Relationship of Average Outcomes Scores and Change in Status Requires Further Interpretation Between 1 and 2 Years Following Hip Arthroscopy.

BACKGROUND: Previous studies have demonstrated a clinically impactful change in patients between 1 and 2 years after hip arthroscopy. Assessment of differences in patient-specific factors between patients who remain the same and those who change (ie, either improve or decline) could provide valuable outcome information for orthopaedic surgeons treating those patients. PURPOSE: To identify patients who experienced change in functional status between 1 and 2 years after hip arthroscopy for femoroacetabular impingement syndrome and assess differences in patient-specific factors between those who improved, remained the same, or declined in functional status. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Prospectively collected data for patients who underwent hip arthroscopy at 1 of 7 centers were analyzed retrospectively at 1 year and 2 years postoperatively. Patients were categorized as "improved,""remained the same," or "declined" between 1- and 2-year follow-up based on the 12-item International Hip Outcome Tool (iHOT-12) minimal clinically important difference (MCID) value. A 1-way analysis of variance was used to assess differences in iHOT-12 scores, age, body mass index (BMI), alpha angle, and center-edge angle (CEA) between groups. Chi-square analyses were used to assess differences in the proportions of male and female patients in the outcome groups. RESULTS: The study included 753 patients (515 women and 238 men), whose mean ± SD age was 34.7 ± 12 years. Average 1-year (±1 month) and 2-year (±2 months) iHOT-12 scores for all patients were 73.7 and 74.9, respectively. Based on the calculated MCID of ±11.5 points, 162 (21.5%) patients improved, 451 (59.9%) remained the same, and 140 (18.6%) declined in status between 1- and 2-year follow-up. Those who improved between 1 and 2 years had lower 1-year iHOT-12 scores (P < .0005). We found no difference in age, BMI, alpha angle, CEA, or sex between groups (P > .05). CONCLUSION: Between 1- and 2-year follow-up assessments, 21.5% of patients improved and 18.6% declined in self-reported functional status. Those with iHOT-12 scores indicating abnormal function at 1 year improved beyond the MCID at 2 years follow-up. Thus, any decisions about the failure or success of arthroscopic hip procedures should not be made until at least the 2-year follow-up. Failing to thrive at 1-year follow-up may not accurately predict outcomes at year 2 or beyond. This could potentially decrease the perceived need for revision surgery in patients who do not thrive before 2-year follow-up.

Reliability of hip range of motion measurement among experienced arthroscopic hip preservation surgeons.

The aim of this study was to determine (i) the reliability of hip range of motion measurement among experienced arthroscopic hip preservation surgeons and (ii) the magnitude of hip flexion change with posterior pelvic tilt. Five experienced arthroscopic hip preservation surgeons (5-18 years of hip surgery experience) performed passive hip range of motion (internal and external rotation), flexion (contralateral hip extended) and flexion with posterior pelvic tilt (contralateral hip maximally flexed) on five young healthy asymptomatic volunteers (three males, two females; 34.4 ± 10.7 years of age). Motion was measured via digital photography and goniometry. Inter-observer reliability was calculated via two-way mixed, single measures, intra-class correlation coefficient. Paired t-test was utilized to compare hip flexion (with contralateral hip extended) to hip flexion with posterior pelvic tilt (with contralateral hip in forced flexion). The reliabilities of measurements of hip flexion with posterior pelvic tilt and external rotation were excellent, that of hip flexion was fair, and that of hip internal rotation was poor. The magnitude of hip flexion increase with posterior pelvic tilt was 17.0° ± 3.0° (P < 0.001). The reliability of hip range of motion measurement by five experienced arthroscopic hip preservation surgeons was excellent for measures of hip flexion with posterior pelvic tilt and external rotation. Contralateral maximal hip flexion significantly increased ipsilateral hip flexion (approximately 17°). Level of Evidence: Diagnostic, level III (without consistently applied reference standard).

