Editorial Commentary: Primary Treatment of Hip Labral, Osseous, Chondral, Capsular, and Extra-Articular Pathology Is Essential: Outcomes Following Revision Are Less Predictable.

Appropriate labral management is one of many procedures during hip arthroscopy that affects postoperative outcomes and revision rates. Both primary labral repair and reconstruction have been shown to have superior clinical and functional outcomes compared with labral debridement when treating unstable labral tears. Arthroscopic labral reconstruction is one of the most powerful techniques in the arsenal of complex hip-preservation surgeons, and although often reserved for the revision setting, when the native labrum is irreparable, a primary reconstruction may be indicated when the only alternatives are selective labral debridement or a suboptimal repair. Labral reconstruction, either in primary or revision procedures, is indicated when the existing labrum is deemed irreparable based on an intraoperative evaluation. Current indications for primary labral reconstruction, either in the primary or revision setting, include a calcified labrum, an irreparable mixed Seldes type 1 and 2 tear, or a hypoplastic labrum with less than 3 mm of viable tissue. Primary hip arthroscopy has been shown to have superior outcomes compared with revision hip arthroscopy, whether with labral repair or reconstruction. Finally, appropriate labral management is necessary but not always sufficient. Hip arthroscopy requires management of osseous deformities, with care taken to avoid under- and over-resection during both femoroplasty and acetabuloplasty; management of chondral injury; and management of the hip capsule with repair or plication. Consideration also must be given to potential extra-articular pain generators, such as abductor insufficiency, ischiofemoral impingement, lumbar spine disease, as well as deformities requiring open surgical correction such as acetabular dysplasia or pathologic femoral version. The primary goal is getting it right the first time.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review.

PURPOSE: To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures. METHODS: Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.). RESULTS: Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS. CONCLUSIONS: The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Orthobiologics as an adjunct in treatment of femoroacetabular impingement syndrome: cell-based therapies facilitate improved postoperative outcomes in the setting of acetabular chondral lesions-a systematic review.

PURPOSE: To evaluate studies utilizing orthobiologics in the management of femoroacetabular impingement syndrome (FAIS) to (1) assess the indications for usage, and (2) analyze patient-reported outcome measures (PROM) following treatment. It was hypothesized that orthobiologics would (1) be utilized for symptomatic FAIS in the setting of labral or chondral pathology, and (2) improve PROM at most recent follow-up. METHODS: The Pubmed, Ovid Medline, Cochrane, and Web of Science databases were searched for clinical studies evaluating orthobiologics [hyaluronic acid (HA), platelet-rich plasma (PRP), or cell-based therapy (CBT) for treatment of FAIS. Exclusion criteria included orthobiologics used in conjunction with cartilage transfer or scaffolding procedures and a primary indication other than FAIS. Data collection included patient demographics, indications, and baseline and most recent PROM. RESULTS: Eleven studies (one level I, four level II, four level III, and two level IV evidence) met inclusion criteria, consisting of 440 patients with mean ages ranging from 32.8 to 47 years. All 11 studies demonstrated an improvement in PROM from baseline to most-recent follow-up. Four studies administered PRP either intraoperatively or the day after surgery as an adjunct to labral repair. CBT was used intraoperatively in the setting of acetabular chondral lesions (three studies) and labral repair (one study). When comparing to a control group at most recent follow-up, three PRP cohorts demonstrated similar PROM (n.s.), while one PRP group exhibited worse visual analog pain scores (2.5 vs. 3.4, p = 0.005) and modified Harris Hip Scores (mHHS) (82.6 vs. 78.7, p = 0.049). The four CBT studies reported favorable results compared to a control group, with a significantly higher mHHS at most recent follow-up or mean improvement from baseline in Hip Outcome Score-Activities of Daily Living (p < 0.05). Three studies reported on HA, which was utilized exclusively in the nonoperative setting. CONCLUSIONS: Intraoperative PRP and CBT have been commonly reported in the setting of hip arthroscopy for labral repairs and acetabular chondral lesions, respectively. The CBT cohorts demonstrated more favorable PROM at most recent follow-up when compared to a control group, though these results should be interpreted with caution due to heterogeneity of orthobiologic preparations. LEVEL OF EVIDENCE: IV.

