Borderline Dysplastic Hips Undergoing Hip Arthroscopy Achieve Equivalent Patient Reported Outcomes When Compared With Hips With Normal Acetabular Coverage: A Systematic Review and Meta-Analysis.

PURPOSE: To systematically review and meta-analyze studies reporting lateral center edge angle as it relates to patient-reported outcome (PRO) measures and clinically notable outcome assessments for patients undergoing hip arthroscopy for femoroacetabular impingement syndrome or labral pathology with borderline dysplastic hips (BDH). METHODS: PubMed, EMBASE, and the Web of Science Core Collection databases were queried for articles evaluating lateral center edge angle as a predictor of PRO after hip arthroscopy. Articles were eligible for meta-analysis if they compared PROs measures between patients with normal acetabular coverage and borderline dysplasia and were at least level III evidence. Continuous random-effects models with standardized mean differences were used to compare postoperative Hip Outcome Score-Activities of Daily Living and sports subscales, modified Harris Hip Score, international Hip Outcome Tool scores, Satisfaction, and Visual Analog Scale Pain scores between normal coverage and borderline dysplastic groups. RESULTS: Overall, 989 hips undergoing arthroscopy from six investigations were included in this meta-analysis, including 315 borderline dysplastic subjects (mean age 27.5 years) and 674 subjects with normal coverage (mean age 26.9 years). Borderline dysplastic and normal coverage cohorts were followed for an average of 37.0 and 36.8 months, respectively. Postoperative PRO measures (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, modified Harris Hip Score, international Hip Outcome Tool-12, Satisfaction, and Visual Analog Scale Pain) collected approximately three years after hip arthroscopy were not markedly different between subjects with BDH when compared with patients with normal coverage. CONCLUSIONS: In a meta-analysis of the available literature, patients with BDH are able to equally reach statistically similar clinical outcomes after isolated hip arthroscopy as compared with control subjects without dysplasia at short-term follow-up. A BDH should not be considered a contraindication to hip arthroscopy when optimal PRO achievement is the goal. LEVEL OF EVIDENCE: Level III, Systematic Review and Meta-Analysis.

Pathogenesis, Evaluation, and Management of Osteolysis After Total Shoulder Arthroplasty.

Radiographic osteolysis after total shoulder arthroplasty (TSA) remains a challenging clinical entity, as it may not initially manifest clinically apparent symptoms but can lead to clinically important complications, such as aseptic loosening. A thorough consideration of medical history and physical examination is essential to rule out other causes of symptomatic TSA-namely, periprosthetic joint infection-as symptoms often progress to vague pain or discomfort due to subtle component loosening. Once confirmed, nonoperative treatment of osteolysis should first be pursued given the potential to avoid surgery-associated risks. If needed, the current surgical options include glenoid polyethylene revision and conversion to reverse shoulder arthroplasty. The current article provides a comprehensive review of the evaluation and management of osteolysis after TSA through an evidence-based discussion of current concepts.

Machine Learning Algorithms Predict Achievement of Clinically Significant Outcomes After Orthopaedic Surgery: A Systematic Review.

PURPOSE: To determine what subspecialties have applied machine learning (ML) to predict clinically significant outcomes (CSOs) within orthopaedic surgery and to determine whether the performance of these models was acceptable through assessing discrimination and other ML metrics where reported. METHODS: The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were queried for articles that used ML to predict achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) after orthopaedic surgical procedures. Data pertaining to demographic characteristics, subspecialty, specific ML algorithms, and algorithm performance were analyzed. RESULTS: Eighteen articles met the inclusion criteria. Seventeen studies developed novel algorithms, whereas one study externally validated an established algorithm. All studies used ML to predict MCID achievement, whereas 3 (16.7%) predicted SCB achievement and none predicted PASS achievement. Of the studies, 7 (38.9%) concerned outcomes after spine surgery; 6 (33.3%), after sports medicine surgery; 3 (16.7%), after total joint arthroplasty (TJA); and 2 (11.1%), after shoulder arthroplasty. No studies were found regarding trauma, hand, elbow, pediatric, or foot and ankle surgery. In spine surgery, concordance statistics (C-statistics) ranged from 0.65 to 0.92; in hip arthroscopy, 0.51 to 0.94; in TJA, 0.63 to 0.89; and in shoulder arthroplasty, 0.70 to 0.95. Most studies reported C-statistics at the upper end of these ranges, although populations were heterogeneous. CONCLUSIONS: Currently available ML algorithms can discriminate the propensity to achieve CSOs using the MCID after spine, TJA, sports medicine, and shoulder surgery with a fair to good performance as evidenced by C-statistics ranging from 0.6 to 0.95 in most analyses. Less evidence is available on the ability of ML to predict achievement of SCB, and no evidence is available for achievement of the PASS. Such algorithms may augment shared decision-making practices and allow clinicians to provide more appropriate patient expectations using individualized risk assessments. However, these studies remain limited by variable reporting of performance metrics, CSO quantification methods, and adherence to predictive modeling guidelines, as well as limited external validation. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