Sex-Dependent Differences in Preoperative, Radiographic, and Intraoperative Characteristics of Patients Undergoing Hip Arthroscopy: Results From the Multicenter Arthroscopic Study of the Hip Group.

PURPOSE: To compare preoperative, radiographic, and intraoperative findings between male and female patients undergoing hip arthroscopy. METHODS: We performed a retrospective review of a multicenter registry of patients undergoing hip arthroscopy between January 2014 and January 2017. Perioperative data from patients who consented to undergo surgery and completed preoperative patient-reported outcome questionnaires were analyzed to determine the effect of sex on preoperative symptoms, patient-reported outcomes, radiographic measures, and surgical procedures. RESULTS: A total of 1,437 patients (902 female and 535 male patients) with a mean age of 34 years were enrolled in the study. Female patients reported greater pain preoperatively on a visual analog scale (55.42 vs 50.40, P = .001) and deficits in functional abilities as per the modified Harris Hip Score (53.40 vs 57.83, P < .001) and International Hip Outcome Tool 12 (31.21 vs 38.51, P = .001) than male patients. There was a significant difference in the alpha angle (67.6° in male patients vs 59.5° in female patients, P < .001) corresponding with a higher prevalence of cam deformity in male patients (94.6% vs 84.5%, P < .001). Male patients had less range of motion in flexion (-5.67°, P < .001), internal rotation (-8.23°, P < .001), and external rotation (-4.52°, P < .001) than female patients. Acetabular chondroplasty was performed in 58% of male patients versus 40.2% of female patients (P < .001). Acetabuloplasty was performed in 59.1% of male patients versus 43.9% of female patients (P < .001). CONCLUSIONS: Male and female patients undergoing hip arthroscopy differ statistically in terms of preoperative hip function, hip morphology, and self-reported functional deficits, as well as the prevalence of surgical procedures. However, they do not differ significantly in terms of symptom localization, duration, or onset. The observed differences in preoperative functional scores between sexes, although statistically significant, may not represent clinically meaningful differences. LEVEL OF EVIDENCE: Level III, retrospective cross-sectional study.

Multicenter Outcomes After Hip Arthroscopy: Epidemiology (MASH Study Group). What Are We Seeing in the Office, and Who Are We Choosing to Treat?

As the field of hip arthroscopy continues to grow rapidly, our understanding of the population of patients undergoing hip arthroscopy has led to improved diagnosis and management of hip joint pathologies. The Multicenter Arthroscopic Study of the Hip (MASH) Study Group conducts multicenter clinical studies in arthroscopic hip preservation surgery. Patients undergoing arthroscopic hip preservation surgery are enrolled in a large prospective longitudinal cohort at 10 separate sites nationwide by 10 fellowship-trained hip arthroscopists. In this study, we collected epidemiologic data on the 1738 patients who enrolled between January 2014 and November 2016. These data include demographics, pathologic entities treated, patient-reported measures of disease, and surgical treatment preferences. Our study results showed that patients who elected hip arthroscopy were younger to middle-aged white females with pain primarily located in the groin region. Most had pain for at least 1 year, and it was commonly exacerbated by sitting and athletic activities. Patients reported clinically significant pain and functional limitation and a decrease in physical and mental health. It was not uncommon for patients to have undergone another, related surgery and nonoperative treatments, including intra-articular injection and/or physical therapy, before surgery. There was a high incidence of abnormal hip morphology suggestive of a cam lesion, but the incidence of arthritic changes on radiographs was relatively low. Labral tear was the most common diagnosis, and most often it was addressed with repair. Many patients underwent femoroplasty, acetabuloplasty, and chondroplasty in addition to labral repair.

Effect of tibial tunnel diameter on femoral tunnel placement in transtibial single bundle ACL reconstruction.

