Describing the women of orthopaedic surgery.

Aims: The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery. Methods: An electronic survey was conducted of practising female orthopaedic surgeons based in the USA through both the Ruth Jackson Society and the online Facebook group "Women of Orthopaedics". Results: The majority of surveyed female orthopaedic surgeons reported being married (76.4%; 285/373) and having children (67.6%; 252/373). In all, 66.5% (247/373) were collegiate athletes; 82.0% (306/373) reported having no female orthopaedic surgeon mentors in undergraduate and medical school. Their mean height is 65.8 inches and average weight is 147.3 lbs. Conclusion: The majority of female orthopaedic surgeons did not have female mentorship during their training. Additionally, biometrically, their build is similar to that of the average American woman.

Editorial Commentary: "Postless Hip Arthroscopy May Help Optimize Outcomes But Use Of A Post Is Acceptable And Is Indicated In Select Cases".

Compared to postless arthroscopy, hip arthroscopy using a perineal post (post-assisted traction) is associated with increased risk of complications in 1-30% of patients, including pudendal neuropraxia (sexual dysfunction, dyspareunia, perineal pain and/or numbness) and perineal soft tissue injuries (vulvar bruising, tears, or scrotal swelling). While these groin-related complications are usually transient in nature, they are significant and should be prevented, if at all possible. Due to the sensitive nature of groin-related injuries after surgery, these complications can also go unrecognized by surgeons, which may result in underappreciation of their true prevalence. In contrast, postless distraction can be performed safely and eliminate the risk of perineal-related complications associated with a perineal post. In addition, dynamic evaluation during cam resection is aided by postless techniques and allows for greater and unimpeded hip range-of-motion compared to motion restriction with the use of a post. Postless hip arthroscopy is an emerging standard for hip arthroscopy surgery, but there are select instances in cases of challenging access to the hip joint where a post may still have utility. Indications for use of a post could be high BMI patients, males with decreased hamstring flexibility, and patients with lower Beighton scores and greater hip stiffness, because if access to the joint is challenging, a perineal post may allow for greater distraction. Of importance, if a perineal post is used, care should be taken toward limiting traction time, as prolonged traction has been shown to be a major risk factor associated with post-related groin complications. In addition, the Trendelenburg position decreases the contact force against the perineal post. Finally, converting from a post-assisted technique to a postless system has a short learning curve for surgeons.

A 10-year perspective on the question of whether surgeries for adolescent idiopathic scoliosis are "one and done"?

PURPOSE: Posterior scoliosis fusion (PSF) for adolescent idiopathic scoliosis (AIS) is considered a highly successful surgery with excellent outcomes. However, especially as many patients "graduate" from their pediatric surgeons, there is the need to quantify the long-term outcomes of such surgeries. METHODS: The 2010-2022 Pearldiver M161 dataset was queried for those who were 10 to 18 years old with AIS undergoing PSF with at least 10 years follow-up. Patient characteristics were abstracted. Reoperations were identified based on coding for any subsequent thoracic/lumbar surgery/revision. The 10-year reoperation rate and reasons for reoperation were determined, and multivariate regression was performed to determine risk factors. RESULTS: In total, 3,373 AIS PSF patients were identified. Of the study cohort, 324 (9.6%) underwent reoperation within 10-years with an interquartile range for timing of surgery of 81-658 days, of which 29.6% were done for infection. Reoperations were done within the first three months for 152 (46.9% of reoperations), three months to 2 years for 97 (29.9%), and 2 years to 10 years for 74 (22.8%). Based on multivariate regression, need for reoperation was associated with male sex (OR: 1.70), asthma (OR: 1.36) and greater than thirteen segments of instrumentation (OR: 1.48) (p < 0.05 for each) but not age, other comorbidities, or insurance. CONCLUSIONS: The current study of a large national AIS PSF population found 9.6% to undergo reoperation in the 10 years following their index operation. Although specifics about the curve pattern could not be determined, the reoperation incidence and correlation with specific risk factors are notable and important for patient counselling.