Clinically Depressed Patients Having Anterior Cruciate Ligament Reconstruction Show Improved but Inferior Rate of Achieving Minimum Clinically Important Difference for Patient-Reported Outcomes Measurement Information System Compared With Situationally Depressed or Nondepressed Patients.

PURPOSE: To determine whether the preoperative diagnosis of depression predicted worse postoperative outcomes, including physical therapy (PT) compliance, return-to-sport, and patient-reported outcomes using the Patient-Reported Outcomes Measurement Information System (PROMIS) after anterior cruciate ligament (ACL) reconstruction. METHODS: A multisurgeon series of consecutive patients who had undergone ACL reconstruction with minimum 2-year follow-up were included. Chart review was conducted to determine depression diagnosis status, demographic data, rehabilitation PT compliance, return to sports, and patient-reported outcome data using PROMIS. Patients who met the PROMIS threshold for mild depression but did not carry a clinical diagnosis of depression were classified as "situationally depressed." RESULTS: Ninety-five of 115 consecutive patients (81%) met inclusion criteria with an average follow-up of 34 ± 1.9 months. Fourteen patients (15%) had a preoperative diagnosis of depression, whereas 21 (22%) were considered situationally depressed. Clinically depressed patients had a greater rate of PT noncompliance (33.2% ± 17.6% vs 21.9% ± 12.6%; P = .02) and a lower postoperative PROMIS Physical Function (50.8 ± 7.7 vs 57.8 ± 11.0; P = .03 compared with patients without depression. Situationally depressed patients had lower preoperative physical function (35.4 vs 42.5; P = .04) with no differences in postoperative outcomes scores compared to the non-depressed cohort.19/21 (90.5%) of situationally depressed patients had postoperative resolution of their depressive symptoms. CONCLUSIONS: Situationally depressed patients without a clinical diagnosis of depression can expect significant improvements in both pain and function, as well as a resolution of their depressed mood based on PROMIS scores as they progress through recovery after ACL reconstruction. Clinically depressed patients also experience significant improvements; however, their rate of achieving the minimum clinically important difference for PROMIS outcomes may be less than their nondepressed or situationally depressed counterparts. LEVEL OF EVIDENCE: III, prognostic comparative trial.

Editorial Commentary: Bilateral Femoroacetabular Impingement Syndrome: What We Know Now and Where Do We Go From Here?

Patients with bilateral femoroacetabular impingement syndrome treated with either staged or simultaneous hip arthroscopy have similar postoperative outcomes compared with patients undergoing unilateral procedures. A longer duration between surgeries is associated with inferior outcomes; however, the reasons underlying this trend are unclear. Identifying prognostic variables that are associated with contralateral symptom onset and disease progression are important goals for future investigation.

Diversity among academic orthopedic shoulder and elbow surgery faculty in the United States.

BACKGROUND: The purpose of this study was to perform a cross-sectional analysis of diversity among academic shoulder and elbow surgeons in the United States. METHODS: US shoulder and elbow surgeons who participated in shoulder and elbow fellowship and/or orthopedic surgery resident education as of November 2018 were included. Demographic data (age, gender, race), practice setting, years in practice, academic rank, and leadership roles were collected through publicly available databases and professional profiles. Descriptive statistics were performed and findings were compared between different racial and gender groups. Statistical significance was set at P <.05. RESULTS: A total of 186 orthopedic shoulder and elbow surgeons were identified as participating in shoulder and elbow fellowship and/or orthopedic surgery residency education. Overall, 83.9% were white, 14.5% were Asian, 1.1% were Hispanic, 0.5% were an other race, and 0% were African American. In addition, 94.6% of surgeons were male, whereas 5.4% were female. Further, 64.5% of all surgeons had been in practice for >10 years, and 39.2% worked in an urban setting. Less than half (40.3%) of the surgeons practicing primarily at academic institutions held a professor rank. White surgeons had a significantly greater time in practice vs. nonwhite surgeons (mean 18.8 vs. 12.6 years, P < .01) and were more likely to hold a professor rank (44.0% vs. 21.7%, P = .04). CONCLUSION: Racial and gender diversity among US shoulder and elbow surgeons who participate in fellowship and residency education is lacking. Hispanic, African American, and female surgeons are underrepresented. Efforts should be made to identify the reasons for these deficiencies and address them to further advance the field of orthopedic shoulder and elbow surgery.

