Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: 24-Month Results From a Randomized Controlled Trial.

BACKGROUND: The indications for hip arthroscopy in patients aged ≥40 years remain controversial, as observational studies have suggested that advanced age portends poor functional outcomes, poor durability of improvement, and high rates of conversion to total hip arthroplasty. PURPOSE: To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients aged ≥40 years with limited radiographic osteoarthritis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This single-surgeon, parallel randomized controlled trial included patients aged ≥40 years with limited osteoarthritis (Tönnis grades 0-2) who were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA). Patients who received PTA and achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy (CO). The primary outcomes were the International Hip Outcome Tool-33 score and modified Harris Hip Score at 24 months after surgery, and secondary outcomes included other patient-reported outcome measures and the visual analog scale for pain. The primary analysis was performed on an intention-to-treat basis using linear mixed-effects models. Sensitivity analyses included modified as-treated and treatment-failure analyses. RESULTS: A total of 97 patients were included, with 52 (53.6%) patients in the SPT group and 45 (46.4%) patients in the PTA group. Of the patients who underwent PTA, 32 (71.1%) patients crossed over to arthroscopy at a mean of 5.10 months (SD, 3.3 months) after physical therapy initiation. In both intention-to-treat and modified as-treated analyses, the SPT group displayed superior mean patient-reported outcome measure and pain scores across the study period for nearly all metrics relative to the PTA group. In the treatment-failure analysis, the SPT and CO groups showed greater improvement across all metrics compared with PTA; however, post hoc analyses revealed no significant differences in improvement between the SPT and CO groups. No significant differences were observed between groups in rates of total hip arthroplasty conversion. CONCLUSION: In patients ≥40 years of age with limited osteoarthritis, hip arthroscopy with postoperative physical therapy led to better outcomes than PTA at a 24-month follow-up. However, additional preoperative physical therapy did not compromise surgical outcomes and allowed some patients to avoid surgery. When surgery is indicated, age ≥40 years should not be considered an independent contraindication to arthroscopic acetabular labral repair. REGISTRATION: NCT03909178 (ClinicalTrials.gov identifier).

Social Determinants of Health Disparities Increase 5-Year Revision Rates but Not Postoperative Complications After Primary Hip Arthroscopy.

PURPOSE: To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and 5-year secondary surgery rates after primary hip arthroscopy using a large national database. METHODS: A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Queries were performed to identify patients who experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH disparities within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. The odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of 5-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis. RESULTS: A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who did not experience SDOH disparities (age of 41.0 years and 79.6% female sex in both cohorts). The odds of adverse events after arthroscopy were low and did not differ between the SDOH cohort (1.51%) and no-SDOH cohort (1.57%, P = .09). Additionally, there was no difference in the odds of 30-day ED visits between the SDOH cohort (5.65%) and no-SDOH cohort (4.79%, P = .10). The rate of 5-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs 4.1%, P = .02); however, there was no difference in the rate of any secondary surgery between cohorts (11.8% vs 10.4%, P = .10). CONCLUSIONS: Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of 5-year revision hip arthroscopy compared with a matched-control cohort of patients not experiencing SDOH disparities. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Biceps tenotomy vs. tenodesis in patients undergoing transtendinous repair of partial thickness rotator cuff tears.

Background: Patients with partial thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps tendon (LHBT). To address both conditions simultaneously, long head of the biceps (LHB) tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy. Methods: A total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index, and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes. Results: When comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs. 130.1°, P = .004), abduction (138.6° vs. 114.2°, P = .019), and external rotation (60.4° vs. 43.8°, P = .014), with differences in forward flexion remaining significant at 6 months (162.4° vs. 149.4°, P = .009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (P = .458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (P = .066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; P = .010). Conclusion: Despite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.

Association Between Chondrolabral Junction Breakdown and Conversion to Total Hip Arthroplasty After Hip Arthroscopy for Symptomatic Labral Tears: Minimum 8-Year Follow-up.