Geriatric Vertebral Compression Fracture: A Database Study Characterizing Use and Trends for Prescribed Thoracic/Lumbar Orthoses.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Geriatric vertebral compression fractures are the most common fracture associated with osteoporosis. Using a large national database, the current study aimed to examine and characterize bracing trends for geriatric thoracic/lumbar compression fracture management. METHODS: The current study utilized the PearlDiver database from 2015-2021. Patients who suffered thoracic/lumbar compression fractures (fifth thoracic to the fifth lumbar vertebra [T5-L5]) were identified. Exclusion criteria included patients less than 65 years old or an indication of infection or neoplasm. Patients who received a brace within 90-days after the initial diagnosis of thoracic/lumbar compression fracture were abstracted and characterized overall and by fracture level. Multivariable logistic regression was performed to assess for correlation with bracing trends. RESULTS: In total 290 388 patients met inclusion criteria and suffered a thoracic/lumbar compression fracture (greatest incidence at the thoracolumbar junction). Of these, bracing was only prescribed for 4263 (1.5%), with the greatest variance of 1.5% by level. Independent predictors of bracing were geographic region (relative to northeast, west WE odds ratio [OR] 1.31, Midwest OR 1.20), younger age (OR 1.27 per decade), female sex (OR 1.17), and ECI (OR 1.02 per 2-point increase) (P < .05 for each). CONCLUSION: Overall, the current study examined over a quarter of a million patients who suffered a T5-L5 compression fractures and found that only 1.5% of patients were braced. This low percentage, and that greatest predictor for bracing was non-clinical (geographic region), highlight the inconsistency of this practice and may be useful for developing treatment algorithms.

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.

Physical Therapy Utilization Following Single Level Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Characterize physical therapy (PT) utilization following single-level posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA: PLF is a common procedure that is increasing in frequency. Following such surgeries, PT may be considered to facilitate mobilization and return to activities. However, the usage of such therapy has not been well-characterized in the literature. METHODS: Patients undergoing single-level PLF were identified from the 2010-2021 PearlDiver administrative database. These patients were stratified based on usage of therapy, home versus outpatient therapy, and timing of therapy within the year following surgery. To determine predictors of therapy, patient characteristics were determined and multivariable regressions were performed. RESULTS: A total of 213,240 patients undergoing single-level PLF were identified, of which therapy was done in the year following surgery for 63,231 (29.0%, of which home therapy accounted for 16.5% of therapy visits). Of those who utilized PT, the average number of visits was 10.6±10.6. Home therapy peaked within the first month following surgery and outpatient therapy peaked at month two. Factors associated with any PT following PLF in decreasing odds ratio (OR) were: having commercial insurance (OR: 1.68), being from the Northeast (OR:1.41), age (OR: 1.13 for 70+ of age) female sex (OR: 1.09), and ECI (OR: 1.04 per point) (P<0.001 for all). Of those who received therapy, factors associated with home PT utilization were: being from the Northeast (OR: 2.55), age (OR: 1.91 for 70+ of age), Medicaid insurance (OR: 1.48), female sex (OR: 1.39), and interbody fusion (OR:1.07) (P<0.001 for all). CONCLUSIONS: Following single-level PLF, the minority of patients received home or outpatient PT. Of those that did, there was significant variation in the number of visits, with nonmedical factors such as insurance plan and geographic region being strongly associated suggesting room for more consistent practice patterns. LEVEL OF EVIDENCE: III.

Low Rates of Postoperative Complications and Revision Surgery After Primary Medial Elbow Ulnar Collateral Ligament Repair.

