The Morphologic Patella Entry Point Into the Proximal Trochlea Is More Lateral in Recurrent Dislocators Than Controls as Measured by Entry Point-Trochlear Groove Angle.

PURPOSE: To create a metric for evaluating the degree of laterality of the patella's entry into the trochlea, the entry point-trochlear groove (EP-TG) angle, and to evaluate if this laterality is associated with recurrent patella instability. METHODS: The time frame of the study was January 2020 to February 2023. The inclusion criteria were patients treated by the senior author (J.P.F.) (with the exception of 2 patients who were treated by another provider at the institution who was aware of the study) who have been diagnosed with recurrent atraumatic patellar dislocations. Controls without knee pathology were selected from the New Mexico Decedent Imaging Database (NMDID). Simpleware ScanIP was used to create 3-dimensional (3D) models of the distal femurs from computed tomography scans. Anteroposterior images of these 3D models were uploaded to a custom EP-TG angle measuring tool. Three measurers used the tool to measure the EP-TG angle of the distal femurs. RESULTS: Twenty-eight patients were included for the recurrent dislocator group. Twenty-four decedents from the NMDID were selected for the control group, each with a left or right knee chosen randomly for measurement. A 1-sided Mann-Whitney U test, used to evaluate whether the recurrent dislocators had higher EP-TG angle values, yielded a P value <.001, demonstrating a high level of significance. A Bayesian mixed-effect model, used to determine how different the EP-TG angles are between the 2 groups, gave a posterior predictive interval of [11.93°, 19.12°] for the EP-TG angle shift of dislocators. The intraclass correlation coefficient was 0.648. CONCLUSIONS: The morphologic entry point of the patella into the proximal trochlea is more lateral in recurrent patella dislocators than in controls. This increased laterality can be measured by the EP-TG angle, which may be useful information for optimizing treatment of recurrent patella instability. LEVEL OF EVIDENCE: Level III, case control study.

Glenohumeral Superior Translation and Subacromial Contract Pressure Are Both Improved With Superior Capsular Reconstruction: A Systematic Review and Meta-analysis of Biomechanical Investigations.

PURPOSE: To review cadaveric studies evaluating the biomechanical outcomes of superior capsular reconstruction (SCR) with different graft types for the treatment of irreparable rotator cuff (RTC) tears. METHODS: PubMed, Cochrane, and Embase were queried in January 2022 to conduct this meta-analysis using the following key words: "superior capsule reconstruction," "superior capsular reconstruction," and "biomechanics." Articles were included if they reported glenohumeral superior translation or subacromial contact pressure following SCR in cadaveric RTC tears. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Number of shoulders, graft types, and biomechanical outcomes were recorded and analyzed with forest plots. RESULTS: Twelve studies (95 shoulders) were included in the statistical analysis. There was a significant reduction in glenohumeral superior translation following SCR compared with RTC tear across 10 studies (79 shoulders) with standardized mean difference (SMD) -2.48 mm; confidence interval (CI) -3.28 mm, -1.69 mm. The SMD between fascia lata graft and RTC tear was -3.84 mm (CI -4.82 mm, -2.86 mm) and between dermal allograft and RTC tear was -2.05 mm (CI -3.10 mm, -1.00 mm). There was a significant reduction in subacromial contact pressure following SCR compared with RTC tear across 5 studies (55 shoulders) with SMD -3.49 MPa (CI -4.54 MPa, -2.44 MPa). The SMD between fascia lata graft and RTC tear was -3.21 MPa (CI -5.08 MPa, -1.34 MPa) and between dermal allograft and RTC tear was -3.89 MPa (CI -5.91 MPa, -1.87 MPa). CONCLUSIONS: Independent of graft type, biomechanical studies suggest that SCR improves glenohumeral superior translation and subacromial contact pressure in comparison with RTC tear at time zero. There was no definitive evidence identified in this study to suggest a biomechanically superior SCR graft option. CLINICAL RELEVANCE: Investigating the biomechanical outcomes of several graft types for superior capsular reconstruction will help surgeons better understand the efficacies of different graft types for use in superior capsule reconstruction surgery.