BACKGROUND: Arthroscopic treatment of femoroacetabular impingement (FAI) and symptomatic labral tears confers short- to midterm benefits, yet further long-term evidence is needed. Moreover, despite the physiological and biomechanical significance of the chondrolabral junction (CLJ), the clinical implications of damage to this transition zone remain understudied. PURPOSE: To (1) report minimum 8-year survivorship and patient-reported outcome measures after hip arthroscopy for FAI and (2) characterize associations between outcomes and patient characteristics (age, body mass index, sex), pathological parameters (Tönnis angle, alpha angle, type of FAI, CLJ breakdown), and procedures performed (labral management, FAI treatment, microfracture). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This retrospective cohort study included patients who underwent primary hip arthroscopy for symptomatic labral tears secondary to FAI by a single surgeon between 2002 and 2013. All patients were ≥18 years of age with minimum 8-year follow-up and available preoperative radiographs. The primary outcome was conversion to total hip arthroplasty (THA), and secondary outcomes included revision arthroscopy, patient-reported outcome measures, and patient satisfaction. CLJ breakdown was assessed using the Beck classification. Kaplan-Meier estimates and weighted Cox regression were used to estimate 10-year survivorship (no conversion to THA) and identify risk factors associated with THA conversion. RESULTS: In this study of 174 hips (50.6% female; mean age, 37.8 ± 11.2 years) with mean follow-up of 11.1 ± 2.5 years, the 10-year survivorship rate was 81.6% (95% CI, 75.9%-87.7%). Conversion to THA occurred at a mean 4.7 ± 3.8 years postoperatively. Unadjusted analyses revealed several variables significantly associated with THA conversion, including older age; higher body mass index; higher Tönnis grade; labral debridement; and advanced breakdown of the CLJ, labrum, or articular cartilage. Survivorship at 10 years was inferior in patients exhibiting severe (43.6%; 95% CI, 31.9%-59.7%) versus mild (97.9%; 95% CI, 95.1%-100%) breakdown of the CLJ (P < .001). Multivariable analysis identified worsening CLJ breakdown (weighted hazard ratio per 1-unit increase, 6.41; 95% CI, 3.11-13.24), older age (1.09; 95% CI, 1.04-1.14), and higher Tönnis grade (4.59; 95% CI, 2.13-9.90) as independent negative prognosticators (P < .001 for all). CONCLUSION: Although most patients achieved favorable minimum 8-year outcomes, several pre- and intraoperative factors were associated with THA conversion; of these, worse CLJ breakdown, higher Tönnis grade, and older age were the strongest predictors.

The Effect of Pelvic Incidence on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement and Acetabular Labral Tears.

BACKGROUND: In the setting of femoroacetabular impingement (FAI), decompression osteoplasties reconcile deleterious loading patterns caused by cam and pincer lesions. However, native variations of spinopelvic sagittal alignment may continue to perpetuate detrimental effects on the labrum, chondrolabral junction, and articular cartilage after hip arthroscopy. PURPOSE: To evaluate the effect of pelvic incidence (PI) on postoperative outcomes after hip arthroscopy for acetabular labral tears in the setting of FAI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective query of prospectively collected data identified patients ≥18 years of age who underwent primary hip arthroscopy for FAI and acetabular labral tears between February 2014 and January 2022, with 3-, 6-, 12-, and 24-month follow-ups. Measurements for PI, pelvic tilt (PT), sacral slope (SS), and acetabular version were obtained via advanced diagnostic imaging. Patients were stratified into low-PI (<45°), moderate-PI (45°≤ PI ≤ 60°), and high-PI (>60°) cohorts. Patient-reported outcome measures (PROMs), clinically meaningful outcomes (ie, minimal clinically important difference, Patient Acceptable Symptom State, substantial clinical benefit, and maximal outcome improvement), visual analog scale (VAS) pain scores, and patient satisfaction were compared across cohorts. RESULTS: A total of 74 patients met eligibility criteria and were stratified into low-PI (n = 28), moderate-PI (n = 31), and high-PI (n = 15) cohorts. Correspondingly, patients with high PI displayed significantly greater values for PT (P = .001), SS (P < .001), acetabular version (P < .001), and acetabular inclination (P = .049). By the 12- and 24-month follow-ups, the high-PI cohort was found to have significantly inferior PROMs, VAS pain scores, rates of clinically meaningful outcome achievement, and satisfaction relative to patients with moderate and/or low PI. No significant differences were found between cohorts regarding rates of revision arthroscopy, subsequent spine surgery, or conversion to total hip arthroplasty. CONCLUSION: After hip arthroscopy, patients with a high PI (>60°) exhibited inferior PROMs, rates of achieving clinically meaningful thresholds, and satisfaction at 12 and 24 months relative to patients with low or moderate PI. Conversely, the outcomes of patients with low PI (<45°) were found to match the trajectory of those with a neutral spinopelvic alignment (45°≤ PI ≤ 60°). These findings highlight the importance of analyzing spinopelvic parameters preoperatively to prognosticate outcomes before hip arthroscopy for acetabular labral tears and FAI.