Purpose: To evaluate the incidence of early postoperative complications and revision surgery in patients who underwent primary medial ulnar collateral ligament (MUCL) repair with minimum of 2-year follow-up. Methods: A retrospective review of a national insurance database was conducted to identify patients with MUCL injuries who underwent primary MUCL repair between 2015 to 2020 with minimum 2-year follow-up. Patients >40 years of age and those who had concomitant elbow fractures or dislocations, lateral UCL injures, medial epicondylitis, elbow arthritis, or a history of previous elbow injury/surgery were excluded. The number of patients who underwent a concomitant ulnar nerve procedure (transposition or decompression) during the primary MUCL repair was recorded. Complications within 90 days of surgery and the incidence and timing of subsequent ipsilateral ulnar nerve surgery or revision MUCL surgery were assessed. Results: A total of 313 patients (63.6% male) were included. The mean age was 20.3 ± 6.9 years, and mean follow-up was 3.7 ± 1.3 years. Concomitant ulnar nerve transposition or decompression was performed in 34.2% (N = 107). The early postoperative complication rate was 7.3% (N = 23). The most common complication was ulnar neuropathy (5.8%, N = 18). Wound complications, elbow stiffness, and medial epicondyle fractures were much less common (N = 5). Sixteen of 18 (88.9%) patients with postoperative ulnar neuropathy underwent transposition or decompression at the time of primary repair. Of these 18 patients, 5 (27.8%) underwent a subsequent ulnar nerve surgery (1 primary and 4 secondary), with the majority occurring within 6 months. The incidence of revision MUCL surgery was low (1.0%, N=3), with all 3 patients undergoing MUCL reconstruction. Conclusion: There was a low incidence of early postoperative complications (7.3%) and 2-year revision MUCL surgery (1.0%) in young patients who underwent primary MUCL repair with no additional ligamentous, fracture, and dislocation-related diagnoses. All 3 (1.0%) MUCL revisions underwent reconstruction. Level of Evidence: Level IV, therapeutic case series.

Editorial Commentary: Magnetic Resonance Imaging May Underestimate Hip Femoral Version Versus Computed Tomography Scan: Both May Be Optimized Using 3-Dimensional Imaging.

Hip arthroscopy has become increasingly popular in the treatment of femoroacetabular impingement syndrome. Careful preoperative planning including evaluation of acetabular and femoral version is necessary to optimize outcomes. Increased femoral anteversion has been associated with microinstability, and conversely, decreased femoral version may predispose to impingement. Computed tomography (CT) is considered the gold standard for femoral version measurements and preoperative planning. However, with recent advancements in technology, magnetic resonance imaging (MRI) has shown comparable measurements to CT imaging. In terms of advantages and disadvantages, CT requires radiation, albeit "low dose." MRI has a longer acquisition time, and movement of the patient may affect image quality and subsequent accuracy. MRI generally underestimates true version, probably as a result of patient positioning. Three-dimensional imaging could resolve this issue and may become the gold standard for both CT and MRI.

Total spine MRI for the preoperative evaluation of adolescent idiopathic scoliosis: part 1.

Adolescent idiopathic scoliosis is a commonly encountered condition often diagnosed on screening examination. Underlying, asymptomatic neural axis abnormalities may be present at the time of diagnosis. At certain institutions, total spine MRI is obtained preoperatively to identify these abnormalities. We provide a framework for the radiologist to follow while interpreting these studies. In part 1, we discuss Arnold Chiari malformations, syringomyelia, and the tethered cord. In part 2, we focus on spinal cord tumors, dysraphisms, to include diastematomyelia, and vertebral anomalies.

Total spine MRI for the preoperative evaluation of adolescent idiopathic scoliosis: Part 2 - spinal cord tumors, dysraphisms, diastematomyelia, and vertebral anomalies.

Adolescent idiopathic scoliosis is a commonly encountered condition often diagnosed on screening examination. Underlying, asymptomatic neural axis abnormalities may be present at the time of diagnosis. At certain institutions, total spine MRI is obtained preoperatively to identify these abnormalities. We provide a framework for the radiologist to follow while interpreting these studies. In part 1, we discuss Arnold Chiari malformations, syringomyelia, and the tethered cord. In part 2, we focus on spinal cord tumors, dysraphisms, to include diastematomyelia, and vertebral anomalies.