Clinically Meaningful Improvements After Hip Arthroscopy for Femoroacetabular Impingement in Adolescent and Young Adult Patients Regardless of Gender.

BACKGROUND: The objective of this study was to determine if adolescent and young adult patients undergoing hip arthroscopy for symptomatic femoroacetabular impingement (FAI) experience clinically meaningful improvements in functional outcome scores. METHODS: A consecutive series of patients under age 18 who underwent primary hip arthroscopy for symptomatic FAI was identified using our institution's hip registry. Demographics, preoperative radiographic measurements, and preoperative and postoperative patient-reported outcome scores [Hip Outcome Score (HOS), Activity of Daily Living (ADL), and Sports-Specific Subscale (SS), and modified Harris Hip Score (MHHS)] were collected. Percentage of patients achieving minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) were determined using published cutoffs for HOS and MHHS in FAI patients. RESULTS: Forty-three patients met study inclusion criteria, and 37 patients (86%) were available at a minimum follow-up of 2 years. Mean age was 17.0±1.4 years, 70% were female, and 8.1% had an open proximal femoral physis. All competitive high school and college athletes were able to return to sport. Patients experienced significant improvements following hip arthroscopy in HOS-ADL, HOS-SS, and MHHS scores (all P<0.0001). MCID was achieved in 81% of patients (27/34) for HOS-ADL, 97% (33/34) for HOS-SS, and 84% (27/32) for MHHS. PASS was achieved for 76% of patients (26/34) for HOS-ADL, 79% (27/34) for HOS-SS, and 81% (26/32) for MHHS. Lower body mass index but not age or sex was correlated with a greater improvement in MHHS scores (r=0.39; P=0.03). There were 2 minor complications and no revision surgery. CONCLUSIONS: Adolescent and young adult patients experienced statistically significant improved functional outcomes 2 years after hip arthroscopy for FAI. In addition, these outcomes can be achieved with a low complication rate and a high return to preoperative activity. Approximately 80% of patients achieved clinically significant outcomes based on MCID and PASS criteria. Patient improvements in MHHS were equal regardless of age or sex; however, lower preoperative body mass index led to greater postoperative MHHS improvements. LEVEL OF EVIDENCE: Level IV-therapeutic case series.

Amateur and Recreational Athletes Return to Sport at a High Rate Following Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To compare the return-to-play rates, patient-reported outcome (PRO) scores, and satisfaction between high-level amateur athletes and recreational athletes and to evaluate for differences in ability to return to sport in these groups based on patient-related and sport-related characteristics. METHODS: Clinical data were retrieved for 66 (26 male/40 female) consecutive athletes undergoing hip arthroscopy for femoroacetabular impingement. Athletes were classified as high-level amateur or recreational. Athletes were also divided into 6 distinct sporting categories based on the physical demands on the hip. Preoperative and 2-year PROs including a sport-specific questionnaire, modified Harris Hip Score (MHHS), and Hip Outcome Scores with Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales were collected. RESULTS: Of the 66 patients, 49 were recreational and 17 were high-level amateur athletes (10 high school and 7 collegiate). High-level athletes were significantly younger than recreational athletes (18.4 ± 2.3 years vs 29.7 ± 6.8 years; P < .001). After 2 years, all PROs had improved significantly, with no differences between the 2 athletic groups. There was a high overall rate of return for both recreational and high-level amateur athletes (94% vs 88%; P = .60). Increasing preoperative withdrawal time from sport prior to surgery was associated with decreased HOS-SS (r = 0.33; P = .04) and MHHS scores (r = 0.02; P = .02). Overall, athletes who had withdrawn from sport for greater than 8 months before surgery returned to sport significantly more slowly (P = .01). Increasing body mass index (BMI) was associated with lower improvements in HOS (r = 0.26; P = .04) and MHHS scores (r = 0.38; P < .01). CONCLUSIONS: Recreational athletes, despite being significantly older than their high-level counterparts, return to play at a similar high rate and with comparable PROs. Increasing preoperative cessation time from sport significantly prolongs return to sport. Additionally, increasing preoperative cessation from sport and higher preoperative BMI were associated with decreased improvements in PROs. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Effect of Capsulotomy and Capsular Repair on Hip Distraction: A Cadaveric Investigation.

