Dysplastic Hips Have Decreased Iliofemoral Ligament Thickness on Coronal Sequences in Magnetic Resonance Imaging: A Matched Cohort Analysis.

PURPOSE: To characterize hip capsule thickness on advanced imaging in patients with and without hip dysplasia and to also evaluate differences in capsular thickness between borderline and true dysplastic patients. METHODS: Patients evaluated by the senior author for concerns of hip pathology from June 2020 to June 2021 were queried and images reviewed to determine dysplasia status by lateral center edge angle (LCEA) ≤ 25 degrees. A group of non-dysplastic patients was identified and matched for age, sex, and body mass index (BMI). Hip capsular thickness was quantified using MRI. A sub-analysis was conducted to compare true dysplastic patients (LCEA < 20°) to borderline dysplastic patients (LCEAs between 20 - 25°). Analysis included independent samples t-tests, Chi-square tests, and multivariable regression. RESULTS: Eighty total patients were included, with a mean age of 31.8 ± 11.7 years, a mean BMI of 26.6 ± 6.5 points, and 70% (56) female patients. Dysplastic patients had a mean LCEA of 19.8 ± 4.3 degrees. Dysplastic individuals had decreased capsular thickness compared to their non-dysplastic controls (2.75 ± 0.96 vs 3.52 ± 1.22 mm, p = 0.003). Multivariable regression showed decreased capsular thickness associated with decreased LCEAs (ß = 2.804, R = 0.432, p<0.001) and dysplasia (ß = -0.709, R2 = 0.056, p = 0.004). Results of a sub-analysis of the dysplastic group examining differences between accepted definitions of borderline dysplasia and true dysplasia showed no significant differences in capsular thickness between the two groups (p = 0.379). CONCLUSIONS: Patients with hip dysplasia were found to have thinner iliofemoral ligaments in the coronal plane on magnetic resonance imaging on magnetic resonance imaging. Further investigation is needed to evaluate any potential implications with hip instability given the thinner hip capsule demonstrated in this study.

Short-term Outcomes After Hip Arthroscopic Surgery in Patients Participating in Formal Physical Therapy Versus a Home Exercise Program: A Prospectively Enrolled Cohort Analysis.

BACKGROUND: Physical therapy is frequently utilized in the postoperative care of femoroacetabular impingement syndrome (FAIS). There has been limited research into the efficacy of a structured home exercise program (HEP) compared with formal physical therapy (FPT) in this patient population. PURPOSE/HYPOTHESIS: The purpose was to evaluate the short-term outcomes of patients utilizing FPT versus an HEP after hip arthroscopic surgery for FAIS. It was hypothesized that both groups would show similar improvements regarding outcome scores, which would improve significantly compared with their preoperative scores. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing hip arthroscopic surgery for FAIS at a single center between October 2020 and October 2021 were prospectively enrolled. Patients were allowed to self-select FPT or an HEP and were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. The survey included the Single Assessment Numeric Evaluation, visual analog scale for pain, 12-item International Hip Outcome Tool, Patient-Reported Outcomes Measurement Information System Physical Function, and patient satisfaction with physical therapy and overall care. Statistical analysis was conducted between the 2 groups and within groups to compare preoperative and postoperative scores. RESULTS: The patients' mean age was 32.6 ± 10.4 years, with 47.2% being female and 57.4% choosing the HEP. At 12 months postoperatively, no significant differences were reported between the FPT and HEP groups regarding the Single Assessment Numeric Evaluation score (P = .795), visual analog scale for pain score (P > .05), Patient-Reported Outcomes Measurement Information System Physical Function T-score (P = .699), 12-item International Hip Outcome Tool score (P = .582), and patient satisfaction (P > .05). Outcome scores at 12 months postoperatively were significantly improved from the preoperative scores across all measures in both groups (P < .001). CONCLUSION: There were no significant differences regarding patient outcomes between FPT and the HEP at 1-year follow-up after hip arthroscopic surgery for FAIS when patients selected their own treatment, with both groups demonstrating significant improvements in their outcome scores from their preoperative values. These findings suggest that a structured HEP may be a viable alternative to FPT after hip arthroscopic surgery in patients who prefer a self-directed rehabilitation program.

Common radiographic indices used to measure patellar height do not consistently identify patella alta and lack interchangeability between measurements.