Is ChatGPT a trusted source of information for total hip and knee arthroplasty patients?

Aims: While internet search engines have been the primary information source for patients' questions, artificial intelligence large language models like ChatGPT are trending towards becoming the new primary source. The purpose of this study was to determine if ChatGPT can answer patient questions about total hip (THA) and knee arthroplasty (TKA) with consistent accuracy, comprehensiveness, and easy readability. Methods: We posed the 20 most Google-searched questions about THA and TKA, plus ten additional postoperative questions, to ChatGPT. Each question was asked twice to evaluate for consistency in quality. Following each response, we responded with, "Please explain so it is easier to understand," to evaluate ChatGPT's ability to reduce response reading grade level, measured as Flesch-Kincaid Grade Level (FKGL). Five resident physicians rated the 120 responses on 1 to 5 accuracy and comprehensiveness scales. Additionally, they answered a "yes" or "no" question regarding acceptability. Mean scores were calculated for each question, and responses were deemed acceptable if ≥ four raters answered "yes." Results: The mean accuracy and comprehensiveness scores were 4.26 (95% confidence interval (CI) 4.19 to 4.33) and 3.79 (95% CI 3.69 to 3.89), respectively. Out of all the responses, 59.2% (71/120; 95% CI 50.0% to 67.7%) were acceptable. ChatGPT was consistent when asked the same question twice, giving no significant difference in accuracy (t = 0.821; p = 0.415), comprehensiveness (t = 1.387; p = 0.171), acceptability (χ2 = 1.832; p = 0.176), and FKGL (t = 0.264; p = 0.793). There was a significantly lower FKGL (t = 2.204; p = 0.029) for easier responses (11.14; 95% CI 10.57 to 11.71) than original responses (12.15; 95% CI 11.45 to 12.85). Conclusion: ChatGPT answered THA and TKA patient questions with accuracy comparable to previous reports of websites, with adequate comprehensiveness, but with limited acceptability as the sole information source. ChatGPT has potential for answering patient questions about THA and TKA, but needs improvement.

Factors affecting risk of recurrence with periprosthetic infection in shoulder arthroplasty.

BACKGROUND: The goal of treating periprosthetic infection, besides its eradication, is to avoid recurrence. The purpose of this study was to evaluate the impact of increasing Infection Severity (IS) score (based on the 2018 International Consensus Meeting on Orthopedic Infections statement), single-stage revision, and pathogenicity of the infective organism on the risk of infection recurrence. METHODS: A database of 790 revisions performed by a single surgeon from 2004-2020 was reviewed for patients with minimum 2-year follow-up and ≥1 positive culture finding and/or pathology result from the revision surgical procedure. In total, 157 cases performed in 144 patients met the inclusion criteria. These cases were then categorized by infection probability (IS score) according to the 2018 consensus statement. Of 157 cases, 46 (29%) were classified as definitely or probably infected; 25 (16%), possibly infected; and 86 (55%), unlikely to be infected. Additionally, patients were grouped by single-stage surgery and pathogenicity of the infective organism. RESULTS: A recurrence in this study was classified as the growth of the same organism in any patient requiring revision surgery. The 86 cases in the group with unlikely infection showed a recurrence rate of 2.3%. The 25 cases in the group with possible infection showed a recurrence rate of 12%. The 46 cases in the group with definite or probable infection showed a recurrence rate of 17.4%. Patients in the definite/probable infection group had a higher rate of recurrence than those in the groups with possible infection and unlikely infection (P = .009). The IS score was higher in the recurrence group than the non-recurrence group (7.5 ± 4.3 vs. 3.9 ± 3.4, P < .001). Overall, patients who underwent 1-stage revision had a 5.0% recurrence rate, but among the 34 patients with an infection classification of definite or probable who underwent 1-stage revision, the recurrence rate was 5.9%. Cases of highly virulent methicillin-resistant Staphylococcus aureus also showed a recurrence rate of 30.8% compared with 4.0% and 5.9% for Cutibacterium acnes and coagulase-negative staphylococci, respectively (P = .005). CONCLUSION: Recurrent infection after treatment of a periprosthetic infection is associated with increasing severity scores, as defined in the 2018 consensus statement, and more aggressive microorganisms. However, a single-stage surgical procedure, even in patients with higher IS scores, did not impart a significantly increased risk of recurrence.