Comparison of Long-term Radiographic Outcomes and Rate and Time for Conversion to Total Knee Arthroplasty Between Repair and Meniscectomy for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Previous meta-analyses have demonstrated superior outcomes in patients undergoing arthroscopic repair of medial meniscus posterior root tears (MMPRTs) compared with meniscectomy. However, these analyses have considered only short- or midterm outcomes and low-quality evidence. PURPOSE: To compare the mid- to long-term rates of radiographic osteoarthritis (OA) between repair and meniscectomy for MMPRT. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed, EMBASE, Ovid/MEDLINE, and Cochrane Central Register of Controlled Trials databases were queried for articles evaluating repair and meniscectomy for MMPRT. Articles were eligible if they had a minimum mean 4-year follow-up for radiographic OA or conversion to total knee arthroplasty (TKA) and were at least level 3 evidence. Radiographic OA was assessed using Kellgren-Lawrence (KL) progression. Rates of conversion to TKA and International Knee Documentation Committee (IKDC) scores were also extracted. DerSimonian-Laird binary random-effects models were created to evaluate differences in radiographic OA and TKA conversion rates, with odds ratios (ORs) representing pooled estimates. Continuous random-effects models with standardized mean differences (SMDs) were used to compare postoperative IKDC scores. RESULTS: Repair and meniscectomy cohorts were followed for a mean of 64.8 months and 62.5 months, respectively, for KL progression; and 82.8 months and 73.8 months, respectively, for TKA rates and IKDC scores. Overall, 59 of 144 (41%) patients undergoing surgical intervention for MMPRT demonstrated OA progression; 18 of 82 (22%) who underwent repair for MMPRT exhibited OA progression compared with 41 of 62 (66%) who underwent meniscectomy (OR, 0.17; 95% CI, 0.03-0.83; P = .029). Overall, 30 of 143 (21%) patients converted to TKA; 9.8% (8/82) of patients who underwent repair converted to TKA (range, 47-131 months), while 36% (22/61) who underwent meniscectomy converted to TKA (range, 17.8-101 months) (OR, 0.15; 95% CI, 0.05-0.44; P < .001). No significant differences between postoperative IKDC scores were observed (SMD, 0.51; 95% CI, -0.02 to 1.05; P = .06). CONCLUSION: Medial meniscus posterior root repair results in significantly lower rates of radiographic OA progression and conversion to TKA at >60-month follow-up. On the basis of these findings, we recommend consideration of repair of MMPRTs when degenerative changes are not severe, as it can yield improved outcomes.

Repeat Revision Hip Arthroscopy Outcomes Match That of Initial Revision But Not That of Primary Surgery for Femoroacetabular Impingement Syndrome.

PURPOSE: To (1) report on pre- and postoperative patient-reported outcome (PRO) scores for patients undergoing repeat revision surgery in short-term follow-up and (2) compare minimal clinically important difference (MCID) and patient acceptable symptomatic state achievement between primary, revision, and repeat revision hip arthroscopy cohorts. METHODS: Data from consecutive patients undergoing revision hip arthroscopy from January 2012 to February 2019 were retrospectively reviewed. Hips that underwent 2 revision hip arthroscopic surgeries were identified and matched 1:3 to patients undergoing revision surgery and 1:3 to patients undergoing primary surgery by age, sex, and body mass index. Baseline demographic data, surgical indications, and hip-specific PROs were collected were obtained preoperatively and at minimum 1-year follow-up. MCID was calculated individually for each cohort. RESULTS: Twenty patients who underwent repeat revision were matched to 60 patients who underwent revision and 60 primary patients. Patients who underwent repeat revision achieved MCID on all investigated PROs at a similar rate to patients undergoing primary surgery (90.0% vs 91.7%, P = .588) and at a greater rate than patients undergoing first-time revision surgery (90.0% vs 71.7%, P = .045). Patients who underwent repeat revision achieved patient acceptable symptomatic state on all investigated PROs at a similar rate to patients who underwent first-time revision (30.0% vs 55.0%, P = .053) but at a significantly lower rate than primary patients (30.0% vs 76.7%, P < .001). However, patients undergoing repeat revision surgery had significantly lower preoperative PROs (P < .001 for all) and no significant difference in PROs at minimum 1-year follow-up compared with patients undergoing revision (P > .05). Compared with the primary cohort, patients who underwent repeat revision had significantly lower Hip Outcome Score-Activities of Daily Living (77.3 ± 16.7 vs 86.1 ± 14.4; P = .034), Hip Outcome Score-Sports Subscale (60.6 ± 27.2 vs 76.1 ± 23.8; P < .001), and modified Harris Hip Score (69.2 ± 19.3 vs 81.7 ± 16.1; P = .048) at a minimum of 1-year follow-up. CONCLUSIONS: Second-time revision hip arthroscopy, which often requires advanced procedures, results in clinically significant improvement in PROs; however, outcomes for repeat revision cases are similar to first-time revision cases but inferior to those obtained following primary surgeries. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Comparison of Suction Seal and Contact Pressures Between 270° Labral Reconstruction, Labral Repair, and the Intact Labrum.