PURPOSE: Abnormal patellar height has been identified as a source of aberrant mechanical functioning within the patellofemoral joint. The purpose of this study is to examine the statistical agreement among three commonly used classification methods: Blackburne-Peel (BPI), Caton-Deschamps (CDI) and Insall-Salvati (ISR), by evaluating (1) the rates of patella alta identification and (2) the ability for one index to predict another. METHODS: One hundred lateral knee radiographs were evaluated using BPI, CDI and ISR to classify each knee as patella normal, patella alta or patella baja. Linear regression analysis was performed to evaluate the relationship between each index. Conversion equations were then derived using the reported linear regression best-fit line, comparing each pair of indices. RESULTS: Patella alta was identified in 15 knees using BPI, 15 using CDI and 25 using ISR. A total of seven knees were classified as patella alta by all BPI, CDI and ISR. Statistical analysis revealed significant correlation (p ≤ 0.001) among BPI and CDI (R2 = 0.706), BPI and ISR (R2 = 0.328) and CDI and ISR (R2 = 0.288). Wilcoxon Signed-Rank test between the three indices revealed no significant difference between the means of converted and original indices. CONCLUSION: Despite their significant correlations and adequate reproducibility, variability between common patellar height indices render predictions and conversions between BPI, CDI and ISR inequivalent. Users of these indices must be aware of their incongruent properties when considering application to patients in the clinical setting. Furthermore, it remains unclear which patellar height measurement technique is the correct index to use in a given knee. This study highlights the need for further investigation to create a reliable and standardised method for identifying patella height. LEVEL OF EVIDENCE: Level IV.

Relationship Between Hip Capsular Thickness and Instability After Previous Hip Arthroscopic Surgery: A Matched-Cohort Analysis.

Background: Thinner anterior hip capsules are associated with hip laxity, but there is little known about the impact of capsular thickness on the development of instability after primary hip arthroscopic surgery. Purpose: To investigate the relationship between hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and the development of hip instability after hip arthroscopic surgery for femoroacetabular impingement. Study Design: Case-control study; Level of evidence, 3. Methods: We reviewed revision hip arthroscopic procedures performed between January 1, 2019, and May 1, 2021, at a single institution. Inclusion criteria were preoperative MRI/magnetic resonance arthrography, completion of the study traction protocol, and asymmetric distraction between the hips of ≥3 mm on examination under anesthesia. A comparison group of patients treated for femoroacetabular impingement with primary hip arthroscopic surgery who did not develop capsular instability were matched 1:1 to the patients with instability. Superolateral hip capsular thickness was measured on MRI before index surgery. Analysis was conducted using independent-samples t tests and multivariable linear regression. Results: A total of 44 patients were included, with 22 patients each in the instability and no-instability groups. The mean capsular thickness was lower in the patients with hip instability than in those without (1.9 ± 0.6 vs 3.4 ± 1.1 mm, respectively; P < .001). Decreased capsular thickness was significantly associated with hips with instability versus no-instability (ß = -1.468 [95% CI, -2.049 to -0.887]; P < .001). Conclusion: Thinner preoperative hip capsules in the region of the iliofemoral ligament were seen in patients who subsequently underwent revision arthroscopic surgery for hip instability compared to patients who underwent primary hip arthroscopic surgery without subsequent revision. Patients at a higher risk for the development of postoperative hip instability had a superolateral hip capsular thickness of <2 mm.

Mid-term outcomes of temporary medial distal femoral hemiepiphysiodesis with and without medial patellofemoral ligament repair for recurrent patellar instability in skeletally immature patients with genu valgum.

Genu valgum contributes to patellar instability, though outcomes following temporary hemiepiphysiodesis via eight plating are less understood. The purpose of this study was to evaluate the outcomes and need for additional procedures following temporary hemiepiphysiodesis for the treatment of pediatric genu valgum and patellar instability, as well as evaluating the utility of a concurrent medial patellofemoral ligament (MPFL) repair. Patients who underwent medial distal femoral epiphysiodesis for the treatment of genu valgum and recurrent patellar instability were identified. Inclusion criteria were minimum 1-year follow-up and lack of concurrent ligamentous reconstruction. Patients were contacted to complete a questionnaire which included the International Knee Documentation Committee (IKDC) form and questions pertaining to knee function and patient satisfaction. Thirty-one patients aged 12.0 ± 1.9 years underwent 47 guided growth procedures and were included in final analysis. Seventeen knees (36%) required subsequent surgery for patellar instability. All patients requiring subsequent surgery were female, compared with 70% of patients not requiring subsequent surgery ( P  = 0.017). The MPFL repair group underwent fewer subsequent procedures to address instability, though this difference was NS (17 vs. 46%, P  = 0.318). Mean IKDC score at 5.3 years follow-up among 18 survey respondents was 78.6. Medial distal femoral hemiepiphysiodesis may partially address recurrent patellar instability in skeletally immature patients with genu valgum. Concurrent MPFL repair may minimize the need for subsequent procedures to address recurrent instability. While correcting alignment may be helpful, patients should be aware of the potential need for further patellar instability surgery. Level of evidence: IV, case series.