Medicaid Insurance Is Associated With More Complications and Emergency Department Visits but Equivalent 5-Year Secondary Surgery Rate After Primary Hip Arthroscopy.

PURPOSE: To compare 90-day complications, 30-day emergency department (ED) visits, and 5-year rate of secondary surgeries for patients with Medicaid vs commercial insurance undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and/or labral tears using a large national database. METHODS: The PearlDiver Mariner151 database was used to identify patients with International Classification of Diseases, Tenth Revision diagnosis codes for FAIS and/or labral tear who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021. Patients with Medicaid were matched 1:4 to a control group of commercially insured patients based on age, sex, body mass index, and Elixhauser Comorbidity Index. Rates of 90-day complications and 30-day ED visits were compared using multivariate regression models. Five-year rates of secondary surgeries-revision arthroscopy or total hip arthroplasty-were compared between cohorts by Kaplan-Meier analysis. RESULTS: A total of 2,033 Medicaid patients were matched with 8,056 commercially insured patients. Rates of adverse events were low; however, Medicaid patients were significantly more likely than commercially insured patients to experience any 90-day complication (2.12% vs 1.43%; odds ratio [OR], 1.2; P = .02). Medicaid patients also experienced more 30-day ED visits than commercially insured patients (8.61% vs 4.28%), and on multivariate logistic regression, insurance status was the strongest determinant of 30-day ED visits (relative to commercial, Medicaid OR, 2.02; P < .001). Despite these differences, 5-year rates of secondary surgeries were comparable between groups (6.1% vs 6.0%; P = .6). CONCLUSIONS: In this large national database study, Medicaid patients undergoing primary hip arthroscopy showed significantly greater odds of experiencing 90-day postoperative complications and 30-day ED visits compared to commercially insured patients. Nevertheless, both groups had similar survivorship rates at 5-year follow-up, similar to prior estimates irrespective of insurance. These results document encouraging secondary surgery rates in Medicaid patients.

Patients Undergoing Revision Hip Arthroscopy With Labral Reconstruction or Augmentation Demonstrate Favorable Patient Reported Outcomes: A Systematic Review.

PURPOSE: To review current literature evaluating patient-reported outcomes (PROs) and survivorship in patients undergoing revision hip arthroscopy with labral reconstruction or augmentation. METHODS: A systematic review was performed with the following key words: (revision) AND (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (reconstruction OR augmentation OR irreparable). PubMed, Cochrane Trials, and Scopus were queried in October 2022 using the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Studies were included if they involved patients undergoing revision hip arthroscopy with labral reconstruction or augmentation and reported preoperative and postoperative PROs at minimum 2-year follow-up. Only original research articles were included. Survivorship was defined as a nonconversion to total hip arthroplasty. Outcomes present in 3 or more studies underwent further statistical analysis with forest plots. Heterogeneity of studies was evaluated using the I2 statistic. RESULTS: Five studies were reviewed, including 359 revision hip arthroscopies (335 with complete follow-up) with a follow-up that ranged from 2.2 to 5.2 years. Four studies reported on outcomes after revision labral reconstruction and 1 study reported on labral augmentation. Two out of 5 included studies evaluated for statistical significance between preoperative and postoperative outcomes. Three out of 5 studies reported a rate of at least 70% for achieving minimal clinically important difference in at least 1 PRO. At minimum 2-year follow-up, survivorship ranged from 93.5% to 100%. CONCLUSIONS: Patients that underwent revision hip arthroscopy with labral reconstruction or augmentation demonstrated improvement in PROs with mixed rates of achieving clinical benefit and rates of survivorship at minimum 2-year follow-up ranging from 93.5% to 100%. LEVEL OF EVIDENCE: Level IV, systematic review of level III to IV studies.

Female Patients Undergoing Latarjet Surgery Show Similar 2-Year Secondary Surgery Rates but Greater Risk of Emergency Department Visits Compared With a Matched Cohort of Male Patients.

