KRAGEN: a knowledge graph-enhanced RAG framework for biomedical problem solving using large language models.

MOTIVATION: Answering and solving complex problems using a large language model (LLM) given a certain domain such as biomedicine is a challenging task that requires both factual consistency and logic, and LLMs often suffer from some major limitations, such as hallucinating false or irrelevant information, or being influenced by noisy data. These issues can compromise the trustworthiness, accuracy, and compliance of LLM-generated text and insights. RESULTS: Knowledge Retrieval Augmented Generation ENgine (KRAGEN) is a new tool that combines knowledge graphs, Retrieval Augmented Generation (RAG), and advanced prompting techniques to solve complex problems with natural language. KRAGEN converts knowledge graphs into a vector database and uses RAG to retrieve relevant facts from it. KRAGEN uses advanced prompting techniques: namely graph-of-thoughts (GoT), to dynamically break down a complex problem into smaller subproblems, and proceeds to solve each subproblem by using the relevant knowledge through the RAG framework, which limits the hallucinations, and finally, consolidates the subproblems and provides a solution. KRAGEN's graph visualization allows the user to interact with and evaluate the quality of the solution's GoT structure and logic. AVAILABILITY AND IMPLEMENTATION: KRAGEN is deployed by running its custom Docker containers. KRAGEN is available as open-source from GitHub at: https://github.com/EpistasisLab/KRAGEN.

Aliro: an automated machine learning tool leveraging large language models.

MOTIVATION: Biomedical and healthcare domains generate vast amounts of complex data that can be challenging to analyze using machine learning tools, especially for researchers without computer science training. RESULTS: Aliro is an open-source software package designed to automate machine learning analysis through a clean web interface. By infusing the power of large language models, the user can interact with their data by seamlessly retrieving and executing code pulled from the large language model, accelerating automated discovery of new insights from data. Aliro includes a pre-trained machine learning recommendation system that can assist the user to automate the selection of machine learning algorithms and its hyperparameters and provides visualization of the evaluated model and data. AVAILABILITY AND IMPLEMENTATION: Aliro is deployed by running its custom Docker containers. Aliro is available as open-source from GitHub at: https://github.com/EpistasisLab/Aliro.

Editorial Commentary: Postless Hip Arthroscopy May Help Optimize Outcomes, but Use of a Post Is Acceptable and Is Indicated in Select Cases.

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

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

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

Medicaid Insurance Is Associated With More Complications and Emergency Department Visits but Equivalent 5-Year Secondary Surgery Rate After Primary Hip Arthroscopy.

PURPOSE: To compare 90-day complications, 30-day emergency department (ED) visits, and 5-year rate of secondary surgeries for patients with Medicaid vs commercial insurance undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and/or labral tears using a large national database. METHODS: The PearlDiver Mariner151 database was used to identify patients with International Classification of Diseases, Tenth Revision diagnosis codes for FAIS and/or labral tear who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021. Patients with Medicaid were matched 1:4 to a control group of commercially insured patients based on age, sex, body mass index, and Elixhauser Comorbidity Index. Rates of 90-day complications and 30-day ED visits were compared using multivariate regression models. Five-year rates of secondary surgeries-revision arthroscopy or total hip arthroplasty-were compared between cohorts by Kaplan-Meier analysis. RESULTS: A total of 2,033 Medicaid patients were matched with 8,056 commercially insured patients. Rates of adverse events were low; however, Medicaid patients were significantly more likely than commercially insured patients to experience any 90-day complication (2.12% vs 1.43%; odds ratio [OR], 1.2; P = .02). Medicaid patients also experienced more 30-day ED visits than commercially insured patients (8.61% vs 4.28%), and on multivariate logistic regression, insurance status was the strongest determinant of 30-day ED visits (relative to commercial, Medicaid OR, 2.02; P < .001). Despite these differences, 5-year rates of secondary surgeries were comparable between groups (6.1% vs 6.0%; P = .6). CONCLUSIONS: In this large national database study, Medicaid patients undergoing primary hip arthroscopy showed significantly greater odds of experiencing 90-day postoperative complications and 30-day ED visits compared to commercially insured patients. Nevertheless, both groups had similar survivorship rates at 5-year follow-up, similar to prior estimates irrespective of insurance. These results document encouraging secondary surgery rates in Medicaid patients.