Single time point quantitation of cerebral glucose metabolism by FDG-PET without arterial sampling.

BACKGROUND: Until recently, quantitation of the net influx of 2-[18F]fluorodeoxyglucose (FDG) to brain (Ki) and the cerebrometabolic rate for glucose (CMRglc) required serial arterial blood sampling in conjunction with dynamic positron emission tomography (PET) recordings. Recent technical innovations enable the identification of an image-derived input function (IDIF) from vascular structures, but are frequently still encumbered by the need for interrupted sequences or prolonged recordings that are seldom available outside of a research setting. In this study, we tested simplified methods for quantitation of FDG-Ki by linear graphic analysis relative to the descending aorta IDIF in oncology patients examined using a Biograph Vision 600 PET/CT with continuous bed motion (Aarhus) or using a recently installed Biograph Vision Quadra long-axial field-of-view (FOV) scanner (Bern). RESULTS: Correlation analysis of the coefficients of a tri-exponential decomposition of the IDIFs measured during 67 min revealed strong relationships among the total area under the curve (AUC), the terminal normalized arterial integral (theta(52-67 min)), and the terminal image-derived arterial FDG concentration (Ca(52-67 min)). These relationships enabled estimation of the missing AUC from late recordings of the IDIF, from which we then calculated FDG-Ki in brain by two-point linear graphic analysis using a population mean ordinate intercept and the single late frame. Furthermore, certain aspects of the IDIF data from Aarhus showed a marked age-dependence, which was not hitherto reported for the case of FDG pharmacokinetics. CONCLUSIONS: The observed interrelationships between pharmacokinetic parameters in the IDIF measured during the PET recording support quantitation of FDG-Ki in brain using a single averaged frame from the interval 52-67 min post-injection, with minimal error relative to calculation from the complete dynamic sequences.

Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse.

INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS: A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS: 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS: Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.

Medial Patellofemoral Ligament Reconstruction in the Pediatric Population: Skeletal Immaturity Does Not Affect Functional Outcomes but Demonstrates Increased Rate of Subsequent Knee Injury.

Purpose: To evaluate short- to mid-term-outcomes, including instability rates, following medial patellofemoral ligament (MPFL) reconstruction in skeletally immature versus mature pediatric patients. Methods: Patients younger than age 18 with recurrent patellar instability who underwent primary allograft MPFL reconstruction by a single surgeon from 2013 to 2019 were identified. Skeletally immature patients underwent all-epiphyseal drilling and mature patients underwent metaphyseal drilling at the Schöttle's point. Patients 1 year from surgery were contacted to complete questionnaires, which included the International Knee Documentation Committee score. Further data included chart and imaging review. Significance was determined by P < .05. Results: Of 118 eligible patients, 88 completed questionnaires. There were 67 skeletally mature and 21 skeletally immature patients. The mature group was older (15 vs 13 years, P < .001), predominantly female (67 vs 43%, P = .046), and heavier (24.7 vs 18.9, P < .001). Trochlear dysplasia (P = .594), concomitant procedures (P = .336), graft choice (P = .274), and follow-up length (P = .107) did not differ, although mature patients more often underwent suture tape augmentation (68 vs 13%, P < .001). Immature patients had greater rates of ipsilateral injury (35 vs 16%, P = .043); redislocation rate did not differ (9 vs 3%, P = .225). Mature patients were more likely to respond "definitely yes or probably yes" when asked if they would undergo the same care if needed (96 vs 76%, P = .007). At minimum 2-year follow-up, subsequent ipsilateral injury rates did not differ, although willingness to undergo the same care remained significant (95 vs 69%, P = .010). In a multivariable elimination logistic regression model, skeletal maturity was the only variable associated with subsequent ipsilateral injury (P = .049). Conclusions: Pediatric patients undergoing MPFL reconstruction have good and comparable outcomes regardless of skeletal maturity. However, younger age and lack of tape augmentation in skeletally immature patients may predispose them to subsequent injury. Level of Evidence: III, case-control study.