PURPOSE: To evaluate sex-based differences in 30-day postoperative emergency department (ED) visits, 90-day complication rates, and 2-year secondary surgery rates after the Latarjet procedure for the treatment of recurrent shoulder instability. METHODS: A national administrative claims database was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for shoulder subluxation or dislocation on the day of first-time stabilization with the Latarjet technique between 2015 and 2021. Male patients were matched 4:1 to female patients based on age, Elixhauser Comorbidity Index (ECI) score, and body mass index class. Rates of 30-day ED visits and 90-day complications were compared between cohorts, and risk factors for ED visits were identified by multivariate regression. The incidence of secondary surgery within 2 years was compared by Kaplan-Meier analysis. RESULTS: Prior to matching, 1,059 male and 360 female patients met the inclusion and exclusion criteria. Subsequent 4:1 (male-to-female) matching controlling for age, ECI score, and body mass index yielded 694 male and 185 female patients who underwent the Latarjet procedure. The overall incidence of 30-day ED visits was 9.3%, with an incidence of 8.2% for male patients and 13.5% for female patients. On the basis of multivariate logistic regression, these 30-day ED visits were associated with female sex (odds ratio, 1.79; P = .029) and incrementally higher ECI scores; relative to an ECI score of 0, ECI scores of 1 to 2, 3 to 4, and 5 or greater were associated with odds ratios of 5.31 (P = .006), 8.12 (P < .001), and 12.84 (P < .001), respectively. Ninety-day complications occurred in 1.5% of the total cohort, and the incidence was not statistically different between sexes. Overall, 2-year secondary surgery rates were similar between male and female patients (5.1% and 6.7%, respectively; P = .4). CONCLUSIONS: Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. Female sex, along with ECI score, however, was associated with a greater rate of 30-day ED visits. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Mid- and Long-Term Outcomes Are Favorable for Patients With Borderline Dysplasia Undergoing Primary Hip Arthroscopy: A Systematic Review.

PURPOSE: To evaluate midterm outcomes, long-term outcomes, and survivorship in the borderline dysplastic population after primary hip arthroscopy. METHODS: A systematic review of current literature was performed with the following key words: "hip, "arthroscopy," "borderline dysplasia," "borderline hip dysplasia," "developmental dysplasia," "ten-year," "survivorship," "10-year," "5-year," "five year," "mid-term," "long-term," "outcomes," "arthroscopic," and "femoroacetabular impingement" in PubMed, Cochrane, and Scopus in March 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The following information was recorded: title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcomes (PROs), characteristics of patients converting to total hip arthroplasty (THA), and rates of secondary surgeries and conversion to THA were recorded. Survivorship was defined as not converting to THA. Kappa values for the title/abstract and full-text screening were calculated. Forest plots were created for PROs that were included in 3 or more studies. RESULTS: Six articles comprising 413 hips were included in the study. Three studies were Level III evidence, and 3 studies were Level IV evidence. Average follow-up ranged from 5.7 to 12.2 years. One study defined borderline hip dysplasia as lateral center-edge angle 18-25° and 5 defined it as lateral center-edge angle 20-25°. All studies included PROs and reported significant improvement after surgery in at least one PRO. Three studies reported clinical benefit and across the studies at least 70% of patients achieved minimum clinically important difference in at least one PRO. Rates of undergoing revision hip arthroscopy and THA ranged from 2.1% to 7% and 0% to 24%, respectively. Tönnis grade 2, Tönnis angle >15, and Outerbridge Grade IV cartilage damage were identified as predictors of conversion to THA. CONCLUSIONS: Patients with borderline hip dysplasia undergoing primary hip arthroscopy demonstrated significant improvement in PROs at midterm and long-term follow-up. Survivorship at midterm follow-up was 98.2% (328/334 hips) and 76.3% (29/38 hips) at long-term follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

Athletes Report Favorable Outcomes at 5-Year Minimum Follow-Up After Primary Hip Arthroscopy: A Systematic Review.