High Rate of Clinically Meaningful Achievement in Outcomes After Subacromial Balloon Spacer Implantation for Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Subacromial balloon spacers have been introduced as a potential treatment option for patients with massive irreparable rotator cuff tears. However, it is important to comprehensively assess the clinical efficacy of this procedure in the context of an increasing amount of contemporary literature. PURPOSE: To perform a systematic review of the contemporary literature to understand the propensity for clinically meaningful improvements after subacromial balloon spacer implantation for massive irreparable rotator cuff tears. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: The PubMed, Ovid/MEDLINE, and Cochrane databases were queried in July 2022 for data pertaining to studies reporting clinically significant outcomes after subacromial balloon spacer implantation. Freeman-Tukey double arcsine transformation was used to quantify the pooled rate of clinically meaningful improvements in outcomes as evaluated using the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB). Qualitative analysis was performed when data were variably presented to avoid misleading reporting. RESULTS: There were 10 studies included, all of which reported MCID achievement. The overall pooled rate of MCID achievement for the Constant-Murley score was 83% (95% CI, 71%-93%; range, 40%-98%), with 6 of 8 studies reporting rates equal to or exceeding 85%. One study reported a 98% rate of PASS achievement for the Constant-Murley score at 3-year follow-up. The rate of MCID achievement for the American Shoulder and Elbow Surgeons (ASES) score ranged between 83% and 87.5%. The rate of PASS achievement for the ASES score was 56% at 2-year follow-up, while the rate of SCB achievement for the ASES score was 83% and 82% at 1- and 2-year follow-up, respectively. At 1-year follow-up, 74% and 78% of patients achieved the MCID for the Numeric Rating Scale and Oxford Shoulder Score, respectively. At 3 years, 69% of patients achieved the MCID for the Numeric Rating Scale and 87% achieved it for the Oxford Shoulder Score. CONCLUSION: Patients who underwent isolated subacromial balloon spacer implantation for massive irreparable rotator cuff tears demonstrated a high rate of clinically significant improvement in outcomes at short- to mid-term follow-up. A paucity of literature exists to appropriately define and evaluate the rates of achieving the PASS and SCB after subacromial balloon spacer implantation, necessitating further study.

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.

Long-Term Patient Outcomes for Treatment of Difficult Osteochondral Lesions of the Talus with Particulated Juvenile Allograft Cartilage Implantation ± Calcaneal Autograft: A Cohort Study.

BACKGROUND: Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared. METHODS: Thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT®) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size > 150 mm2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs. RESULTS: When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5 ± 50.9 vs. 118.7 ± 29.4 mm2 respectively; p value = 0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.032). The AOFAS score improvement did not differ between cohorts (p value = 0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting. CONCLUSION: While patients followed over the course of ~ 8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT®) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear. LEVEL OF EVIDENCE: III, retrospective cohort study.

Rates of subsequent surgeries after meniscus repair with and without concurrent anterior cruciate ligament reconstruction.

OBJECTIVES: The purpose of this study was to compare the rates of secondary knee surgery for patients undergoing meniscus repair with or without concurrent anterior cruciate ligament reconstruction (ACLr). METHODS: Utilizing a large national database, patients with meniscal repair with or without concurrent arthroscopic ACLr were identified. The two cohorts were then queried for secondary surgical procedures of the knee within the following 2 years. Frequency, age distribution, rates of secondary surgery, and type of secondary procedures performed were compared. RESULTS: In total, 1,585 patients were identified: meniscus repair with ACLr was performed for 1,006 (63.5%) and isolated meniscal repair was performed for 579 (36.5%). Minimum of two year follow up was present for 487 (30.7% of the overall study population). Secondary surgery rates were not significantly different between meniscus repair with concurrent ACLr and isolated meniscus repairs with an overall mean follow up of 13 years (1.5-24 years) (10.6% vs. 13.6%, p = 0.126). For the 2 year follow up cohort, secondary surgery rates were not significantly different (19.3% vs. 25.6%, p = 0.1098). There were no differences in survivorship patterns between the two procedures, both in the larger cohort (p = 0.2016), and the cohort with minimum 2-year follow-up (p = 0.0586). CONCLUSION: The current study assessed secondary surgery rates in patients undergoing meniscus repair with or without concurrent ACLr in a large patient database. Based on this data, no significant difference in rates of secondary knee surgery was identified.

Concurrent Repair of Medial Meniscal Ramp Lesions and Lateral Meniscus Root Tears in Patients Undergoing Anterior Cruciate Ligament Reconstruction: The "New Terrible Triad".