Female Patients and Decreased Hip Capsular Thickness on Magnetic Resonance Imaging Associated With Increased Axial Distraction Distance on Examination Under Anesthesia: An In Vivo Study.

PURPOSE: To investigate the relation of hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and intraoperative hip joint axial distraction distance on an examination under anesthesia. METHODS: A retrospective review of primary arthroscopic hip procedures performed between November 2018 and June 2021 was conducted. The inclusion criteria included a diagnosis of femoroacetabular impingement syndrome and preoperative radiographic imaging and MRI. Fluoroscopic images were obtained at 0 lb and 100 lb of axial traction force. Total distraction distance was calculated by comparing the initial joint space with the total joint space at 100 lb. Hip capsular thickness was measured on MRI. Analysis was conducted using multiple linear regression, independent-samples t tests, and Mann-Whitney U tests. RESULTS: Eighty patients were included. Bivariable regression showed an association between an increased distraction distance and female sex (ß = 4.303, R = 0.561, P < .001), as well as decreased anterior axial (ß = -1.291, R = 0.365, P < .001) and superior coronal (ß = -1.433, R = 0.501, P < .001) capsular thickness. Multivariable regression (R = 0.645) showed an association between an increased distraction distance and female sex (ß = 3.175, P < .001), as well as decreased superior coronal capsular thickness (ß = -0.764, P = .022). Independent-samples t tests showed that female patients had significantly decreased superior coronal capsular thickness (2.92 ± 1.14 mm vs 3.99 ± 1.15 mm, P < .001). CONCLUSIONS: Female sex and decreased hip capsular thickness in the superior aspect of the coronal plane on magnetic resonance scans were found to be predictors of increased hip joint axial distraction distance on examination under anesthesia prior to hip arthroscopy, with anterior axial capsular thickness being a moderate predictor. Poor predictors of distraction distance were posterior axial and inferior coronal capsular thickness, age, body mass index, and lateral center-edge angle. Female patients were also found to have thinner hip capsules in the superior region, which may explain the association between female patients and increased distraction. These findings further characterize the relation between capsular thickness and hip laxity. LEVEL OF EVIDENCE: Level IV, case series.

Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care.

BACKGROUND: With rising healthcare costs and campaigns aimed at avoiding low-value care, reducing cancer overtreatment has emerged as an important measure of cancer care quality. The extent to which avoidance of low-value care has been incorporated in cancer-specific quality measures is unknown. We aimed to identify and characterize cancer quality measures that promote the avoidance of low-value care, and identify gaps that may guide future measure development. METHODS: We systematically identified cancer-specific quality measures from leading quality measure organizations [e.g., National Quality Forum (NQF), National Quality Measures Clearinghouse (NQMC)]. We reviewed measures promoting the avoidance of low-value cancer care and subclassified them into disease site- or non-disease site-specific categories and the phase of care they targeted. RESULTS: We reviewed 313 quality measures from six organizations. Of these, 18% (n = 55) focused on avoidance of low-value care. Quality measures focused on end-of-life care were most likely to focus on low-value care [n = 13 (50%)], followed by breast [n = 12 (18%)], lung [n = 9 (31%)], colon [n = 8 (20%)], prostate [n = 5 (38%)], general cancer care [n = 4 (3%)], symptoms and toxicities [n = 2 (40%)], and palliative cancer care [n = 2 (11%)] measures. The phases of care quality measures targeted included low-value screening [n = 5 (9%)], diagnostic testing and staging [n = 7 (13%)], treatment [n = 19 (34%)], surveillance [n = 6 (11%)], and clinical outcomes [n = 18 (33%)]. All categories had a treatment-specific quality measure, but no category had a representative measure for every phase of care. DISCUSSION: A minority of cancer quality measures are aimed at avoiding low-value care, and multiple evidence-based recommendations targeting low-value care have not been incorporated.

Incidence of Subsequent Surgical Intervention at Short-term Follow-up in Previously Healing and Stable Juvenile Osteochondritis Dissecans of the Knee.