PURPOSE: To quantify how increasing interportal capsulotomy size affects the force required to distract the hip and to biomechanically compare simple side-to-side suture repair to acetabular-based suture anchors as capsular repair techniques. METHODS: Twelve fresh-frozen cadaveric hip specimens were dissected to the capsuloligamentous complex of the hip joint and fixed in a material testing system, such that a pure axial distraction of the iliofemoral ligament could be achieved. After each hip in was tested an intact state, sequential distraction was tested with 2, 4, 6, and 8 cm capsulotomies. Specimens were assigned randomly to be repaired with either 4 side-to-side suture repair (n = 6) or 2 double-loaded all-suture anchors (n = 6). The distraction force as well as the relative distraction force percentage normalized to the intact capsule were compared between suture repair and suture anchor repair groups. RESULTS: Increasing the size of the capsulotomy resulted in less force required to distract the hip to 6 mm. The force decreased as the capsulotomy was extended with statistical significance in distraction force seen between the intact state and the 4 cm (P = .003), 6 cm (P < .001), and 8 cm (P ≤ .001) capsulotomy but not for the intact state compared to the 2 cm capsulotomy (P = .28). Statistical significance in relative distraction force was seen for each of the capsulotomy conditions (P < .001 for all conditions compared with the intact state). The side-to-side suture repair construct (104.3% of intact force) required greater force to distraction to 6 mm compared with the suture anchor repair (87.1% of intact force) (P = .008). CONCLUSIONS: An interportal capsulotomy significantly affected the force required to distract the hip in a cadaveric model, with the larger the size of capsulotomy resulting in less force required to distract the hip. When we performed an interportal capsulotomy, the iliofemoral ligament strength was altered significantly but capsular repair with either side-to-side sutures or suture anchor-based repair was able to restore the capsular strength to a native intact hip. We found, however, that the side-to-side suture repair was better able to restore the distraction force compared with suture anchor repair. CLINICAL RELEVANCE: Capsular management during hip arthroscopy remains a debated topic, with multiple techniques involving both capsulotomy and capsular closure published in the literature. This study provides insight into capsular stability against axial stress under capsulotomy and capsular repair conditions.

Does the Hip Capsule Remain Closed After Hip Arthroscopy With Routine Capsular Closure for Femoroacetabular Impingement? A Magnetic Resonance Imaging Analysis in Symptomatic Postoperative Patients.

PURPOSE: The purpose of this study was to examine the hip capsule in a subset of symptomatic patients who underwent capsular closure during hip arthroscopy. METHODS: All patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) with routine capsular closure between January 1, 2012, and December 31, 2015, were eligible. Only patients with unilateral surgery and a postoperative magnetic resonance imaging (MRI; ordered for persistent symptoms) were included. Four independent reviewers evaluated each hip capsule for thickness and the absence or presence of defects. RESULTS: During the study, 1,463 patients had hip arthroscopy for FAI with routine capsular closure, and 53 (3.6%) underwent a postoperative MRI. Fourteen of the 53 were excluded owing to revision status or additional procedures. The final study population included 39 patients (23 female patients and 16 male patients), with an average patient age of 31.7 ± 11.4 years and an average body mass index of 23.3 ± 2.9. There were 3 (7.5%) capsular defects, and the intraclass correlation coefficient (ICC) was 0.82. The operative hip capsule was significantly thicker in the zone of capsulotomy, and subsequent repair as compared with the unaffected, contralateral hip capsule (5.0 ± 1.2 mm vs 4.6 ± 1.4 mm; P = .02), ICC 0.83. Additionally, males had thicker hip capsules as compared with their female counterparts, on the operative side (5.4 ± 1.1 mm vs 4.5 ± 1.2 mm; P = .02) and the nonoperative side (4.8 ± 1.6 mm vs 4.1 ± 0.9 mm; P = .08). CONCLUSIONS: In a subset of symptomatic patients after hip arthroscopy for FAI, the majority (92.5%) of the repaired hip capsules remained closed at greater than 1 year of follow-up. The hip capsule adjacent to the capsulotomy and subsequent repair is thickened compared with the same location on the contralateral, nonoperative hip. Aside from gender, patient-related and FAI-related factors do not correlate with capsular thickness nor do they seem to correlate with the propensity to develop a capsular defect. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Hip Arthroscopy Outcomes With Respect to Patient Acceptable Symptomatic State and Minimal Clinically Important Difference.