PURPOSE: To evaluate minimum 5-year outcomes and survivorship after primary hip arthroscopy in athletes. METHODS: A systematic review of current literature was performed with the following key words: "hip arthroscopy," "long-term," "outcomes," "ten-year," "survivorship," "10-year," "5-year," "five-year," "midterm," "athlete," "sport," and "femoroacetabular impingement" in PubMed, Cochrane Trials, and Scopus in April 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Study and demographic variables such as title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcome scores, and rates of secondary surgeries and conversion to total hip arthroplasty. Radiographic, intraoperative surgical treatment, and clinical benefit was documented as well. RESULTS: Ten studies that captured data on 691 hips were included in this study. Eight studies reported mean and standard deviation for the modified Harris Hip Score. Significant improvements were reported in all studies with postoperative scores ranging from 83.3 to 94.4 (standardized mean difference [SMD] 1.65; 95% confidence interval [CI] 1.39-1.91, P < .00001). Eight studies reported significant improvement in Hip Outcome Score - Sports Specific Scale with postoperative scores ranging from 59.2 to 94.6 (SMD 1.66; 95% CI 1.33-1.98, P < .00001). Seven studies reported significant improvement in Nonarthritic Hip Score with postoperative scores ranging from 79.6 to 95.3 (SMD 1.41; 95% CI 1.16-1.65, P < .00001). Seven studies also reported significant improvement in VAS with postoperative scores ranging from 0.7 to 3.1 (SMD -1.57; 95% CI -1.88, -1.26, P < .00001). Nine of 10 studies reported achieving at least 1 psychometric threshold at a rate of least 75%. Rates of secondary arthroscopy and conversion to total hip arthroplasty varied from 0% to 15.2% and 0% to 33.3%. CONCLUSIONS: Athletes who underwent primary hip arthroscopy demonstrated favorable outcomes and high rates of clinical benefit at 5-year follow-up. In addition, they demonstrated high rates of survivorship and achieving psychometric thresholds. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Short Symptom Duration Is Associated With Superior Outcomes in Patients Undergoing Primary Hip Arthroscopy: A Systematic Review.

PURPOSE: To evaluate the effect of duration of preoperative hip pain symptoms on outcomes in patients undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome. METHODS: A systematic review of the literature was conducted with the following key words: "hip arthroscopy," "outcomes," "femoroacetabular impingement," "duration," "symptoms," "time," "delay," "earlier," and "timing" was performed in PubMed and Cochrane in May 2022. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for this review. When available, article information including the author, study type, study period, and follow-up, demographics, preoperative duration of symptoms, surgical outcome tools, and secondary surgeries were recorded. RESULTS: Six studies including 3,298 hips were included in this systematic review. Five studies had a minimum of 2 years' follow-up, and 1 study had a minimum of 5 years' follow-up. Femoroacetabular impingement (including subtypes cam and pincer impingement) was a surgical indication in all 6 studies and the most common indication for surgery. All 6 studies reported patient-reported outcome scores. All studies conducted statistical analyses comparing the duration of symptoms' effect on outcomes and found superior outcomes in patients with shorter duration of symptoms before hip arthroscopy. In 3 studies, modified Harris Hip Score, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sports-Specific Subscale, and visual analog scale for satisfaction ranged from 79.1-82.6, 86.3-88.4, 75-75.5. and 75.3-82.5, respectively, in cohorts with <2-year duration of symptoms, compared with 72-77.7, 79.6-84, 65.0-66.7, and 69.7-75.3 in >2-year cohort. Similarly, in one study, the <2-year duration group was reported to have a conversion to total hip arthroplasty rate of 0.6% and an overall secondary surgery rate of 0.9%, whereas the >2-year duration group had a conversion to total hip arthroplasty rate of 6.4% and an overall secondary surgery rate of 10.1%. CONCLUSIONS: Patients with hip pain symptoms of less than 2 years before arthroscopic treatment of femoroacetabular impingement syndrome have better outcomes than those patients who had a longer duration of symptoms. However, significant improvements can still be expected regardless of time between onset of symptoms and surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

Patients Undergoing Primary Hip Arthroscopy Report Favorable Outcomes at Minimum 10 Year Follow-Up: A Systematic Review.