BACKGROUND: Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery. METHODS: A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression. RESULTS: Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery (B=-2.6, P=0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm2, respectively, though not significantly different (P=0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different (P=0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities. CONCLUSIONS: While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions. LEVEL OF EVIDENCE: Level IV-prognostic study.

Postoperative Pain Medication Utilization in Pediatric Patients Undergoing Sports Orthopaedic Surgery: Characterizing Patient Usage Patterns and Opioid Retention.

INTRODUCTION: Opioid overprescribing is a problem in orthopaedic surgery, with many patients having leftover opioid medications after surgery. The purpose of our study was to capture utilization patterns of opioids in pediatric patients undergoing orthopaedic sports medicine surgery, in addition to evaluating patient practices surrounding unutilized opioid medication. Our hypothesis was that there would be low utilization of opioids in this patient population and would in turn contribute to notable overprescribing of opioids and opioid retention in this population. METHODS: Pediatric patients undergoing orthopaedic surgery for knee and hip pathology were prospectively enrolled. A survey was administered 14 days postoperatively, with questions centered on the patient-reported number of opioids prescribed, number of opioids used, number of days opioids were used, and incidences of leftover opioid medication and disposal of leftover medication. The magnitude of opioid overprescribing was calculated using the reported prescribed and reported used number of opioid pills. Linear regression was used to examine associations between opioids and NSAIDs prescribed. RESULTS: One hundred fourteen patients reported a mean prescription of 12.0 ± 5.0 pills, with utilization of 4.4 ± 6.1 pills over 2.7 ± 5.1 days. Patients were prescribed 2.73 times the number of opioid pills required on average. One hundred patients (87.7%) reported having unused opioid medication after their surgery, with 71 (71.0%) reporting opioid retention. Regression results showed an association with opioids used and prescribed opioid amount (ß = 0.582, R = 0.471, P < 0.001). DISCUSSION: Overall, our study results help characterize the utilization patterns of opioid medications in the postsurgical pediatric sports orthopaedic population and suggest that orthopaedic surgeons may be able to provide smaller quantities of opioid pills for analgesia than is typically prescribed, which in turn may help reduce the amount of prescription opioid medications present in the community. LEVEL OF EVIDENCE: Level IV.

Editorial Commentary: Not Yet Convinced That the Femoroacetabular Impingement Resection (Fair) Arc Measurement Provides a "Fair" Assessment of Cam Resection Principles.

Hip arthroscopy has proven to be an effective surgical approach for the treatment of femoroacetabular impingement (FAI) syndrome. Studies have shown that patients typically have improved functional outcomes and high rates of return to activity following cam lesion resection and reshaping of the femoral head-neck junction. However, despite these favorable outcomes, there is still a steep and well-recognized learning curve in FAI hip arthroscopy. Although it is common dogma to consider an ideal reshaping of the femoral head-neck junction as being perfectly spherical, the ability to achieve this intraoperatively can be quite challenging. A new tool is the "femoroacetabular impingement resection (FAIR) arc," measured on a 45° Dunn lateral radiograph where a best-fit circle incorporates the region immediately inferior to the anteroinferior iliac spine, the subspine region, and lateral femoral neck base. The maximal radial distance height is then measured from the circumference of this circle to the apex of the cam lesion. This radiographic aid may assist with intraoperative estimate of appropriate cam lesion resection depth. While I tend to utilize preoperative radiographs and intra-operative neck sclerosis to determine cam resection depth, I continue to seek out other ways to effectively perform a femoral osteoplasty. While my initial attempt to utilize the FAIR index in my practice did not seem effective, I will continue to test this measurement in my patients.

Sociodemographic Factors Associated With Decreased Compliance to Prescribed Rehabilitation After Surgical Treatment of Knee Injuries in Pediatric Patients.