PURPOSE: To determine whether the hip arthroscopy literature to date has shown outcomes consistent with published patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) estimates. METHODS: All clinical investigations of hip arthroscopy using modified Harris Hip Score (mHHS) and/or Hip Outcome Score (HOS) outcomes with at least 1 year of follow-up were reviewed. Ninety-one studies (9,746 hips) were included for review. Eighty-one studies (9,317 hips) contained only primary hip arthroscopies and were the primary focus of this review. The remaining studies (429 hips) did not exclude patients with prior surgical history and were thus considered separately. Mean mHHS, HOS-ADL (Activities of Daily Living) and HOS-SS (Sports-Specific) scores were compared with previously published PASS and MCID values. RESULTS: After 31 ± 20 months, 5.8% of study populations required revision arthroscopy and 5.5% total hip arthroplasty. A total of 88%, 25%, and 30% of study populations met PASS for mHHS, HOS-ADL, and HOS-SS, respectively, and 97%, 90%, and 93% met MCID. On bivariate analysis, increasing age was associated with significantly worse postoperative mHHS (P < .01, R(2) = 0.14), HOS-SS (P = .05, R(2) = 0.12), and rates of reoperation (P = .02, R(2) = 0.08). Increasing body mass index was associated with significantly worse HOS-ADL (P = .02, R(2) = 0.35) and HOS-SS (P = .03, R(2) = 0.30). CONCLUSIONS: In this meta-analysis of 81 studies of primary hip arthroscopy, we have found that more than 90% of study populations meet MCID standards for the most commonly used patient-reported outcomes measures in hip arthroscopy literature, mHHS and HOS. Eighty-eight percent meet PASS standards for the mHHS, but PASS standards are far more difficult to achieve for HOS-ADL (25%) and HOS-SS (30%) subscales. Differences in psychometric properties of the mHHS and HOS likely account for the discrepancies in PASS. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Ten-Year Outcomes in Patients Aged 40 Years and Older After Primary Arthroscopic Treatment of Femoroacetabular Impingement With Labral Repair.

BACKGROUND: Arthroscopic labral repair has been shown to result in favorable short- and midterm outcomes; however, the durability of outcomes specifically in older patients remains underreported. PURPOSE: To (1) report prospectively collected hip preservation rates and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up in patients aged ≥40 years after primary hip arthroscopy with labral repair and (2) perform a matched analysis comparing patients aged ≥40 years with patients aged <40 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected and retrospectively reviewed on all patients who underwent primary hip arthroscopy between February 2008 and December 2011. Patients aged ≥40 years who underwent labral repair were included. Preoperative and minimum 10-year follow-up scores were collected for multiple PROMs. Propensity score matching was utilized to compare these patients with a cohort of patients <40 years. RESULTS: Of the 113 hips eligible, 91 hips (80.5%) on 85 patients (6 bilateral) had a minimum 10-year follow-up. There were 58 women (68%) and 27 men (32%) with a mean age and body mass index of 47.8 years and 25.8, respectively. The hip preservation rate for patients aged ≥40 years was 78%, with 20 patients requiring arthroplasty during the study period. There was significant improvement in all PROMs from baseline to minimum 10-year follow-up with high rates of achieving the minimal clinically important difference and Patient Acceptable Symptom State clinical outcome thresholds. In total, 69 patients aged ≥40 years were propensity matched to 107 patients <40 years. Patients ≥40 tended to have a lower hip preservation rate (81.2% vs 91.6%; P = .06), while patients in the younger cohort had significantly higher rates of secondary hip arthroscopy (14% vs 3%; P = .02). Improvement in PROMs was comparable between the groups. CONCLUSION: Patients ≥40 years who underwent primary hip arthroscopy with labral repair demonstrated a hip preservation rate of 78%, significant and durable improvement in PROMs, and high rates of satisfaction at a minimum 10-year follow-up. Matched analysis with patients <40 years revealed comparable improvement in patient-reported outcomes between the 2 groups, with a tendency to a higher level of arthroplasty in patients ≥40 years.

Parachute Technique for Dermal Allograft Augmentation in Open Gluteal Abductor Repair.