PURPOSE: (1) To evaluate minimum 10-year PROs (patient-reported outcomes) and survivorship after primary hip arthroscopy and (2) to identify predictors of failure for secondary arthroscopy and conversion to total hip arthroplasty (THA). METHODS: A systematic review of the literature was conducted with the following key words: "hip arthroscopy," "long-term," "outcomes," "ten-year," "survivorship," "10-year," "15-year," "fifteen-year," 20-year," "twenty-year," and "femoroacetabular impingement" in PubMed and Embase in March 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Level I to Level IV evidence was included and reported on minimum 10-year outcomes or greater after primary hip arthroscopy. Long-term studies were defined as minimum 10-year follow-up in accordance with established standards in the literature. Case reports, review articles, technique articles, and opinion articles were excluded. Articles not in English were excluded. Title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, PROs, predictors of failure for THA, and rates of secondary surgeries were recorded. Survivorship was defined as a nonconversion to THA. P < .05 was defined as statistical significance. RESULTS: Twelve studies met the inclusion criteria. In total, 4 studies were Level III, and 8 studies were Level IV. A total of 1,344 hips were included, and follow-up ranged from 10 to 20 years. Femoroacetabular impingement syndrome was the most common indication for hip arthroscopy. Ten of the 12 studies reported on PROs, and 8 studies reported significant improvement after hip arthroscopy at long-term follow-up. The remaining 2 studies reported favorable outcomes that satisfied clinical benefit thresholds at minimum 10-year follow-up. Five studies reported clinical benefit where each patient cohort achieved 80% minimal clinically important difference and 75% patient acceptable symptomatic state for at least one PRO. Rates of secondary arthroscopy ranged from 4.5% to 24%, and rates of conversion to THA varied from 0% to 44.1%. Older age and chondral damage were the most commonly cited predictors for conversion to THA. CONCLUSIONS: At long-term follow-up, patients who underwent primary hip arthroscopy demonstrated favorable outcomes and variable rates of secondary surgeries. Patients undergoing hip arthroscopy within the last 20 years with Tönnis grade <1 and labral repair experienced greater than 90% survivorship. Chondral damage and older age were the most cited predictors for conversion to THA. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

Over 50% of Studies Report Low-Back Pain Is Associated With Worse Outcomes After Hip Arthroscopy When Compared With a Control Group: A Systematic Review.

PURPOSE: To review outcomes of patients with low-back pathology undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement (FAI) syndrome. METHODS: The PubMed, Cochrane Trials, and Scopus databases were queried in June 2022 to conduct this systematic review using the following terms: ("hip" OR "femoroacetabular impingement") AND ("arthroscopy" OR "arthroscopic") AND ("spine" OR "lumbar" OR "sacral" OR "hip-spine" OR "back") AND ("outcomes"). Articles were included if they reported on patient-reported outcomes (PROs) and/or clinical benefit of patients undergoing hip arthroscopy with concomitant low-back pathology. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Case reports, opinion articles, review articles, and technique articles were excluded from this study. Forest plots were created to analyze preoperative and postoperative outcomes among patients with low-back pathology. RESULTS: Fourteen studies were included in the review. There were 750 hips with low-back pathology and FAI (hip-spine syndrome) and 1,800 hips with only FAI (no hip-spine syndrome). All 14 studies reported PROs. In 4 studies in the group with hip-spine syndrome and 8 studies in the group with FAI without low-back pathology, the respective cohorts were reported to achieve the minimal clinically important difference in at least 1 PRO at a rate of 80%. Eight studies reported that patients with low-back pathology were associated with inferior outcomes or clinical benefit compared with patients without low-back pathology. CONCLUSIONS: Patients undergoing primary hip arthroscopy with concomitant low-back pathology can expect favorable outcomes, but outcomes are superior in patients undergoing hip arthroscopy for FAI alone compared with FAI with concomitant low-back pathology. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to Level IV studies.

Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses.

PURPOSE: To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR. METHODS: Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance. RESULTS: There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation. CONCLUSION: This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR. LEVEL OF EVIDENCE: IV.

Is There an Association Between Negative Patient-Experience Comments and Perioperative Outcomes After Primary Total Hip Arthroplasty?