PURPOSE: The purpose of this study was to identify the impact of tibial reamer size and placement on the position of femoral tunnel placement via a transtibial approach for anterior cruciate ligament (ACL) reconstruction. METHODS: Eight cadaveric knee specimens were fixed to a stationary table at 90° of flexion and neutral rotation. After removing the anterior capsule and patella, native joint anatomy was recorded with a digitizer (MicroScribe™; CNC Services, Amherst, VA) accurate to 0.05 mm. Tibial and femoral tunnels were drilled via a transtibial ACLR technique using the optimal tibial starting point described by Piasecki et al. On the tibial side, tunnels were drilled progressively with 6-, 7-, 8-, 9-, 10-, and 11-mm reamers. After each reaming, a beath pin was placed in the posterior aspect of the tibial tunnel, positioned relative to the native anatomic ACL femoral footprint, and digitized. Rhino software (McNeel, Seattle, WA) was used to geometrically determine the center of the native femoral footprint and measure in millimeters the relationship of this point with the femoral position achieved using a 7-mm offset femoral guide with each tibial tunnel size. The surface areas of each tibial and femoral insertion were measured using the insertional periphery data recorded with the digitizer. Statistical analysis of continuous variable data was performed with t tests; P values below 0.05 were deemed significant. RESULTS: The center of the femoral ACL footprint was reached with a 9-mm tibial tunnel in six knees, and with an 8-mm tunnel in two knees. A 6- or 7-mm tibial tunnel did not allow for anatomic positioning in any specimen, with femoral positioning significantly more superior than that achieved with a 9-, 10-, or 11-mm tibial tunnel (P < 0.01). The 6- and 7-mm tunnels produced errors of 4.6 ± 1.6 and 2.9 ± 0.5 mm, respectively. After use of the 11-mm tibial reamer, the average tibial tunnel length was 32.1 ± 2.6 mm. CONCLUSIONS: Limitations of a transtibial ACLR technique may result in non-anatomic femoral tunnel placement with tibial tunnel sizes smaller than 9 mm. However, tibial tunnels placed in the proximal entry position with at least a 9-mm tunnel size allowed anatomic femoral tunnel placement via a transtibial approach.

Assessment of glenoid chondral healing: comparison of microfracture to autologous matrix-induced chondrogenesis in a novel rabbit shoulder model.

BACKGROUND: Management of glenohumeral arthrosis in young patients is a considerable challenge, with a growing need for non-arthroplasty alternatives. The objectives of this study were to develop an animal model to study glenoid cartilage repair and to compare surgical repair strategies to promote glenoid chondral healing. METHODS: Forty-five rabbits underwent unilateral removal of the entire glenoid articular surface and were divided into 3 groups--untreated defect (UD), microfracture (MFx), and MFx plus type I/III collagen scaffold (autologous matrix-induced chondrogenesis [AMIC])--for the evaluation of healing at 8 weeks (12 rabbits) and 32 weeks (33 rabbits) after injury. Contralateral shoulders served as unoperated controls. Tissue assessments included 11.7-T magnetic resonance imaging (long-term healing group only), equilibrium partitioning of an ionic contrast agent via micro-computed tomography (EPIC-µCT), and histologic investigation (grades on International Cartilage Repair Society II scoring system). RESULTS: At 8 weeks, x-ray attenuation, thickness, and volume did not differ by treatment group. At 32 weeks, the T2 index (ratio of T2 values of healing to intact glenoids) was significantly lower for the MFx group relative to the AMIC group (P = .01) whereas the T1ρ index was significantly lower for AMIC relative to MFx (P = .01). The micro-computed tomography-derived repair tissue volume was significantly higher for MFx than for UD. Histologic investigation generally suggested inferior healing in the AMIC and UD groups relative to the MFx group, which exhibited improvements in both integration of repair tissue with subchondral bone and tidemark formation over time. DISCUSSION: Improvements conferred by AMIC were limited to magnetic resonance imaging outcomes, whereas MFx appeared to promote increased fibrous tissue deposition via micro-computed tomography and more hyaline-like repair histologically. The findings from this novel model suggest that MFx promotes biologic resurfacing of full-thickness glenoid articular injury.