Retracted full-thickness tears of the gluteus medius tendon are a well-recognized cause of disabling weakness and pain that significantly impact patients' quality of life. We present an efficient knotless parachute technique for dermal allograft augmentation in open gluteal abductor tendon repairs. Our technique reinforces the suture-tendon interface by incorporating a robust biological scaffold into a knotless double-row fixation. This approach capitalizes on the increased pressure and contact area achieved between the greater trochanter and the dermal allograft/gluteus medius tendon construct without the prominence of knotted sutures.

Three-dimensional analysis of age and sex differences in femoral head asphericity in asymptomatic hips in the United States.

BACKGROUND: The sphericity of the femoral head is a metric used to evaluate hip pathologies and is associated with the development of osteoarthritis and femoral-acetabular impingement. AIM: To analyze the three-dimensional asphericity of the femoral head of asymptomatic pediatric hips. We hypothesized that femoral head asphericity will vary significantly between male and female pediatric hips and increase with age in both sexes. METHODS: Computed tomography scans were obtained on 158 children and adolescents from a single institution in the United States (8-18 years; 50% male) without hip pain. Proximal femoral measurements including the femoral head diameter, femoral head volume, residual volume, asphericity index, and local diameter difference were used to evaluate femoral head sphericity. RESULTS: In both sexes, the residual volume increased by age (P < 0.05). Despite significantly smaller femoral head size in older ages (> 13 years) in females, there were no sex-differences in residual volume and aspherity index. There were no age-related changes in mean diameter difference in both sexes (P = 0.07) with no significant sex-differences across different age groups (P = 0.06). In contrast, there were significant increases in local aspherity (maximum diameter difference) across whole surface of the femoral head and all quadrants except the inferior regions in males (P = 0.03). There were no sex-differences in maximum diameter difference at any regions and age group (P > 0.05). Increased alpha angle was only correlated to increased mean diameter difference across overall surface of the femoral head (P = 0.024). CONCLUSION: There is a substantial localized asphericity in asymptomatic hips which increases with age in. While 2D measured alpha angle can capture overall asphericity of the femoral head, it may not be sensitive enough to represent regional asphericity patterns.

Evaluating the Morphology of Unique Superficial Fissured Cartilage Lesions at the Femoral Head-Neck Junction in Patients with Femoroacetabular Impingement Syndrome.

Background: While an association between femoroacetabular impingement (FAI) and osteoarthritis (OA) has been reported, the mechanistic differences and transition between the 2 conditions is not fully understood. In FAI, cartilage lesions at the femoral head-neck junction can sometimes be visualized during hip arthroscopy. Purpose/Hypothesis: The purpose of this study was to describe a unique dimpled pattern of superficial fissured cartilage lesions on the femoral head-neck junction at impingement site in patients with FAI syndrome (FAIS) and to evaluate the clinical, histological, and genetic phenotype of this cartilage. We hypothesized that the cartilage lesions may indicate risk for, or predict occurrence of, OA. Study Design: Controlled laboratory study. Methods: Six hips (6 patients; mean age, 34.2 ± 12.9 years; range, 19-54 years) with dimpled or fissured cartilage were included among patients who underwent hip arthroscopy for treatment of FAIS from October 2020 through December 2021. This affected cartilage (dimple-pattern group) and normal cartilage (control group) on the femoral head-neck junction were collected from the same patients and evaluated for histological quantification by Mankin scores and expression of proteins related to cartilage degeneration (eg, matrix metalloproteinase [MMP]-1, MMP-2, MMP-3, MMP-10, and MMP-12, tissue inhibitor of metalloproteinase [TIMP]-1 and TMP-2, aggrecan neopepitope CS846, and hyaluronic acid [HA]) with the use of Milliplex Multiplex Assays. Results: All 6 hips were of the mixed FAI subtype. Preoperatively, 4 of 6 hips had Tönnis grade 1 radiographic changes, which was associated with greater femoral head chondral damage visualized intraoperatively. Mankin scores for the normal cartilage group and the dimple-pattern group were 0.67 ± 0.82 and 3.3 ± 0.82, respectively. Dimple pattern fissured cartilage showed a significant increase in Mankin score (P = .031) and a significant increase in protein expression of CS846 (P = .031) compared with normal cartilage. There were no significant differences in MMPs, TIMPs, or HA levels between the 2 groups. Conclusion: The dimple pattern fissured cartilage, compared to normal cartilage, showed histologically significant cartilage degeneration and a significant increase in protein expression of CS846, a biomarker for early OA. Clinical Relevance: This lesion serves as helpful visual indicator of early degeneration of the cartilage of femoral head-neck junction caused by FAIS.

