I, and transforming growth factor-beta pathways, provide promising therapeutic targets to improve healing after rotator cuff tears. ¼: The role of platelet-rich plasma in the treatment and prevention of RCTA has been investigated, with conflicting results.

Comparison of time to healing and major complications after surgical fixation of nondisplaced femoral neck stress fractures: A systematic review.

INTRODUCTION: There is no recent literature review comparing outcomes of fixation methods for nondisplaced stress fractures of the femoral neck. METHODS: A systematic review of the literature on operative fixation of femoral neck stress fractures was performed. Inclusion criteria consisted of diagnosis of nondisplaced femoral neck stress fractures, implants used for fixation, articles in English language or available English translation, all ages, and Level 1-5 evidence, documented time to healing, and incidence of complications. Statistical analysis was performed to compare outcomes. RESULTS: Eight studies with 13 subjects and 15 fractures undergoing operative fixation were included. Six fracture were compression sided, five were tension sided, and four were complete. Radiographic healing occurred on average at 32.7 ± 36.3 weeks (range 8-121 weeks). Four subjects were noted to have a metabolic disturbance. Six subjects did not participate in vigorous exercise. There were no complications. There was no significant difference in radiographic healing time between: cannulated screws or SHS ± osteotomy (p = 0.21); compression sided, tension sided, or complete fractures (p = 0.41); ages (p = 0.09); sex (p = 0.09) or individuals with or without metabolic disturbances (p = 0.92). There was no difference between use of cannulated screw fixation, SHS + osteotomy, and SHS alone based on the subject's age (p = 0.27) or cannulated screw vs SHS ± osteotomy given subject's age (p = 0.19) or sex (p = 1.0). Time to full weight bearing (FWB) did not significantly differ between implants (p = 0.22). However, >8 weeks restricted weight bearing had increased healing times (p = 0.002). DISCUSSION: Time to healing was not dependent on subjects' sex or age, fracture location, implant choice, or presence of metabolic abnormality. No complications were reported. Time to full weight bearing was not dependent on implant choice. However, restricted weight bearing beyond 8 weeks can lead to prolonged healing times. Fixation should be safe, effective and promote early weight bearing and mobilization.

Longitudinal analysis of pediatric distal radius alignment parameters in a cohort of serial radiographs.

BACKGROUND: Growth in pediatric patients necessitates changes to bony structures throughout the entire body to suit development. Changes in the distal radius during growth are of interest in the pediatric population due to the high incidence of fractures. The purpose of this study was to assess for trends in three radiographic measurements (height of the radial styloid process, radial inclination, ulnar variance) of the distal radius using serial radiographs in subjects aged between 6 and 14 years of age. MATERIALS AND METHODS: Longitudinal radiographs from 68 healthy children (n = 34 males, 34 females) with a minimal of three annual radiographs between 6 and 14 years of age were analyzed. Measurements of height of the radial styloid process, radial inclination, and ulnar variance were performed in each available radiograph. Repeated measures analysis of variance (ANOVA) was performed to measure the association between alignment values and subject age. RESULTS: A total of 436 images in 68 subjects were analyzed, comprising a mean of 6.5 ± 2.0 radiographs per subject. Repeated measures ANOVA demonstrated that all measurement variables changed significantly with age (p < .001). Ulnar variance demonstrated the most variability with negative ulnar variance in younger children, and trends towards a more neutral ulnar variance by approximately 7 years in females and 11 years in males, while height of the radial styloid process and radial inclination changed relatively minimally with development. CONCLUSIONS: In the adolescent age range, ulnar variance, height of the radial styloid process and inclination are all relatively stable and adult parameter values can be used to judge restoration of distal radius alignment.

Complications and Return to Activity After Arthroscopic Repair of Isolated Type II SLAP Lesions: A Systematic Review Comparing Knotted Versus Knotless Suture Anchors.