The Patient Acceptable Symptomatic State for the Modified Harris Hip Score and Hip Outcome Score Among Patients Undergoing Surgical Treatment for Femoroacetabular Impingement.

BACKGROUND: There is minimal information available on the threshold at which patients consider themselves to be well for patient-reported outcome measures used in patients treated with hip arthroscopy for femoroacetabular impingement (FAI). PURPOSE: To determine the patient acceptable symptomatic state (PASS) for the modified Harris Hip Score (mHHS) and the Hip Outcome Score (HOS) in patients with FAI treated with arthroscopic hip surgery. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A consecutive series of patients at a single institution with FAI who were treated with arthroscopic labral surgery, acetabular rim trimming, and femoral osteochondroplasty were eligible. The mHHS (score range, 0-100) and the HOS (score range, 0-100) were administered at baseline and at 12 months postoperatively. An external anchor question at 1 year postoperatively was utilized to determine PASS values: "Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?" RESULTS: There were 130 patients (mean ± SD age, 35.6 ± 11.7 years), and 42.3% were male. Based on a receiver operator curve analysis, the PASS values-at which patients considered their status to be satisfactory-at 1 year after surgery were 74 (mHHS), 87 (HOS-activities of daily living subscale), and 75 (HOS-sports subscale). The PASS threshold was not affected by baseline scores across different instruments. However, patients with higher baseline scores were more likely to achieve the PASS (odds ratios: 3.36 [mHHS], 3.83 [HOS-activities of daily living], 3.38 [HOS-sports]). Age and sex were not significantly related to the odds of achieving the PASS for the mHHS or the HOS. CONCLUSION: This is the first study to determine the PASS for 2 commonly used hip joint patient-reported outcome measures in patients undergoing surgery for FAI. The study findings can allow researchers to determine if interventions related to FAI are meaningful to patients at the individual level across various domains and will also be useful for responder analyses in future randomized trials related to hip arthroscopy and the treatment of FAI.

Magnetic resonance imaging evaluation of normal glenoid length and width: an anatomic study.

PURPOSE: The purpose of this study was to evaluate the measured dimensions of the normal glenoid on sagittal magnetic resonance (MR) imaging to determine whether a fixed ratio of glenoid length and width can be determined. METHODS: MR images of 90 glenoids in 84 patients were analyzed. The mean age was 54.8 years, with 44 male and 40 female patients. Glenoid length and width at the widest dimension were measured and recorded by 3 independent examiners. The ratio of length to width and the ratio of the length of the superior pole at the widest point to the total length were calculated. Intraclass correlation coefficients, Spearman and Pearson correlations, regression analysis with cross validation, and coefficients of variation were calculated. RESULTS: The mean glenoid length was 37.5 ± 3.8 mm, whereas the mean width was 24.4 ± 2.9 mm. The mean ratio of length to width was 1.55 ± 0.1, whereas the mean ratio of the distance from the superior pole to the widest point to the total glenoid length was 0.64 ± 0.03. The calculated ratios were less variable than the absolute length and width. Cross validation of length for width showed a 95% prediction band width of 4.48 mm, with an average absolute error of prediction of 1.46 mm, and was equally specific when separated by gender. The width was equal to 0.65 times the length. CONCLUSIONS: Measurement of glenoid length and width using MR imaging results in a consistent ratio of length to width independent of patient age and gender, where the width was equal to 0.65 times the length at a point two-thirds along the inferosuperior axis. LEVEL OF EVIDENCE: Level IV, case series.

Medial unicompartmental knee arthroplasty in patients less than 55 years old: minimum of two years of follow-up.