Do preoperative scapular fractures affect long-term outcomes after reverse shoulder arthroplasty?

BACKGROUND: Postoperative scapular stress fractures (SSFs) are a formidable problem after reverse shoulder arthroplasty (RSA). Less is known about patients who have these fractures preoperatively. The primary aim of this study was to examine postoperative satisfaction in patients undergoing primary RSA who have preoperative SSF and compared to a matched cohort without preoperative fracture. The secondary aim was to examine the differences in patient-reported outcomes between and within study cohorts. METHODS: A retrospective chart review of primary RSAs performed by a single surgeon from 2000 to 2020 was conducted. Patients diagnosed with cuff tear arthropathy (CTA), massive cuff tear (MCT), or rheumatoid arthritis (RA) were included. Five hundred twenty-five shoulders met inclusion criteria. Fractures identified on preoperative computed tomography scans were divided into 3 groups: (1) os acromiale, (2) multifragments (MFs), and (3) Levy types. Seventy-two shoulders had an occurrence of SSF. The remaining 453 shoulders were separated into a nonfractured cohort. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and visual analog scale (VAS) scores were compared pre- and postoperatively in the total fracture group and the nonfractured group cohort. The multifragment subgroup was also compared to the pooled Os/Levy subgroup. RESULTS: The total incidence of SSF in all shoulders was 13.7%. There was a difference in satisfaction scores at all time points between the nonfracture (7.9 ± 2.8) and total fracture group (5.4 ± 3.6, P < .001, at last visit). There was also a greater ASES total score in the nonfractured group vs the total fracture group at the final visit (69.4 ± 23.4 and 62.1 ± 24.2; P = .02). The MF group had worse ASES functional or VAS functional scores than the Os/Levy group at all time points: at 1 year, ASES function: MF 24.2 ± 14.5 and Os/Levy 30.7 ± 14.2 (P = .045); at 2 years, ASES function: MF 21.4 ± 14.4 and Os/Levy 35.5 ± 10.6 (P < .001); and at last follow-up, VAS function: MF 4.8 ± 2.8 and Os/Levy 6.4 ± 3.2 (P = .023). DISCUSSION: Scapular fractures were proportionally most common in patients diagnosed with CTA (16.3%) compared with a 9.2% and 8.6% incidence in patients diagnosed with MCT and RA, respectively. Patients with preoperative SSF still see an improvement in ASES scores after RSA but do have lower satisfaction scores compared with the nonfractured cohort. The multifragment fracture group has lower functional and satisfaction scores at all postoperative time points compared with both the nonfracture and the Os/Levy fracture group.

Preoperative Paralabral Cysts Predict More Significant Chondral Damage but Not 2-Year Functional Outcomes Following Arthroscopic Labral Repair.