Recent studies have suggested that up to 8% of patients with anterior cruciate ligament (ACL) tears can present with a combined medial meniscal ramp lesion (MMRL) and lateral meniscus root tear (LMRT). MMRLs and LMRTs often are missed preoperatively and can increase the risk of ACL graft failure if left untreated. Given the potential synergistic biomechanical consequences and challenging repair techniques used for treatment, our group commonly refers to this presentation (MMRL-LMRT-ACL) as the "new terrible triad" of ACL pathology. This Technical Note aims to describe a systematic approach for arthroscopic assessment and our preferred inside-out and transtibial pull-out repair techniques to efficiently diagnose and treat a combined MMRL and LMRT at the time of ACL reconstruction surgery.

Factors Associated With Increased Opioid Prescriptions Following Anterior Cruciate Ligament Reconstruction in Opioid-Naïve Patients.

Purpose: To identify the mean morphine milligram equivalent (MME) opioid prescriptions for opioid-naïve patients undergoing isolated anterior cruciate ligament reconstruction (ACLR) between 4 weeks before surgery and the first 90 days after surgery and to describe opioid prescriptions filled per patient and mean MMEs per year within 90 days following ACLR. Methods: Exclusion criteria were patients having concurrent other cruciate or collateral ligament repair or reconstruction, meniscus procedures (repair and debridement), any cartilage procedure, lower-extremity osteotomy, or knee procedures for fracture, infection, or neoplasms; patients with substance use disorder or chronic pain also were excluded. Opioid use between 4 weeks before surgery and the first 90 days after surgery was recorded. Prescribing physician specialty also was tracked. The correlation of patient factors and prescriber specialty of MME were compared using the Student's t-test. Significance was defined at P < .05. Results: Opioid-naïve patients undergoing isolated ACLR were included. Isolated arthroscopic ACLRs performed between 2010 and Q3 2020 in opioid-naïve patients were identified within the PearlDiver M91 national database. A total of 37,200 patients were identified. Mean MME per patient was 340.9 ± 198.2, with an average MME per day of 59.9. Factors associated with increased opioid use during the 90 days following ACLR were older age (P < .001) and preoperative diagnosis of depression (P < .001). Orthopaedic surgeons were primarily responsible for the number of opioid prescriptions after ACLR (n = 29,326, 73.0%) but 27% (n = 10,797) of prescriptions came from nonorthopaedic surgeon medical providers who prescribed significantly greater MMEs of opioids than orthopaedic surgeons (456.5 vs 339.2, P < .001) per patient. Lastly, decreasing yearly opioid prescriptions per patient (2.4 to 1.6 prescriptions) and the mean MME per patient (428.4 to 257.1) occurred from 2010 to 2020. Conclusions: Older age and preoperative diagnosis of depression are associated with greater opioid doses after ACLR. In addition, the vast majority of opioid prescriptions are written by orthopaedic surgeons on the day of ACLR and decreased considerably by four weeks after surgery. Patients receiving opioid prescriptions by nonorthopaedic surgeon medical providers receive significantly greater doses. Level of Evidence: Level IV, retrospective cohort study.

Low Rates of 5-Year Secondary Surgery and Postoperative Complications After Primary Hip Arthroscopy in More Than 30,000 Patients.

PURPOSE: To evaluate 90-day complications, 5-year secondary surgery rates, and risk factors for secondary surgery following primary hip arthroscopy performed for femoroacetabular impingement and/or labral tears using a large national dataset. METHODS: A retrospective analysis was conducted using the PearlDiver Mariner151 database. Patients with International Classification of Diseases, Tenth Revision, diagnosis codes for femoroacetabular impingement and/or labral tear undergoing primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021 were identified. Those with concomitant International Classification of Diseases, Tenth Revision, codes for infection, neoplasm, or fracture were excluded, as were patients with a history of previous hip arthroscopy or total hip arthroplasty, or age ≥70 years. Rates of complications within 90 days of surgery were assessed. Five-year rates of secondary surgery-revision hip arthroscopy or conversion to total hip arthroplasty-were determined by Kaplan-Meier analysis, and risk factors for secondary surgery were identified by multivariate logistic regression. RESULTS: A total of 31,623 patients underwent primary hip arthroscopy from October 2015 to April 2021, with annual volumes ranging from 5,340 to 6,343 surgeries per year. Femoroplasty was the most frequent surgical procedure (performed in 81.1% of surgical encounters), followed by labral repair (72.6%) and acetabuloplasty (33.0%). Ninety-day postoperative complication rates were low, with 1.28% of patients experiencing any complication. The 5-year secondary surgery rate was 4.9% (N = 915 patients). Multivariate logistic regression identified age <20 years (odds ratio [OR] 1.50; P < .001), female sex (OR 1.33; P < .001), class I obesity (body mass index 30-34.9: OR 1.30; P = .04), and class II/III obesity (body mass index ≥35.0: OR 1.29; P = .02) as independent predictors of secondary surgery. CONCLUSIONS: In this study of primary hip arthroscopy, 90-day adverse events were low at 1.28%, and the 5-year secondary surgery rate was 4.9%. Age younger than 20 years, female sex, and obesity were risk factors for secondary surgery, suggesting the need for increased surveillance in these patient groups. LEVEL OF EVIDENCE: Level IV, case series.