PURPOSE: To biomechanically compare the suction seal, contact area, contact pressures, and peak forces of the intact native labrum, torn labrum, 12- to 3-o'clock labral repair, and 270° labral reconstruction in the hip. METHODS: A cadaveric study was performed using 8 fresh-frozen hemipelvises with intact labra and without osteoarthritis. Intra-articular pressure maps were produced for each specimen using an electromechanical testing system under the following conditions: (1) intact labrum, (2) labral tear, (3) labral repair between the 12- and 3-o'clock positions, and (4) 270° labral reconstruction using iliotibial band allograft. Specimens were examined in neutral position, 20° of extension, and 60° of flexion. In each condition, contact pressure, contact area, and peak force were obtained. Repeated-measures analysis of variance was used to identify differences in biomechanical parameters among the 3 conditions. Qualitative differences in suction seal were compared between labral repair and labral reconstruction using the Fisher exact test. RESULTS: Repeated-measures analysis of variance for contact area in neutral position, extension, and flexion showed statistically significant differences between the normalized study states (P < .05). Post hoc analysis showed significantly larger contact areas measured in labral repair specimens than in labral reconstruction specimens in the extension and flexion positions. Region-of-interest analysis for the normalized contact area in the extension and flexion positions, as well as normalized contact pressures in neutral position, showed statistically significant differences between the labral states (P < .05). Finally, 8 labral repairs (100%) versus only 1 labral reconstruction (12.5%) retained the manually tested suction seal (P < .001). CONCLUSIONS: In this in vitro biomechanical model, 270° labral reconstruction resulted in decreased intra-articular contact area and loss of suction seal when compared with labral repair. Clinically, labral reconstruction may not restore the biomechanical characteristics of the native labrum as compared with labral repair. CLINICAL RELEVANCE: Labral reconstruction may result in lower intra-articular hip contact area and loss of suction seal, affecting the native biomechanical function of the acetabular labrum. Further biomechanical studies and clinical studies are necessary to determine whether there are any long-term consequences of 270° labral reconstruction.

Preoperative Hip Extension Strength Is an Independent Predictor of Achieving Clinically Significant Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: The effect of preoperative hip strength on outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is unclear. The purpose of this study was to determine whether preoperative isometric hip strength is associated with outcome scores at 6 months as well as achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients undergoing hip arthroscopy for FAIS. HYPOTHESIS: Increased preoperative isometric strength will be correlated with short-term postoperative outcomes and will be predictive of achieving higher functional status. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: Data from 92 consecutive patients undergoing primary hip arthroscopy for treatment of FAIS from March through August 2018 were analyzed. All patients included in the analysis had preoperative measures of isometric hip strength on both affected and unaffected limbs, as well as preoperative and 6-month patient-reported outcome (PRO) scores. Analysis was performed to determine correlations between normalized isometric hip strength measurements and PROs and whether strength measurements were predictive of achieving MCID or PASS. RESULTS: A total of 74 (80.4%) patients had 6-month PROs and were included in the final analysis. Hip extension strength on both sides was correlated with all postoperative PROs (all P > 0.05). Abduction strength on both sides was correlated with postoperative Hip Outcome Score-Activities of Daily Living subscale score, achieving MCID on at least 1 score threshold, and reaching the international Hip Outcome Tool-12 threshold score for achieving PASS (all P < 0.05). Regression analysis showed that extension strength on the affected side was the only strength measurement predictor of achieving PASS (1.043; P = 0.049). CONCLUSION: Preoperative isometric hip extension and abduction strength are correlated with 6-month postoperative PRO scores. Furthermore, hip extension strength is a predictor of achieving clinically meaningful outcomes. CLINICAL RELEVANCE: This study highlights the possible importance of preoperative optimization of hip function to maximize outcomes in patients undergoing hip arthroscopy for FAIS.