PURPOSE: To investigate whether paralabral cysts identified incidentally on preoperative magnetic resonance imaging (MRI/MRA) predict 2-year functional outcomes after arthroscopic acetabular labral repair. METHODS: Prospectively collected data for patients undergoing primary hip arthroscopy by a single surgeon from 2014 to 2020 were retrospectively reviewed. Included patients were ≥18 years and completed baseline patient-reported outcome measures (PROMs) with additional follow-up at 3, 6, 12, and 24 months. Exclusion criteria were labral debridement, hip dysplasia, advanced hip osteoarthritis (Tönnis >1), or previous ipsilateral hip surgery. Patients were stratified based on the presence of paralabral cysts identified on MRI/MRA. Primary outcomes were International Hip Outcome Tool (iHOT-33) and modified Harris Hip Score (mHHS). Secondary outcomes included other PROMs and the visual analog pain scale. Outcomes were compared between cohorts using linear mixed-effects models and Fisher's exact tests. Sensitivity analyses accounted for preoperative PROMs, nonlinear improvement trajectories, and relevant baseline characteristics. RESULTS: Of the 182 included hips (47.8% female; mean ± standard deviation age, 36.9 ± 11.4), 30 (16.4%) had paralabral cysts. During the 2-year study period, there were no significant differences between patients with and without paralabral cysts in terms of iHOT-33 scores (weighted difference = 1.60; 95% confidence interval [CI], -5.09, 8.28; P = .64), mHHS scores (weighted difference = 0.56; 95% CI, -4.16, 5.28; P = .82), or any secondary outcomes (except for HOS-Sports Subscale at 3 months [mean difference = -11.85; 95% CI, -22.85, -0.84; P = .035]). Furthermore, there were no significant differences in clinically meaningful outcomes (P > .05 for all), revision rates (P = 1.00), or conversion to total hip arthroplasty between cohorts (P = 1.00). These results held across all sensitivity analyses. CONCLUSIONS: Although preoperative paralabral cysts were associated with worse cam impingement and more severe chondral damage observed intraoperatively, they did not predict 2-year functional outcomes or clinically meaningful improvements, suggesting that incidentally discovered paralabral cysts are not a contraindication for arthroscopic labral repair. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Operative Fixation of a Humeral Shaft Periprosthetic Fracture After IlluminOss: A Case Report.

CASE: An 82-year-old man sustained a periprosthetic fracture after IlluminOss photodynamic bone stabilization system (PBSS) stabilization for an impending pathologic fracture. Nonoperative management was unsuccessful, and he subsequently underwent operative fixation, which featured lag screw fixation of the spiral distal humeral shaft fracture and osteotomy followed by plate fixation of the pathologic humeral shaft fracture. CONCLUSION: This is the first article to report this complication with IlluminOss PBSS stabilization and details regarding revision surgery.

Labral Reconstruction via Capsular Augmentation Maintains Perfusion to the Acetabular Labrum and Locally Transferred Autograft: An in Vivo Laser Doppler Flowmetry Analysis.

Background: The purpose of the present study was to examine the effects of arthroscopic labral repair with capsular augmentation on blood flow in vivo with use of laser Doppler flowmetry (LDF) to measure microvascular perfusion of the labrum and autograft tissue. Methods: The present prospective case series included patients ≥18 years old who underwent arthroscopic acetabular labral repair with capsular augmentation; all procedures were performed by a single surgeon between 2018 and 2022. The LDF probe measured microvascular blood flow flux within 1 mm3 of the surrounding labral and capsular tissue of interest. Mean baseline measurements of flux were compared with readings immediately following capsular elevation and after completing labral augmentation. Blood flux changes were expressed as the percent change from the baseline measurements. Results: The present study included 41 patients (24 men [58.5%] and 17 women [41.5%]) with a mean age (and standard deviation) of 31.3 ± 8.4 years, a mean BMI of 24.6 ± 3.4 kg/m2, a mean lateral center-edge of angle 35.3° ± 4.9°, a mean Tönnis angle of 5.8° ± 5.8°, and a mean arterial pressure of 93.7 ± 10.9 mm Hg. Following capsular elevation, the mean percent change in capsular blood flow flux was significantly different from baseline (-9.24% [95% confidence interval (CI), -18.1% to -0.04%]; p < 0.001). Following labral augmentation, the mean percent change in labral blood flow flux was significantly different from baseline both medially (-22.3% [95% CI, -32.7% to -11.9%]; p < 0.001) and laterally (-32.5% [95% CI, -41.5% to -23.6%]; p = 0.041). There was no significant difference between the changes in medial and lateral perfusion following repair (p = 0.136). Conclusions: Labral repair with capsular augmentation sustains a reduced blood flow to the native labrum and capsular tissue at the time of fixation. The biological importance of this reduction is unknown, but these findings may serve as a benchmark for other labral preservation techniques and support future correlations with clinical outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up.

BACKGROUND: The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion. PURPOSE: To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA). RESULTS: A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up. CONCLUSION: After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.

Using a Combined All-Inside, Inside-Out, and Outside-In Technique to Repair Bucket-Handle Medial Meniscal Tears Without a Safety Incision.