Eighty-five fixed bearing medial unicompartmental arthroplasties were performed in 42 men and 33 women with a mean age of 49 years (range, thirty-three to fifty-five years old) at the time of surgery. At a mean of 4.0 years (range two to twelve years), the mean pre-operative Knee Society score improved from 49 to 95.1 points (P<0.0001) and the mean UCLA activity score was 7.5 (range 5 to 9). Three knees underwent revision to a total knee arthroplasty; two for arthritic progression in the lateral compartment and one for pain. At the time of final follow-up, two knees (2.4%) demonstrated progressive Grade 4 arthritis of the patellofemoral compartment but were asymptomatic. There was no radiographic evidence of loosening, osteolysis, or premature polyethylene wear. Estimated survivorship was 96.5% at 10 years. UKA offered excellent early outcomes in this cohort of younger, active patients.

Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has been indicated primarily for patients aged older than 65 years with symptomatic rotator cuff deficiency, poor function, and pain. However, conditions that benefit from RTSA are not restricted to an elderly population. This study evaluates a consecutive series of RTSA patients aged younger than 60 years. METHODS: We evaluated 36 shoulders (mean age, 54 years) at a mean follow-up of 2.8 years (range, 24-48 months). Of these shoulders, 30 (83%) had previous surgery, averaging 2.5 procedures per patient. The preoperative conditions compelling RTSA were as follows: failed rotator cuff repair (12), fracture sequelae (11), failed arthroplasty (5), instability sequelae (4), cuff tear arthropathy (CTA) (4), and rheumatoid arthritis (2). Follow-up examinations included range-of-motion and strength testing, as well as Single Assessment Numeric Evaluation, visual analog scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES), and Constant scores. Preoperative and postoperative radiographs were reviewed for component loosening and scapular notching. Failure criteria were defined as undergoing revision, having gross loosening, or having an ASES score below 50. RESULTS: The mean Single Assessment Numeric Evaluation score improved from 24.4 to 72.0; the visual analog scale pain score improved from 6 to 2.1. The Simple Shoulder Test score improved from 1.4 to 6.2, and the ASES score improved from 31.4 to 65.8. Active forward elevation improved from 56° to 121°. The normalized postoperative mean Constant score was 54.3. In 9 patients (25.0%), we recorded an ASES score below 50, and these cases were considered failures. CONCLUSION: RTSA can improve shoulder function in a younger, complex patient population with poor preoperative functional ability. This study's success rate was 75% at 2.8 years. This is a limited-goals procedure, and longer-term studies are required to determine whether similar results are maintained over time.

Computed tomographic analysis of curved and straight guides for placement of suture anchors for acetabular labral refixation.

PURPOSE: The purpose of this study was to compare suture anchor placement in the acetabular rim between straight and curved drill guides regarding angle and distance of the suture anchor tip from the articular cartilage during labral refixation. METHODS: A total of 14 fresh-frozen cadaveric hips underwent arthroscopic labral incision from the 12 to 3 o'clock positions and subsequent repair with either a curved drill guide or a straight drill guide. These hips were then compared by computed tomographic imaging analysis by measuring the angle of suture anchor insertion and the distance of the tip of the suture anchor to the articular cartilage at the 1 o'clock, 2 o'clock, and 3 o'clock positions. RESULTS: The curved suture anchor (CSA) guide significantly increased the insertion angle (P = .009) and distance from the articular cartilage to anchor (P = .003) at the 1 o'clock position on the acetabulum. The angle of insertion at the 2 and 3 o'clock positions was greater for the CSA guide compared with the straight suture anchor (SSA) guide but did not reach statistical significance. CONCLUSIONS: A CSA guide was shown to be significantly more effective in increasing the angle of insertion of suture anchors and increased the distance of the suture anchor tip to the articular cartilage surface at the 1 o'clock position but not at the 2 or 3 o'clock position. CLINICAL RELEVANCE: The use of SSA guides can be difficult because of the osseous morphologic characteristics of the acetabular rim, leading to placement of the suture anchor away from the acetabular rim and therefore resulting in a nonanatomical refixation of the acetabular labrum. The use of a curved guide, flexible drill, and flexible suture anchor inserter may provide more precise placement of suture anchors in the acetabular rim.