A Cadaveric Study of Cam-Type Femoroacetabular Impingement: Biomechanical Comparison of Contact Pressures Between Cam Morphology, Partial Femoral Osteoplasty, and Complete Femoral Osteoplasty.

PURPOSE: To compare the biomechanical properties of the hip joint with an intact femoral cam lesion, partial cam resection, and complete cam resection. METHODS: A cadaveric study was performed using 8 hemipelvises with cam-type morphology (alpha angle > 55°) and intact labra. Intra-articular pressure maps were produced for each specimen under the following conditions: (1) native cam morphology (intact), (2) cam morphology with incomplete resection (partial), and (3) cam morphology with complete resection (complete). By use of an open technique, resection of the superior portion of the cam morphology was performed with a 5.5-mm burr to create the partial resection, followed by the inferior portion to create the complete resection. In each condition, 3 biomechanical parameters were obtained: contact pressure, contact area, and peak force within a region of interest. Measurements were performed 3 times in each condition, and the average value was used for statistical analysis. Analysis of variance was used to compare biomechanical parameters between conditions. RESULTS: A statistically significant difference was found between the pre- and post-resection alpha angles (62.2° ± 3.9° vs 40.9° ± 1.4°, P < .001). Repeated-measures analysis of variance showed that the normalized average pressure values of hips with complete resection of cam lesions were significantly lower than those of hips with incomplete femoral cam lesions and hips with intact cam morphology (100% vs 93.6% ± 8.3% and 82.6% ± 16.2%, respectively; P < .0001). The percentage reduction of contact pressure in the complete and partial groups was 17.4% and 6.4%, respectively, compared with the intact group. Contact area and peak force showed no statistically significant differences across the 3 conditions (P > .05). CONCLUSIONS: Complete cam resection results in significantly lower intra-articular hip contact pressures than incomplete cam resection and native cam morphology in a cadaveric hip model. These observations underscore the importance of ensuring complete resection of femoral cam lesions in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. CLINICAL RELEVANCE: Previous studies have shown that the most common reason for revision hip arthroscopy in patients with femoroacetabular impingement syndrome is incomplete femoral cam resection during the index operation. This study shows biomechanical differences associated with partial cam resection compared with the complete cam resection state that may translate to persistent symptoms.

The Effect of Postoperative Opioid Prescription Refills on Achieving Meaningful Clinical Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To determine whether requiring postoperative opioid refills has an effect on both baseline and postoperative functional scores, as well as rates of achieving clinical success 2 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 were analyzed. Patients with at least 1 postoperative opioid refill were matched 1:2 by age and body mass index to patients not requiring refills. Preoperative and postoperative patient-reported outcomes including the Hip Outcome Score-Activities of Daily Living Subscale, HOS-Sports Subscale, and modified Hip Harris Score, as well as visual analog scale (VAS) pain and satisfaction surveys, were compared between the 2 groups, as well as between patients who requested 1 refill versus those requiring 2 or more refills. The minimal clinically important difference and patient acceptable symptomatic state (PASS) were calculated for the study group and compared between patient groups. RESULTS: A total of 128 patients (14.5%) requesting at least 1 postoperative opioid refill and 256 with no refills were included in the study. Analysis showed that the refill group had lower patient-reported outcomes (P < .05 for all), a lower VAS satisfaction score average (73.2 ± 30.7 vs 80.1 ± 25.9, P = .029), and a higher VAS pain score average (27.2 ± 26.1 vs 19.9 ± 22.7, P = .007). Similar trends were seen when patients with 1 refill were compared with those with 2 or more refills. Analysis of meaningful clinical outcomes showed that patients in the refill group had lower rates of achieving the PASS (68.3% vs 77.2%, P = .006). However, there were no statistically significant differences in achieving the minimal clinically important difference between the 2 groups (P > .05 for all). CONCLUSIONS: Patients undergoing hip arthroscopy for FAIS who require 1 or more opioid refills postoperatively are likely to have lower baseline and postoperative functional scores, as well as to achieve the PASS at lower rates, compared with patients who do not require an additional opioid prescription to what is routinely given after surgery. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Quality of Online Video Resources Concerning Patient Education for the Meniscus: A YouTube-Based Quality-Control Study.