Previous Isolated Medial Bucket-Handle Meniscus Repair Significantly Increases Risk of Subsequent Ipsilateral Anterior Cruciate Ligament Reconstruction.

Purpose: (1) To define the incidence of surgically treated isolated bucket-handle meniscus tears (BHMTs); (2) to investigate risk of subsequent ipsilateral anterior cruciate ligament reconstruction (ACLR) in patients who underwent previous isolated bucket handle (BH) meniscus repair; and (3) to investigate the risk of subsequent ACLR for various types of surgically treated meniscal tears. Methods: A retrospective review of a national database was conducted to identify patients, aged 10 to 40 years, who underwent primary isolated BH meniscus surgery from 2015 to 2020. Patients were stratified by operative method. A control group of 500,000 age-matched patients was randomly selected to establish a benchmark rate of ACLR. Kaplan-Meier analysis was performed to compare the timing and incidence of subsequent ipsilateral ACLR after primary isolated BH meniscus surgery to the control group within 2 and 5 years. Results: In total, 1,767 patients with isolated BHMTs treated with surgery were identified and met inclusion criteria. The incidence of isolated BHMTs among all surgically treated (repair or meniscectomy) meniscal injuries was 1.67%. Isolated BH repairs had significantly greater odds of ACLR within 5 years compared to the control group (odds ratio [OR] 6.09; 95% confidence interval [CI] 2.86-12.99; P < .001). Medial BH repairs had the greatest odds of ACLR within 5 years (OR 9.15; 95% CI 4.27-19.57; P < .001). Lateral BH repair was not associated with subsequent ipsilateral ACLR within 5 years (OR 2.63; CI 0.37-18.90; P = .340). Conclusions: Isolated BHMTs comprised 1.67% of all surgically treated meniscal injuries. Patients who underwent prior surgery for isolated BHMT were at increased risk of undergoing subsequent ipsilateral ACLR compared with the general population. Isolated medial BHMTs treated with repair had the highest risk for subsequent ACLR. Level of Evidence: Level III, retrospective cohort study.

Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method.

BACKGROUND: Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS: A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS: There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS: Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE: Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.

The Posterior Trans-Septal Portal in Knee Arthroscopy Review of the Technique Evolution, Indications, and Technical Pearls.

Complete arthroscopic visualization of the posterior com-partment of the knee is limited when using the traditional anterior portals. The trans-septal portal technique, created in 1997, has allowed surgeons to view the complete posterior compartment of the knee in a less-invasive way compared to open surgery. Since the description of the posterior trans-septal portal, several authors have modified the technique. However, the paucity of literature describing the trans-septal portal technique hints that widespread arthroscopic adop-tion has not yet been achieved. While still in its infancy, the literature has cumulatively reported over 700 successful knee surgeries using the posterior trans-septal portal technique with no reports of neurovascular injury. However, creation of the trans-septal portal carries risks due to its close prox-imity to the popliteal and middle geniculate artery, giving surgeons little room for technical error when developing this portal. Knowledge of the posterior anatomy, the evolution of the trans-septal portal, and current recommendations and safety options for using the technique will benefit orthopedic surgeons looking to incorporate this technique into their surgical arsenal. Furthermore, utilization of the trans-septal portal technique offers a significant benefit to the surgical treatment of conditions that involve the need for posterior knee access or visualization.