Age-related differences in radiographic parameters for femoroacetabular impingement in hip arthroplasty patients.

PURPOSE: To compare the prevalence of femoroacetabular impingement (FAI) radiographic findings between patients aged younger than 50 years and those aged 50 years or older who underwent total hip arthroplasty. METHODS: Total hip arthroplasty patients aged younger than 50 years and those aged 50 years or older were identified retrospectively from a facility medical record database. Fifty patients from each group were randomly selected, and preoperative radiographs were collected. Dysplastic, inflammatory, post-traumatic, and osteonecrosis patients were excluded. Radiographs were evaluated for FAI-specific findings. Intraobserver and interobserver reliability was evaluated with κ statistics for categorical variables and intraclass correlation coefficients for continuous variables. An independent t test was used to compare continuous variables, χ(2) analysis was used for discrete variables, and a z ratio was used to analyze proportions. RESULTS: The mean age between the subgroups of patients aged younger than 50 years and those aged 50 years or older (43 years and 68 years, respectively) was significantly different (P < .05). Findings in the subgroup aged younger than 50 years included significantly more men (P < .001), decreased lateral joint space with maintained medial joint space (P < .05), significantly greater alpha angle on both the anteroposterior view and the frog-leg lateral view (P < .05), significantly higher Tönnis and Sharp angles (P < .01), and significantly lower center-edge angle (P < .001). CONCLUSIONS: This retrospective case series shows an increased prevalence of FAI findings (specifically cam pathology) in a patient population aged younger than 50 years undergoing total hip arthroplasty when compared with a cohort aged 50 years or older. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effect of reamer design on posteriorization of the tibial tunnel during endoscopic transtibial anterior cruciate ligament reconstruction.

BACKGROUND: It is known that small alterations in tunnel positioning during anterior cruciate ligament (ACL) reconstruction significantly affect ACL length and tensioning patterns as well as alter force vectors and joint kinematics. PURPOSE: To compare the amount of inadvertent posteriorization of the ACL tibial tunnel anatomy during transtibial ACL femoral reaming in the "over-the-top" position with a full femoral reamer versus a half femoral reamer, in comparison to the native tibial ACL footprint. It is hypothesized that the half reamer will result in less distortion of tibial tunnel anatomy and improved anatomic footprint coverage. It is also hypothesized that the true center of the tibial ACL footprint lies more anterior than previously described. STUDY DESIGN: Controlled laboratory study. METHODS: Eight cadaveric knee specimens were securely fixed to a stationary table at 90° of flexion and neutral rotation. After removal of the anterior capsule and patella, native joint anatomy was precisely recorded with a digitizer accurate to 0.05 mm. Tibial and femoral tunnels were then drilled in the manner of transtibial ACL reconstructions using the optimal tibial starting point of 15.9 mm below the medial plateau and 9.8 mm posteromedial to the medial margin of the tibial tubercle. After the 11-mm tibial tunnel was drilled, femoral tunnels were first drilled with a 10-mm half-fluted reamer, followed by a 10-mm full reamer. Each tibial tunnel's location and geometry relative to the native ligamentous insertion sites and joint anatomy were digitized. RESULTS: Digitized measurements of ACL insertional anatomy demonstrated that the center of the native ACL tibial footprint was 2.0 ± 0.49 mm (range, 1.1-2.7 mm) anterior to the posterior aspect of the lateral meniscus' anterior horn. Use of the 10-mm full femoral reamer resulted in a tibial-articular aperture that had a posterior edge 4.35 mm more posterior (P = .049) and extra-anatomic (P = .006) than the footprint of the 10-mm half femoral reamer. CONCLUSION: Half-fluted reamers may be more advantageous for femoral tunnel reaming with a more oblique transtibial approach, as they result in less posterior tibial tunnel expansion than full reamers, possibly leading to improved graft function. Based on the digitized anatomy, the center of the tibial attachment site is anterior to the posterior aspect of the lateral mensicus's anterior horn, which has been traditionally described as the anatomic center. CLINICAL RELEVANCE: Use of half-fluted reamers for transtibial femoral tunnel reaming could lead to more anatomic tunnel placement and possibly improved graft mechanics after transtibial single-bundle ACL reconstruction.