BACKGROUND: Multiple stakeholders are interested in improving patient experience after primary total hip arthroplasty due to shifts toward patient-centered care. Patient free-text narratives are a potentially valuable but largely unexplored source of data. METHODS: The records of 383 patients who underwent primary total hip arthroplasty between August 2016 and August 2019 were combined with vendor-supplied patient satisfaction data, which included patient free-text comments and the Press Ganey satisfaction survey. A total of 1295 patient comments were analyzed for sentiment, and negative comments were categorized into nine themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not. Multivariable regression was used to determine perioperative variables associated with providing a negative comment. RESULTS: Of the 1295 patient comments: 54% were positive, 24% were negative, 10% were mixed, and 12% were neutral. Top two themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in studied outcomes (eg. peak pain intensity, length of stay, or improvements in hip injury and osteoarthritis outcome scores Jr. and pain visual analog scale scores at 6-week follow-up) between those who provided negative comments vs those who did not (P > .05). However, patients who made negative comments were less likely to recommend their hospital care to peers (P < .001). Finally, patients who had >2 allergies (P = .024) were more likely to provide negative comments. CONCLUSION: The present study demonstrates that patient satisfaction appears not to be a reliable sole proxy for traditional objective outcome measures of pain relief and functional improvement.

Modern Internet Search Analytics and Total Joint Arthroplasty: What Are Patients Asking and Reading Online?

BACKGROUND: Patients considering total joint arthroplasty often search for information online regarding surgery; however, little is known about the specific topics that patients search for and the nature of the information provided. Google compiles frequently asked questions associated with a search term using machine learning and natural language processing. Links to individual websites are provided to answer each question. Analysis of this data may help improve understanding of patient concerns and inform more effective counseling. METHODS: Search terms were entered into Google for total hip and total knee arthroplasty. Frequently asked questions and associated websites were extracted to a database using customized software. Questions were categorized by topic; websites were categorized by type. JAMA Benchmark Criteria were used to assess website quality. Pearson's chi-squared and Student's t-tests were performed as appropriate. RESULTS: A total of 620 questions (305 total knee arthroplasties, 315 total hip arthroplasties) were extracted with 602 associated websites. The most popular question topics were Specific Activities (23.5%), Indications/Management (15.6%), and Restrictions (13.4%). Questions related to Pain were more common in the TKA group (23.0% vs 2.5%, P < .001) compared to THA. The most common website types were Academic (31.1%), Commercial (29.2%), and Social Media (17.1%). JAMA scores (0-4) were highest for Government websites (mean 3.92, P = .005). CONCLUSION: The most frequently asked questions on Google related to total joint arthroplasty are related to arthritis management, rehabilitation, and ability to perform specific tasks. A sizable proportion of health information provided originate from non-academic, non-government sources (64.4%), with 17.1% from social media websites.

Natural Language Processing of Patient-Experience Comments After Primary Total Knee Arthroplasty.

BACKGROUND: There is interest in improving patient experience after total knee arthroplasty (TKA) due to recent shifts toward value-based medicine. Patient narratives are a valuable but unexplored source of information. METHODS: Records of 319 patients who had undergone primary TKA between August 2016 and August 2019 were linked with vendor-supplied patient satisfaction data, which included patient comments and the Press Ganey satisfaction survey. Using machine-learning-based natural language processing, 1048 patient comments were analyzed for sentiment and classified into themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not (positive, neutral, mixed grouped together). Multivariable regression was used to determine perioperative variables associated with providing a negative comment. RESULTS: Of the 1048 patient comments, 25% were negative, 58% were positive, 8% were mixed, and 9% were neutral. Top 2 themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in most of the studied outcomes (eg, peak pain intensity, length of stay, or Knee Injury and Osteoarthritis Outcome Score Junior and pain scores at 6-week follow-up) between the 2 cohorts (P > .05). However, patients who made negative comments were less likely to highly recommend their hospital care to peers (P < .001). Finally, patients who had higher American Society of Anesthesiologists Score and those who received a scopolamine patch were more likely to provide negative comments (P < .05). CONCLUSION: Although the current study showed that patient satisfaction might not be a proxy for traditional objective perioperative outcomes, efforts to improve the nontechnical aspects of medicine are still crucial in providing patient-centered care.