We describe a combined all-inside, inside-out, and outside-in technique for the repair of unstable bucket-handle medial meniscal tears. Notably, a greater incidence of neurovascular complications has been associated with meniscal repair techniques that employ an accessory skin incision, especially when damage involves the body of the medial meniscus. However, with the operative knee in relative extension, passing inside-out needles anteromedial to the posterior horn and posterior to the semitendinosus tendon and saphenous nerve allows for the needles to exit the posteromedial knee through a "safe zone." Therefore, we reduce iatrogenic damage by avoiding the necessity of a large safety incision while still maintaining suture placement versatility and meniscal fragment stabilization. Thus, the objective of this Technical Note is to outline an efficient technique for treating bucket-handle medial meniscal tears that yields a strong, durable repair while avoiding damage to adjacent neurovascular structures and eliminating the need for a posteromedial safety incision.

Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes.

Background: The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament. Purpose: To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique. Study Design: Case series; Level of evidence, 4. Methods: The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs. Results: A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively. Conclusion: Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.

Racial disparities in arthroscopic rotator cuff repair: an analysis of utilization and perioperative outcomes.

Background: There remains a paucity of literature addressing racial disparities in utilization and perioperative metrics in arthroscopic rotator cuff repair procedures. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to evaluate patients undergoing arthroscopic rotator cuff repair from 2010 to 2019. Baseline demographics, utilization trends, and perioperative measures, including adverse events, operative time, length of hospital stay, days from operation to discharge, and readmission, were analyzed. Results: Of 42,443 included patients, 38,090 (89.7%) were White, and 4353 (10.3%) were Black or African American. Black or African American patients had a significantly higher percentage of diabetes mellitus (23.6% vs. 15.6%), smoking (16.9% vs. 14.8%), congestive heart failure (0.3% vs. 0.1%), and hypertension (59.2% vs. 45.9%). In addition, logistic regression showed that Black or African American patients had increased odds of longer operative time (adjusted rate ratio 1.07, 95% confidence interval 1.05-1.08) and time from operation to discharge (adjusted rate ratio 1.19, 95% confidence interval 1.04-1.37). Disparities in relative utilization decreased as the proportion of Black or African American patients undergoing arthroscopic rotator cuff repair increased (7.4% in 2010 vs. 10.4% in 2019) compared with White patients (P trend < .0001). Conclusion: Racial disparities exist regarding baseline comorbidities and perioperative metrics in arthroscopic rotator cuff repair. Further investigation is needed to fully understand and address the causes of these inequalities to provide equitable care.

Evidence-Based Hamstring Injury Prevention and Risk Factor Management: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Hamstring injuries are common among athletes. Considering the potentially prolonged recovery and high rate of recurrence, effective methods of prevention and risk factor management are of great interest to athletes, trainers, coaches, and therapists, with substantial competitive and financial implications. PURPOSE: To systematically review the literature concerning evidence-based hamstring training and quantitatively assess the effectiveness of training programs in (1) reducing injury incidence and (2) managing injury risk factors. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 1. METHODS: A computerized search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus with manual screening of selected reference lists was performed in October 2020. Randomized controlled trials investigating methods of hamstring injury prevention and risk factor management in recreational, semiprofessional, and professional adult athletes were included. RESULTS: Of 2602 articles identified, 108 were included. Eccentric training reduced the incidence of hamstring injury by 56.8% to 70.0%. Concentric hamstring strength increased with eccentric (mean difference [MD], 14.29 N·m; 95% CI, 8.53-20.05 N·m), concentric, blood flow-restricted, whole-body vibration, heavy back squat, FIFA 11+ (Fédération Internationale de Football Association), and plyometric training methods, whereas eccentric strength benefited from eccentric (MD, 26.94 N·m; 95% CI, 15.59-38.30 N·m), concentric, and plyometric training. Static stretching produced greater flexibility gains (MD, 10.89°; 95% CI, 8.92°-12.86°) than proprioceptive neuromuscular facilitation (MD, 9.73°; 95% CI, 6.53°-12.93°) and dynamic stretching (MD, 6.25°; 95% CI, 2.84°-9.66°), although the effects of static techniques were more transient. Fascicle length increased with eccentric (MD, 0.90 cm; 95% CI, 0.53-1.27 cm) and sprint training and decreased with concentric training. Although the conventional hamstring/quadriceps (H/Q) ratio was unchanged (MD, 0.03; 95% CI, -0.01 to 0.06), the functional H/Q ratio significantly improved with eccentric training (MD, 0.10; 95% CI, 0.03-0.16). In addition, eccentric training reduced limb strength asymmetry, while H/Q ratio and flexibility imbalances were normalized via resistance training and static stretching. CONCLUSION: Several strategies exist to prevent hamstring injury and address known risk factors. Eccentric strengthening reduces injury incidence and improves hamstring strength, fascicle length, H/Q ratio, and limb asymmetry, while stretching-based interventions can be implemented to improve flexibility. These results provide valuable insights to athletes, trainers, coaches, and therapists seeking to optimize hamstring training and prevent injury.