Transosseous-equivalent rotator cuff repair: a systematic review on the biomechanical importance of tying the medial row.

PURPOSE: Double-row and transosseous-equivalent repair techniques have shown greater strength and improved healing than single-row techniques. The purpose of this study was to determine whether tying of the medial-row sutures provides added stability during biomechanical testing of a transosseous-equivalent rotator cuff repair. METHODS: We performed a systematic review of studies directly comparing biomechanical differences. RESULTS: Five studies met the inclusion and exclusion criteria. Of the 5 studies, 4 showed improved biomechanical properties with tying the medial-row anchors before bringing the sutures laterally to the lateral-row anchors, whereas the remaining study showed no difference in contact pressure, mean failure load, or gap formation with a standard suture bridge with knots tied at the medial row compared with knotless repairs. CONCLUSIONS: The results of this systematic review and quantitative synthesis indicate that the biomechanical factors ultimate load, stiffness, gap formation, and contact area are significantly improved when medial knots are tied as part of a transosseous-equivalent suture bridge construct compared with knotless constructs. Further studies comparing the clinical healing rates and functional outcomes between medial knotted and knotless repair techniques are needed. CLINICAL RELEVANCE: This review indicates that biomechanical factors are improved when the medial row of a transosseous-equivalent rotator cuff is tied compared with a knotless repair. However, this has not been definitively proven to translate to improved healing rates clinically.

Screw fixation of an OCD loose body: 21-year results.

Osteochondritis dissecans (OCD) lesions can progress to loose body formation for which treatment is controversial and may involve excision or fixation. There is a paucity of published data regarding long-term outcomes following OCD loose body fixation. This case report presents an interval follow-up of a patient from a previous small case series of individuals who underwent open reduction internal fixation of large, lateral OCD loose bodies. At 21-year follow-up the patient has full, pain-free range of motion, and has not required subsequent surgery. This case, to our knowledge, is the first to report over 20-year follow-up from fixation of an OCD loose body and demonstrates a good long-term outcome. Clinicians should consider replacement and fixation of an OCD loose body when possible, as this may provide the best chance of long-term function.

The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis.

PURPOSE: Despite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP. METHODS: We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals. RESULTS: Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score. CONCLUSIONS: PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings. LEVEL OF EVIDENCE: Level III, systematic review of Level I, II, and III studies.

The use of double-loaded suture anchors for labral repair and capsular repair during hip arthroscopy.

With the development of hip joint preservation procedures, the use of hip arthroscopy has grown dramatically over the past decade. However, recent articles have reported cases of hip instability after hip arthroscopy. Little is known about the role of static and dynamic stabilizers on hip joint stability, but there are concerns that an extensile capsulotomy or capsulectomy, osteoplasty of the acetabulum and proximal femur, and labral detachment or debridement during hip arthroscopy could potentially compromise hip stability. The safety parameters for arthroscopic hip surgery have not yet been fully established, and techniques are being developed for labral refixation and capsular repair after arthroscopic treatment of femoroacetabular impingement in an attempt to decrease the chance of iatrogenic hip instability or microinstability. The surgical technique presented in this article may provide anatomic repair of both the labrum and capsule using a double-loaded suture anchor technique. We believe that this technique increases both operative efficiency and the strength of the overall repair, which may minimize the risk of iatrogenic hip instability after hip arthroscopy.

Biomechanical evaluation of a high tibial osteotomy with a meniscal transplant.