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty.

BACKGROUND: Absenteeism is costly, yet evidence suggests that presenteeism-illness-related reduced productivity at work-is costlier. We quantified employed patients' presenteeism and absenteeism before and after total joint arthroplasty (TJA). METHODS: We measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization's Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved. RESULTS: In total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value). CONCLUSION: Among employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.

What Are the Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Hip Arthroplasty?

BACKGROUND: A higher volume of primary total hip arthroplasty (THA) is starting to be performed as an outpatient procedure. However, data on appropriate patient selection for this surgical protocol is scarce. METHODS: Patients who underwent primary THA were identified in the 2012-2018 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Risk factors for and effect of overnight hospital stay on 30-day readmission after outpatient THA were identified through multivariable models. Reasons for and timing of readmission were also identified. RESULTS: A total of 5245 outpatient THA patients and 44,171 patients who stayed 1 night were identified. The incidence of 30-day readmission after outpatient THA was 1.60% (95% confidence interval [CI] 1.26-1.94). Risk factors for 30-day readmission after outpatient THA include the following: older age relative to 18-60 years old (most notably 71-75 years old, relative risk [RR] = 2.3, 95% CI = 1.15-4.62; 76-80 years old, RR = 6.6, 95% CI = 3.55-12.43; and >80 years old, RR = 5.6, 95% CI = 2.43-12.89, P < .001) and bleeding disorders (RR = 4.5, 95% CI = 1.45-14.31, P = .010). For patients who had some of these risk factors, their risk of medically related 30-day readmission was reduced if they had stayed 1 night at the hospital (P < .05). The majority of readmissions were surgically related (62%), including wound complications (27%) and periprosthetic fractures (25%). CONCLUSION: The rate of 30-day readmission after outpatient THA was low. Patients who are at high risk for 30-day readmission after outpatient THA include those with older age and bleeding disorders. Some of these patients may benefit from an inpatient hospital stay.

What Are the Minimal and Substantial Improvements in the HOOS and KOOS and JR Versions After Total Joint Replacement?