Harvest and Application of Bone Marrow Aspirate Concentrate to Address Acetabular Chondral Damage During Hip Arthroscopy.

Background: During hip arthroscopy, managing concomitant cartilage damage and chondrolabral junction breakdown remains an ongoing challenge for orthopaedic surgeons, as previous studies have associated such lesions with inferior postoperative outcomes1-7. Although higher-level studies are needed to fully elucidate the benefits, recent literature has provided supporting preliminary evidence for the utilization of bone marrow aspirate concentrate (BMAC) in patients with moderate cartilage damage and full-thickness chondral flaps undergoing acetabular labral repair7,8. Thus, as the incorporation of orthobiologics continues to advance, there is a clinical demand for an efficient and reliable BMAC-harvesting technique that utilizes an anatomical location with a substantial concentration of connective tissue progenitor (CTP) cells, while avoiding donor-site morbidity and minimizing additional operative time. Thus, we present a safe and technically feasible approach for harvesting bone marrow aspirate from the body of the ilium, followed by centrifugation and application during hip arthroscopy. Description: After induction of anesthesia and appropriate patient positioning, a quadrilateral arrangement of arthroscopic portals is established to perform puncture capsulotomy9. Upon arthroscopic visualization of cartilage/chondrolabral junction injury, 52 mL of whole venous blood is promptly obtained from an intravenous access site and combined with 8 mL of anticoagulant citrate dextrose solution A (ACD-A). The mixture is centrifuged to yield approximately 2 to 3 mL of platelet-rich plasma (PRP) and 17 to 18 mL of platelet-poor plasma (PPP). Then, approaching along the coronal plane and aiming toward the anterior-superior iliac spine under fluoroscopic guidance, a heparin-rinsed Jamshidi bone marrow biopsy needle is driven through the lateral cortex of the ilium just proximal to the sourcil. Under a relative negative-pressure vacuum, bone marrow is aspirated into 3 separate heparin-rinsed 50 mL syringes, each containing 5 mL of ACD-A. Slow and steady negative pressure should be used to pull back on the syringe plunger to aspirate a total volume of 40 mL into each syringe. To avoid pelvic cavity compromise and minimize the risk of mobilizing marrow-space contents, care should be taken to ensure that no forward force or positive pressure is applied during the aspiration process. A total combined bone marrow aspirate/ACD-A mixture of approximately 120 mL is consistently harvested and subsequently centrifuged to yield roughly 4 to 6 mL of BMAC. The final mixture containing BMAC, PRP, and PPP is combined with thrombin to generate a megaclot, which is then applied to the central compartment of the hip. Alternatives: Currently, strategies to address acetabular cartilage lesions may include microfracture, autologous chondrocyte implantation, matrix-induced autologous chondrocyte implantation, autologous matrix-induced chondrogenesis, osteochondral allografts, and orthobiologics10. Orthobiologics have shown mixed yet promising results for addressing musculoskeletal injuries and may include bone-marrow-derived mesenchymal stromal cells, adipose tissue derivatives, and PRP7,8,11,12. Specifically, bone marrow aspirate can be harvested from numerous locations, such as the iliac crest, the proximal aspect of the humerus, the vertebral body, and the distal aspect of the femur. Moreover, alternative approaches have utilized multiple-site and/or needle-redirection techniques to optimize cellular yield16,17, while also appreciating the potentially variable cellular characteristics of aspirated and/or processed samples18. However, previous literature has demonstrated that the body of the ilium contains a CTP cell concentration that is similar to or greater than other harvest locations when utilizing this outlined single-site and unidirectional aspirating technique13,14. Rationale: This versatile and updated technique is a safe and reproducible method for BMAC harvesting, processing, and application that avoids donor-site morbidity, obtains a substantial concentration of CTP cells, minimizes additional operative time, and limits the hip arthroscopy and aspiration to a single procedure15. Specifically, this technique details an evidence-supported approach to addressing chondral injury in patients undergoing acetabular labral repairs7,8. Expected Outcomes: Patients with moderate cartilage damage treated with BMAC at the time of labral repair experienced significantly greater improvements in functional outcomes at 12 and 24 months postoperatively compared with similar patients without BMAC augmentation7. Furthermore, patients with full-thickness chondral flaps treated with BMAC at the time of arthroscopic labral repair demonstrated significantly greater improvements in functional outcomes at 12 months compared with microfracture. Moreover, 77.6% of the BMAC cohort reached the minimal clinically important difference threshold for the International Hip Outcome Tool-33 (iHOT-33) compared with 50.0% in the microfracture group8. Important Tips: Utilize the previously established Dienst arthroscopic portal for the bone marrow aspiration in order to avoid secondary donor site morbidity.Under fluoroscopic guidance, approach the ilium along the coronal plane, aiming toward the anterior superior iliac spine.With a heparin-rinsed Jamshidi bone marrow biopsy needle, penetrate the lateral cortex of the ilium just proximal to the sourcil in order to consistently harvest a total combined bone marrow aspirate/ACD-A volume of approximately 120 mL.Simultaneously perform the bone marrow aspirate and whole venous blood centrifugation during the hip arthroscopy procedure in order to minimize additional operative time.Bone marrow aspiration should be performed without applied traction in order to minimize the risk of neurovascular complications associated with extended traction time. Acronyms and Abbreviations: ACD-A = anticoagulant citrate dextrose solution AADSCs = adipose-derived stem cellsASIS = anterior superior iliac spineBMAC = bone marrow aspirate concentrateCI = confidence intervalCTP = connective tissue progenitorDVT = deep vein thrombosisHOS-ADL = Hip Outcome Score, Activities of Daily LivingiHOT-33 = International Hip Outcome Tool-33MCID = minimal clinically important differenceMRA = magnetic resonance arthrogramMSCs = mesenchymal stromal cellsPPP = platelet-poor plasmaPRP = platelet-rich plasmaRBCs = red blood cellsSD = standard deviationT1 = longitudinal relaxation timeT2 = transverse relaxation timeWBCs = white blood cells.