BACKGROUND: Rehabilitation is an important component of care in postsurgical knee patients, especially as it pertains to return to preinjury activity level. Despite the established significance of rehabilitation in improving outcomes after certain surgical procedures, there is a lack of investigation into compliance rates and factors that affect compliance in pediatric patients. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate sociodemographic factors associated with noncompliance in pediatric patients after knee surgery to characterize health disparities in this population. Our hypothesis was that certain sociodemographic factors would be associated with decreased compliance. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective review of medical records was used to gather data on compliance rate, demographics, and socioeconomic factors for pediatric patients undergoing rehabilitation after knee surgery. Compliance rate was determined by counting the total scheduled appointments, cancellations, and no-shows (defined as visits for which patients did not show up and did not provide notification of cancellation). Various types of knee injuries were included in this study. Data were evaluated using bivariate analyses in addition to hierarchical linear and binary logistic regression to assess for associations between sociodemographic factors and compliance rate. RESULTS: Our total sample size was 186 patients. When compared with patients from non-single-parent households, patients from single-parent households were found to have a lower rate of physical therapy compliance (72.2% vs 80.1%; P < .001), were less likely to reach the 85% compliance threshold (9.1% vs 42.4%; P < .001), and had an increased amount of cancellations and no-shows (16.7 vs 11.7 visits; P = .02). Although a small sample size, Hispanic/Latino patients were shown to have a lower achievement of the 85% compliance threshold compared with non-Hispanic/Latino patients (0% vs 38.2%; P = .04). Increased distance from the rehabilitation clinic was associated with lower achievement of the 85% compliance threshold (P = .033). CONCLUSION: Overall, there were several significant demographic and socioeconomic variables associated with rehabilitation compliance, specifically single-parent status, distance to rehabilitation clinic, and ethnicity. These results suggest potential predictors of decreased compliance that warrant prospective investigation.

Hip Capsular Deficiency-A Cause of Post-Surgical Instability in the Revision Setting Following Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE OF REVIEW: To characterize current concepts in capsular repair and hip instability, and examine findings from biomechanical and clinical studies on hip capsular management strategies as they pertain to hip stability, patient outcomes, and hip arthroscopy failure. Further, we discuss the clinical evaluation and treatment of capsular deficiency. RECENT FINDINGS: There remains debate regarding the optimal capsular management strategies in hip arthroscopy, particularly concerning the necessity of routine capsular repair. A variety of capsulotomy techniques exist and may be used to access the hip joint. Additionally, a wide variety of techniques are employed to repair the hip capsule. Biomechanical evidence supports capsular closure restores hip joint stability to that of the intact, native state. Several clinical studies in both primary and revision hip arthroscopy settings have demonstrated improved pain and functional outcomes in patients who underwent capsular repair or capsular reconstruction. Studies have shown capsular repair may be especially important in patients with ligamentous laxity and hip dysplasia, and in competitive athletes. Post-surgical hip instability secondary to capsular insufficiency is increasingly recognized as a cause of hip arthroscopy failure. Capsular closure restores native biomechanical stability to the hip joint, and several clinical studies report improved pain and functional outcomes following capsular repair or capsular reconstruction in both the primary and revision hip arthroscopy settings. There remains much to learn regarding capsular hip instability as it relates to optimal capsular management surgical technique, intra-operative capsular management decision-making, clinical diagnosis, and related advanced imaging findings.

Larvicidal Evaluation against Aedes aegypti and Antioxidant and Cytotoxic Potential of the Essential Oil of Tridax procumbens L. Leaves.

The present study evaluated the antioxidant, cytotoxic, and larvicidal potential of the essential oil of Tridax procumbens leaves, as well as identified the compounds present in the essential oil. The antioxidant activity was evaluated by the sequestration method of 2,2-diphenyl-1-picrylhydrazyl radical, the cytotoxic activity was evaluated using Artemia salina, the larvicidal bioassay was performed with larvae in the third stage of development of the Aedes aegypti mosquito, and the identification of the metabolites was performed by gas chromatography coupled to the mass spectrometer (GC-MS). The phytochemical oil analysis showed the presence of 20 compounds, with thymol and γ-terpinene being the main ones. It presented antioxidant activity with an IC50 of 194.51 µg mL-1, demonstrating antioxidant activity in the highest concentrations tested. It presented low cytotoxic activity against A. salina, with an LC50 of 1238.67 µg mL-1, demonstrating atoxicity in the concentrations tested. The essential oil presented good larvicidal activity when compared to the literature, with an LC50 = 79.0 µg mL-1 in 24 hours and LC50 of 69.15 µg mL-1 in 48 hours. In this way, it was possible to identify that the essential oil of the leaves of T. procumbens presented potential for the development of a natural larvicide, as well as antioxidant activity satisfactory to the radical DPPH and low toxicity to A. salina.

Cystic squamous cell carcinoma of the orbit.