BACKGROUND: Patient-reported outcome measures (PROMs) are a gold standard for measuring therapeutic outcomes in research. Extending their use to inform clinical care decisions, determine the appropriateness of therapeutic choices, and assess healthcare quality is attractive but will require our professional community to establish valid estimates of minimal and substantial clinical improvements. QUESTIONS/PURPOSES: The purposes of this study were (1) to assess the validity of estimates for the minimal clinically important difference (MCID) calculated using distribution- and anchor-based methods by determining whether they exceed the minimal detectable change (MDC) for the Hip Disability and Osteoarthritis Outcome Score (HOOS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) domains, the HOOS, joint replacement (JR) and the KOOS, JR among patients who underwent THA or TKA; (2) to determine substantial clinical benefit thresholds for the HOOS and KOOS domains, the HOOS, JR, and the KOOS, JR among patients who underwent THA or TKA; and (3) to assess the proportions of patients who underwent THA or TKA who achieved an MCID for the HOOS and KOOS domains, HOOS, JR, and KOOS, JR based on distribution-based and anchor-based methods as well as the percentages of patients who achieved substantial clinical benefit using the anchor-based method. METHODS: Medicare patients enrolled in our institutional joint replacement registry who subsequently underwent THA (n = 2323) or TKA (n = 2630) between 2007 and 2012 completed HOOS or KOOS preoperatively and 2 years postoperatively. Short-form joint replacement (JR) versions of each PROM were derived from the full PROMs. Of all eligible patients, 78% (3161 of 4080) of THAs and 74% of TKAs (3815 of 5156) consented to join the registry and completed a baseline survey, 88% (2796 of 3161) of THAs and 85% (3230 of 3815) of TKAs were eligible for followup survey administration, and 83% of THAs (2323 of 2796) and 81% (2630 of 3230) of TKAs returned 2-year surveys. For each HOOS domain, KOOS domain, HOOS, JR, and KOOS, JR, we calculated the calibration variation of the instrument (MDC) with confidence intervals (CIs) reflecting 80% (MDC80), 90% (MDC90), and 95% (MDC95) certainty; we calculated the smallest difference joint health patients might detect (MCID) using distribution- and anchor-based approaches and the difference that can be considered a large improvement in joint health (substantial clinical benefit) using an anchor-based approach. RESULTS: Patients undergoing THA were 57% female with a mean (± SD) age of 73 ± 6 years, whereas patients undergoing TKA were 63% female with a mean age of 74 ± 6 years. Depending on the CI chosen for the MDC, values ranged from 7 to 16 for the HOOS and KOOS domains and the JRs. The MCIDs ranged from 6 to 9 for the distribution-based approach and 7 to 36 for the anchor-based approach. All HOOS and KOOS domains and all JR scores are scores from 0 (worst joint health) to 100 (best joint health). The MCIDs calculated using the distribution-based approach were not valid, because they were lower than the MDC for all HOOS/KOOS domains and both JRs at every confidence level. The anchor-based receiver operating characteristic approach, on the other hand, resulted in MCIDs exceeding MDC80 for seven of eight HOOS/KOOS domains and MDC95 for both JR scores. For all domains and JR versions, substantial clinical benefits ranged from 15 to 36, exceeding MDC95 in all domains and JR scores. Across HOOS and KOOS domains as well as the JR, the proportion of patients undergoing THA who achieved an MCID ranged from 77% to 95% with the distribution-based method and from 67% to 96% using the anchor-based method. The proportion achieving substantial clinical benefit ranged from 67% to 85%. CONCLUSIONS: The MDC and MCID differ greatly based on assumptions and methods used. The MCID anchor-based approach had superior construct and face validity compared with the MCID distribution-based approach, which never exceeded even small MDCs. Achieving consensus about standard definitions of meaningful improvement will be necessary to maximize utility of these PROMs to inform clinical care or performance measurement. LEVEL OF EVIDENCE: Level III, diagnostic study.

Knotless Implant for Arthroscopic Hip Capsule Closure.

The hip joint capsule plays a significant role in maintaining hip stability, including translation and rotation. Hip capsular closure or plication has been shown to increase stability of the joint following capsulotomy in hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) and/or associated labral tears. This technique article describes a knotless method of closing the hip capsule.

Outcomes After Concomitant Hip Arthroscopy and Periacetabular Osteotomy: A Systematic Review.

Background: Despite several studies' reports on outcomes of concomitant hip arthroscopy and periacetabular osteotomy (PAO), there is a paucity of aggregate data in the literature. Purpose: To evaluate outcomes and survivorship after concomitant hip arthroscopy and PAO. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Cochrane, and Scopus databases were searched in April 2022 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following keywords were used: (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (periacetabular osteotomy or rotational osteotomy) AND (outcomes OR follow-up). Of 270 articles initially identified, 10 studies were ultimately included. The following information was recorded for each study if available: publication information; study design; study period; patient characteristics; follow-up time; indications for hip arthroscopy; patient-reported outcomes (PROs); rates of secondary hip preservation surgeries; and rates of conversion to total hip arthroplasty (THA). Survivorship was defined as nonconversion to THA. Results: The study periods for the 10 included articles ranged from 2001 to 2018. Three studies were level 3 evidence, and 7 studies were level 4 evidence. This review included 553 hips with a mean follow-up of 1 to 12.8 years. All 10 studies listed dysplasia as an indication for surgery. Of 9 studies that reported PRO scores, 7 reported significant improvement after surgery. Studies with a <5-year follow-up reported conversion to THA rates of 0% to 3.4% and overall secondary surgery rates of 0% to 10.3%. Similarly, studies with >5-year follow-up reported conversion to THA rates of 0% to 3% and overall secondary surgery rates of 0% to 10%. Conclusion: Patients who underwent concomitant hip arthroscopy and PAO reported favorable outcomes, with 7 of the 9 studies that provided PRO scores indicating significant preoperative to postoperative improvement.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

BACKGROUND: Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS: Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS: There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS: In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE: Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.