Return to Full Function in Patient with Nonoperative Management of a Comminuted, Displaced Clavicle Fracture: A Case Report.

Case: Clavicle fractures are common skeletal injuries that account for 2%-10% of adult fractures. Surgical indications include presence of an open fracture, severe angulation, comminution, displacement, skin tenting with a threat of skin perforation, neurovascular compromise, symptomatic nonunion, or fracture shortening >1.5-2cm. In this case, the patient had a comminuted, displaced fracture - thus meeting criteria for operative treatment. However, the patient opted for nonoperative management. Conclusion: After 3 months, the patient regained full strength and range-of-motion. This case highlights the current heterogenous mixture of studies in the literature surrounding the best management for midshaft clavicle fractures. The patient was informed that data concerning the case would be submitted for publication and provided consent.

Sex differences in utilization and perioperative outcomes of arthroscopic rotator cuff repair.

Background: As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes. Methods: Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex. Results: Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable. Conclusion: Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

Adhesive Capsulitis of the Hip: A Case Presentation and Review.

There remains a paucity of literature addressing adhesive capsulitis of the hip (ACH), making the diagnosis and treatment a continued challenge for healthcare providers. ACH encompasses restricted hip range-of-motion and pain that progresses through analogous Stages (1-4) to adhesive capsulitis of the shoulder. We report a case presentation of a middle-aged man that illustrates the significance of certain patient factors and provide a review of current literature to aid in the diagnostic evaluation and treatment for addressing ACH. Initial conservative treatment of ACH includes the appropriate management of associated comorbidities, oral and/or injectable pharmacologics, and physical therapy. While frequently resolving with time, refractory cases of ACH may require more aggressive approaches including pressure dilation, manipulation under anesthesia, synovectomy, capsular release and, for select patients, total hip arthroplasty. Given the limited available literature addressing ACH, healthcare providers may be forced to rely on a small number of published case reports and outdated review articles to guide their diagnostic evaluation and treatment approaches. Thus, this case presentation and review provides an updated approach to better diagnose and manage patients with ACH.