Impact of Sports Participation on Achievement of Clinically Relevant Outcomes 2 Years After ACL Reconstruction.

Background: Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement. Purpose/Hypothesis: The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement. Study Design: Case series; Level of evidence, 4. Methods: Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS. Results: In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF. Conclusion: Preoperative athletic participation significantly affected the ability to achieve PASS.

Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility.

SUMMARY: Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

Whole-genome RNA sequencing identifies distinct transcriptomic profiles in impingement cartilage between patients with femoroacetabular impingement and hip osteoarthritis.

Femoroacetabular impingement (FAI) has a strong clinical association with the development of hip osteoarthritis (OA); however, the pathobiological mechanisms underlying the transition from focal impingement to global joint degeneration remain poorly understood. The purpose of this study is to use whole-genome RNA sequencing to identify and subsequently validate differentially expressed genes (DEGs) in femoral head articular cartilage samples from patients with FAI and hip OA secondary to FAI. Thirty-seven patients were included in the study with whole-genome RNA sequencing performed on 10 gender-matched patients in the FAI and OA cohorts and the remaining specimens were used for validation analyses. We identified a total of 3531 DEGs between the FAI and OA cohorts with multiple targets for genes implicated in canonical OA pathways. Quantitative reverse transcription-polymerase chain reaction validation confirmed increased expression of FGF18 and WNT16 in the FAI samples, while there was increased expression of MMP13 and ADAMTS4 in the OA samples. Expression levels of FGF18 and WNT16 were also higher in FAI samples with mild cartilage damage compared to FAI samples with severe cartilage damage or OA cartilage. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. We independently validated the results of the sequencing analysis and found increased expression of anabolic markers in patients with FAI and minimal histologic cartilage damage, suggesting that anabolic signaling may be increased in early FAI with a transition to catabolic and inflammatory gene expression as FAI progresses towards more severe hip OA. Clinical significance:Cam-type FAI has a strong clinical association with hip OA; however, the cellular pathophysiology of disease progression remains poorly understood. Several previous studies have demonstrated increased expression of inflammatory markers in FAI cartilage samples, suggesting the involvement of these inflammatory pathways in the disease progression. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. In addition to differences in inflammatory gene expression, we also identified differential expression in multiple pathways involved in hip OA progression.

Academic Orthopaedics As a Driver of Gender Diversity in the Orthopaedic Workforce: A Review of 4,519 Orthopaedic Faculty Members.

BACKGROUND: The purpose of this study was to perform a cross-sectional analysis on the gender composition of practicing academic orthopaedic surgeons using three databases composed of clinical orthopaedic surgeons. METHODS: A comprehensive database of 4,519 clinically active academic orthopaedic surgeons was compiled for this study after the review of publicly available data. The complied data set was evaluated alongside orthopaedic databases obtained from the 2017 Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System and the 2016 American Academy of Orthopaedic Surgery (AAOS) Orthopaedic Practice in the US census representing the entire academy membership orthopaedic workforce. Gender status was obtained and compared between the three databases. RESULTS: Of the 4,519 clinically active academic orthopaedic surgeons analyzed, 435 (10%) were female compared with 19% for the AAMC faculty database and 7% for the AAOS members. Fourteen percent of women had achieved the rank of professor compared with 25% of the men (P < 0.001). AAMC faculty had a significantly higher percentages of female representation compared with both the clinical faculty (19% versus 10%; P < 0.001) and AAOS members (19% versus 7%; P < 0.001). CONCLUSION: Despite multiple initiatives designed to increase diversity, the 7% female representation in the orthopaedic workforce identified in this study remains markedly lower than other medical and surgical specialties. A higher percentage of women were associated with the AAMC orthopaedic faculty compared with clinically active female surgeons at these institutions. Academic orthopaedic surgeons had greater female representation than the general orthopaedic workforce, highlighting the importance of training institutions at promoting gender equity.