BACKGROUND: Superior labral anterior to posterior (SLAP) tears are one of the most common injuries to the shoulder, with the type II variant representing the most frequently encountered subtype. PURPOSE: To systematically review the literature to better understand outcomes after arthroscopic repair of isolated type II SLAP lesions using knotted versus knotless anchors based on implant number, implant location, patient position, and portal position. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review investigating all studies in the literature between January 2000 and June 2019 reporting on patients undergoing arthroscopic repair for isolated type II SLAP lesions using knotted versus knotless suture anchors was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the PubMed, BIOSIS Previews, SPORTDiscus, PEDro, and Embase databases. RESULTS: A total of 234 patients undergoing isolated arthroscopic repair of type II SLAP lesions using suture anchors were identified, with 76% (179/234) treated using knotted anchors versus 24% (55/234) treated using knotless anchors. Complications were reported in 12% of patients treated using knotted anchors versus no patients treated using knotless anchors (P = .008). The incidence of complications for knotted anchor repair was not significantly affected by patient position (P = .22) or portal position (P = .19). Using multiple regression analysis, we found no significant association with the incidence of complications when analyzing for anchor design (R 2 = 0.02; P = .06) or anchor position (R 2 = 0.02; P = .92). No significant difference in return-to-activity timing was appreciated based on anchor type (P = .28), patient position (P = .98), or portal position (P = .97) in patients treated using knotted anchors. CONCLUSION: Patients treated using knotted anchors were significantly more likely to experience a postoperative complication compared with patients treated using knotless anchors after arthroscopic repair of isolated type II SLAP lesions. Despite the increased incidence of a postoperative complication after knotted anchor fixation compared with knotless anchor fixation, multiple regression analysis showed that anchor design and anchor position were not significantly predictive of the incidence of complications. Given the increasing popularity of knotless anchor fixation, further study on the long-term outcomes after knotless repair for isolated type II SLAP lesions is warranted.

A comprehensive three-phase opiate sparing multimodal pain protocol for hip arthroscopy: a retrospective review.

The aim of this study is to assess the efficacy of a three-phase, multimodal, perioperative pain protocol for primary hip arthroscopy based on pain scores, narcotic use, time to discharge, hospital admission and complications. A retrospective study of patients undergoing primary hip arthroscopy over a 48-month time period was conducted. Patients were separated into a multimodal group consisting of non-narcotic medication, local analgesia and a peripheral nerve block (PNB) versus patients receiving only a PNB. Differences in post-anesthesia care unit (PACU) visual analog scores, PACU time to discharge, PACU opioid consumption, hospital admission and complications between protocols were recorded and analyzed. There were 422 patients who underwent 484 surgeries, with 15 patients crossing over pain protocol groups for surgery on the contralateral hip. One hundred and ninety-six patients underwent 213 procedures in the multimodal group and 241 patients underwent 271 procedures in the PNB group. No differences in baseline characteristics were appreciated between groups. Mean time to discharge was significantly shorter in the multimodal group (137.4 ± 49.3 min versus 176.3 ± 6.5 min; P < 0.001) which also had less post-operative admissions (0 versus 9; P = 0.006) than the PNB group. In patients who crossed over protocol groups, a statistically shorter time to discharge was appreciated with the multimodal protocol compared with the PNB protocol (119.9 ± 32.1 min versus 187.9 ± 9.2; P = 0.012). The three-phase, multimodal pain protocol led to significantly faster discharge times and fewer hospital admissions when compared with isolated PNB in patients undergoing primary hip arthroscopy.

Peri-operative pain management in hip arthroscopy: a systematic review of the literature.

The purpose of this article was to review current literature on peri-operative pain management in hip arthroscopy. A systematic review of the literature on pain control in hip arthroscopy published January 2008 to December 2018 was performed. Inclusion criteria consisted of English language or articles with English translations, subjects undergoing hip arthroscopy with documented peri-operative pain control protocols in studies reporting Level I to IV evidence. Exclusion criteria were non-English articles, animal studies, prior systematic review or meta-analyses, studies not reporting peri-operative pain control protocols, studies documenting only pediatric (<18 years of age) patients, studies with Level V evidence and studies including less than five subjects. Statistical analysis was performed to assess pain protocols on narcotic consumption in PACU, VAS score on discharge, time to discharge from PACU and incidence of complications. Seventeen studies were included, comprising 1674 patients. Nerve blocks were administered in 50% of patients (n = 838 of 1674), of which 88% (n = 740 of 838) received a pre-operative block while 12% (n = 98 of 838) post-operative block. Sixty-eight complications were recorded: falls (54%, n = 37), peripheral neuritis (41%, n = 28), seizure (1.5%, n = 1), oxygen desaturation and nausea (1.5%, n = 1) and epidural spread resulting in urinary retention (1.5%, n = 1). No significant differences in narcotic consumption, VAS score at discharge, time until discharge or incidence of complication was found based on pain control modality utilized. No statistically significant difference in PACU narcotic utilization, VAS pain scores at discharge, time to discharge or incidence of complications was found between peri-operative pain regimens in hip arthroscopy.