Both primary and secondary squamous cell carcinoma (SCC) of the orbit are rare entities, though cystic SCC is even more so. It may provide a significant diagnostic conundrum to oculoplastic surgeons. We present a case of an 86 year old male with a supero-medial transilluminating cystic lesion of the orbit. There was a preceding history of a moderately differentiated SCC of the cheek, excised 3 months prior. Computed tomography (CT) demonstrated no bone erosion. The cyst was excised aided by fibrin glue. This demonstrated a poorly differentiated cystic SCC with perineural infiltration. The patient elected for palliative aspirations of the cyst and is alive 12 months later. Cystic SCC of the orbit may present to a number of specialties, including maxillofacial and orbital surgeons. Both diagnosis and management may be challenging. We review common patterns in previous cases and discuss management.

Three-Dimensional Magnetic Resonance Arthrography of Post-Arthroscopy Hip Instability Demonstrates Increased Effective Intracapsular Volume and Anterosuperior Capsular Changes.

PURPOSE: To quantify the magnetic resonance arthrography (MRA) capsular morphologic findings associated with postarthroscopy hip instability. METHODS: Among patients with clinically significant iatrogenic hip instability at a single center, patients with preindex and postindex surgery MRAs were identified. These MRAs were compared regarding effective intracapsular volume calculated by semi-automated 3-dimensional pixel intensity region segmentation, 2-dimensional anterior proximal intracapsular area in the femoral neck axial plane reconstruction, maximal anterior fluid pocket depth, capsule retraction distance, and capsular instability grade. Morphological measurements were conducted using Horos image processing software. Paired t-test, paired Wilcoxon signed rank test, and the McNemar test were used for identifying statistical significance. RESULTS: In 42 patients, mean effective intracapsular volume was significantly greater in the postindex surgery MRAs (19.44 cm3 vs 17.26 cm3; P = .006). Proximal anterosuperior (12-3 o'clock) intracapsular area was also significantly greater after index surgery (2.84 cm2 vs 1.43 cm2; P < .001. Proximal anteroinferior (3-6 o'clock) intracapsular area (1.34 cm2 vs 0.97 cm2; P = .002), capsule deficiency grade (P < .001), anterior capsule retraction distance (4.83 mm vs 0.34 mm; P < .001), and maximum anterior fluid depth (8.33 mm vs 4.90 mm; P <.001) were also significantly increased after index surgery. CONCLUSION: In comparison to the preoperative state, iatrogenic hip instability is associated with MRA findings that include increases in total effective intracapsular volume, proximal anterosuperior and anteroinferior intracapsular cross-sectional area, maximum proximal anterosuperior fluid depth, and capsule retraction distance. LEVEL OF EVIDENCE: Level IV, diagnostic case series.

Brassinosteroids trigger tolerance to iron toxicity in rice.

Iron (Fe) toxicity is one of the most frequent abiotic stresses in rice, as it affects from 15% to 30% of the total production. Brassinosteroids (BRs), including 24-epibrassinolide (EBR), regulate ion homeostasis and improve the antioxidant system. The aim of this research was to determine whether EBR can contribute to the tolerance of rice plants exposed to Fe toxicity and to evaluate the possible effect on anatomical characteristics, nutrient concentrations, the antioxidant system, and gas exchange. The experiment was randomized with four treatments, two with different concentrations of Fe (250 and 6250 µM, control and toxicity, respectively) and these were either supplied with EBR or not (0 and 10 nM EBR, described as -EBR and +EBR, respectively). Treating plants grown under Fe toxic conditions with EBR caused an 70% increase in root aerenchyma area, compared to plants without steroid treatment. Our results revealed that EBR treatment could mitigate the deleterious effects of Fe toxicity in rice plants, by modulating the aerenchyma area, which contributes to the formation of an oxidative barrier and reduce the Fe mobilization at the root surface. Plants that were exposed to Fe toxic concentrations and treated with EBR showed (1) an increase in the enzyme activities of superoxide dismutase, catalase, ascorbate peroxidase and peroxidase, (2) mitigation of oxidative damage and (3) increased scavenging of reactive oxygen species. Finally, EBR alleviated the negative impacts induced by excess Fe on the net photosynthetic rate and the instantaneous carboxylation efficiency. These benefits were directly related to higher electron transport and stomatal density and indirectly linked to the protection mechanism exercised by the antioxidant enzymes on photosynthetic machinery. We conclude that EBR is able to confer tolerance to Fe toxicity in rice plants.