PURPOSE: To evaluate the reliability and educational content of YouTube videos concerning the menisci. METHODS: YouTube was queried using the keyword "meniscus." The first 50 videos were evaluated. Eleven video characteristics were extracted, and videos were categorized by source and content. Video reliability was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-5). Video educational content was assessed using the Global Quality Score (GQS; score range, 0-4) and a meniscus-specific score (MSS; score range, 0-20). RESULTS: The mean video duration was 551.44 ± 1,046.04 seconds (range, 75-7,282 seconds). The mean number of views was 288,597.7 ± 735,275.9. Collectively, the 50 videos accrued 14,141,285 views. The mean JAMA score, GQS, and MSS were 1.55, 2.12, and 3.67, respectively. The video source was predominately non-physician based (24.49% of source uploaders), whereas video content was predominately concerned with disease information (37.50% of content). Significant between-group effects were observed for the JAMA score and video content (P = .0155), with videos concerning disease information, exercise training, and nonsurgical intervention having the highest mean JAMA scores. Significant between-group effects were also observed for the JAMA score based on video upload source (P < .001), with videos uploaded by physicians receiving the highest mean JAMA scores. The mean GQS and MSS were significantly greater for videos categorized as having disease-specific content (P = .0377 and P = .0404, respectively) and for physician video uploaders (P = .0133 and P = .0100, respectively). The number of video dislikes was a negative independent predictor of the JAMA score (ß = -0.007, P = .003). Disease-specific content was a positive independent predictor of the GQS (ß = 1.13, P = .042). There were no independent predictors of the MSS. CONCLUSIONS: Information on the meniscus found in YouTube videos is of low quality and reliability. CLINICAL RELEVANCE: Orthopaedic health practitioners should caution patients about the inaccuracy of YouTube videos regarding the meniscus given the low quality of content. These health care providers should make efforts to provide patients with higher-quality alternatives.

Radiographic Prevalence of Sacroiliac Joint Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome.

PURPOSE: To quantify the prevalence of sacroiliac joint (SIJ) abnormalities in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) by use of various imaging modalities and to compare outcomes based on SIJ abnormalities. METHODS: Plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. The exclusion criteria included patients undergoing bilateral or revision surgery, those with a history of dysplasia, and those with less than 2 years' follow-up. On radiographs, the SIJs were graded using modified New York criteria for spondyloarthropathy. CT and MRI scans were reviewed for joint surface erosion, subchondral sclerosis, joint space narrowing, pseudo-widening, bone marrow edema, and ankylosis. Patients with SIJ abnormalities were matched to patients without SIJ abnormalities in a 1:2 ratio by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain, and VAS for satisfaction. RESULTS: Of 1,009 consecutive patients, 743 (73.6%) were included; 187 (25.2%) showed SIJ changes. Of these 187 patients, 164 (87.7%) had changes on plain radiographs, 88 (47.1%) had changes on CT, and 125 (66.8%) had changes on MRI. SIJ changes on any imaging modality were weakly correlated with pain to palpation of the SIJ (r = 0.11, P = .004) on physical examination. Pain to palpation of the SIJ on physical examination (odds ratio [OR], 1.12; P = .031) and a history of SIJ pain (OR, 1.93; P = .018) increased the odds of having an SIJ abnormality on any imaging modality. After matching, patients without SIJ abnormalities had a significantly greater HOS-ADL (95.4 vs 90.6, P = .001), HOS-SS (91.1 vs 77.5, P < .001), and mHHS (91.3 vs 84.5, P < .001) and a significantly lower VAS pain score (10.9 vs 25.7, P < .001) than patients with abnormalities at a mean follow-up of 34.1 ± 9.7 months (range, 24-54 months). Patients without SIJ abnormalities had greater odds of achieving the minimal clinically important difference for the HOS-ADL (OR, 2.91; P = .001) and for the HOS-SS (OR, 2.83; P < .001) but not for the mHHS (OR, 1.73; P = .081). CONCLUSIONS: A high prevalence of SIJ abnormalities (25.2%) is seen on imaging in FAIS patients. These patients may show significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment. The results of this study may allow treating orthopaedic surgeons to better inform patients with SIJ abnormalities that they may not achieve clinically significant outcome improvement after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective comparative study.