This study determines the biomechanical advantage and the optimal configuration of a high tibial osteotomy (HTO) and meniscus transplantation performed concurrently. Six cadaver knees were placed in a spatial frame, and an HTO was completed. Loading points between a mechanical 6 degrees of varus and 8 degrees ofvalgus were loaded to 800 N for medial meniscal intact, meniscectomized, and transplanted states. Posterior slope was also increased by 3 degrees in these specimens. Contact data was recorded. Peak pressures significantly increased in the meniscectomized state in every degree of varus/valgus (p < 0.05). For both peak and total medial compartment pressures, there was a significant drop (p < 0.001) between neutral and 3 degrees of valgus. Lateral compartment pressures linearly increased from varus to valgus orientation. There was no significant change in the pressure profile of the knee with a 3-degree increase in posterior slope. This biomechanical study confirms the hypothesis that an HTO improves the peak pressures in the medial compartment at all degrees of varus/valgus alignment in the setting of meniscal transplantation. Furthermore, the largest decrease in medial pressures was between neutral and 3 degrees of valgus, suggesting that perhaps neutral aligned knees could benefit from an HTO.

The vertical humeral osteotomy for stem removal in revision shoulder arthroplasty: results and technique.

HYPOTHESIS: Revision shoulder arthroplasty represents a complex and difficult problem for the treating surgeon, with multiple potential complications. In the setting of a well-fixed humeral component, removal can lead to fractures and compromise the outcome of the revision. The current study describes and evaluates the results of a novel vertical humeral osteotomy (VHO) for stem extraction. We hypothesized that the VHO will enable successful stem extraction without perioperative or postoperative fractures. MATERIALS AND METHODS: Twenty-seven patients were retrospectively identified who had a VHO for revision shoulder arthroplasty, with 23 patients available for final follow-up. Records and radiographs were reviewed for postoperative complications. Final follow-up was completed with the inclusion of shoulder scores. RESULTS: There were no perioperative or postoperative fractures on clinical examination and radiographic review at an average follow-up of 41 months. Average American Shoulder and Elbow Surgeons (ASES) score was 64.7 (contralateral ASES, 76.9), average Simple Shoulder Test was 6.3, and the visual analog score pain average was 1.3. There were no instability events. DISCUSSION: The glenoid is the more common site for failure in both hemiarthroplasty and total shoulder arthroplasty. This can lead to a difficult revision procedure if the ingrown or cemented humeral stem requires removal. CONCLUSION: In the current study, we found the VHO was an effective tool for the removal of the humeral prosthesis with no perioperative or postoperative fractures.

Intraoperative molds to create an articulating spacer for the infected knee arthroplasty.

BACKGROUND: Chronic infections in TKA have been traditionally treated with a two-stage protocol incorporating a temporary antibiotic-loaded cement spacer. The use of a static as opposed to an articulating spacer is controversial. Some surgeons believe a static spacer results in a higher rate of infection eradication, whereas others believe an articulating spacer provides equivalent rates of infection control with improved function between stages and the potential for better eventual range of motion. QUESTIONS/PURPOSES: We determined the rates of infection control and postoperative function for an articulating all-cement antibiotic spacer fashioned intraoperatively from prefabricated silicone molds. METHODS: We retrospectively reviewed 60 patients with an infected TKA using the same cement-on-cement articulating spacer. A minimum of 4 g antibiotic per package of cement was used when making the spacer. Complications and pre- and postoperative knee flexion, extension, and Knee Society scores were recorded. Bone loss associated with the spacer was determined radiographically and by intraoperative inspection of the bony surfaces at the second stage. Minimum followup was 24 months (mean, 35 months; range, 24-51 months). RESULTS: Seven patients (12%) became reinfected, four with an organism different from that identified at the index resection arthroplasty. One spacer femoral component broke between stages but did not require any specific treatment. We identified no bone loss between stages and no complications related to the cement-on-cement articulation. The mean pretreatment Knee Society scores of 53 improved to 79. The mean preoperative flexion of 90.6º improved to 101.3º at final followup. CONCLUSIONS: An articulating antibiotic spacer was associated with control of a deep periprosthetic infection in 88% of patients while allowing range of motion between stages. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.