Female Patients Undergoing Latarjet Surgery Show Similar 2-Year Secondary Surgery Rates but Greater Risk of Emergency Department Visits Compared With a Matched Cohort of Male Patients.

PURPOSE: To evaluate sex-based differences in 30-day postoperative emergency department (ED) visits, 90-day complication rates, and 2-year secondary surgery rates after the Latarjet procedure for the treatment of recurrent shoulder instability. METHODS: A national administrative claims database was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for shoulder subluxation or dislocation on the day of first-time stabilization with the Latarjet technique between 2015 and 2021. Male patients were matched 4:1 to female patients based on age, Elixhauser Comorbidity Index (ECI) score, and body mass index class. Rates of 30-day ED visits and 90-day complications were compared between cohorts, and risk factors for ED visits were identified by multivariate regression. The incidence of secondary surgery within 2 years was compared by Kaplan-Meier analysis. RESULTS: Prior to matching, 1,059 male and 360 female patients met the inclusion and exclusion criteria. Subsequent 4:1 (male-to-female) matching controlling for age, ECI score, and body mass index yielded 694 male and 185 female patients who underwent the Latarjet procedure. The overall incidence of 30-day ED visits was 9.3%, with an incidence of 8.2% for male patients and 13.5% for female patients. On the basis of multivariate logistic regression, these 30-day ED visits were associated with female sex (odds ratio, 1.79; P = .029) and incrementally higher ECI scores; relative to an ECI score of 0, ECI scores of 1 to 2, 3 to 4, and 5 or greater were associated with odds ratios of 5.31 (P = .006), 8.12 (P < .001), and 12.84 (P < .001), respectively. Ninety-day complications occurred in 1.5% of the total cohort, and the incidence was not statistically different between sexes. Overall, 2-year secondary surgery rates were similar between male and female patients (5.1% and 6.7%, respectively; P = .4). CONCLUSIONS: Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. Female sex, along with ECI score, however, was associated with a greater rate of 30-day ED visits. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Changes in Body Composition and Athletic Performance in National Collegiate Athletic Association Division I Female Field Hockey Athletes Throughout a Competitive Season.

ABSTRACT: Summer, LC, Cheng, R, Moran, JT, Lee, M, Belanger, AJ, TaylorIV, WL, and Gardner, EC. Changes in body composition and athletic performance in National Collegiate Athletic Association Division I female field hockey athletes throughout a competitive season. J Strength Cond Res 38(1): 146-152, 2024-The purposes of this study were (a) to analyze the changes in total and regional body composition measurements in a National Collegiate Athletic Association (NCAA) Division I female field hockey team throughout a 17-game competitive season using dual X-ray absorptiometry (DXA); (b) to examine improvements, if any, in athletic performance measures after a season; and (c) to report on the relationship between these body composition changes and changes in athletic performance. Preseason and postseason dual-energy DXA and performance data from the 2019-2020 season were retrospectively identified for 20 field players (forwards, midfielders, and defenders). Body composition data included total and regional fat mass, lean mass, and body fat percentage, whereas athletic performance measures included the vertical jump, 10-yard dash, and pro-agility (5-10-5) shuttle run. All variables were quantitative and analyzed using paired t -tests or its nonparametric equivalent and an alpha level of p < 0.05 was used to determine significance. After a competitive season, athletes had significant decreases in fat mass and increases in lean mass in their arms, legs, trunks, gynoids, and total body measurements. Android fat mass and body fat percentage also decreased. Athletes performed significantly better on the pro-agility shuttle run at the end of the season, but no significant differences were observed in other performance metrics. Moderate correlations were observed between changes in body composition (total fat mass and total lean mass) and changes in athletic performance. Our study provides a novel, longitudinal assessment of body composition and athletic performance for elite female field hockey athletes that will help trainers and coaches better understand how these variables change throughout a season and allow them to better prepare their players for competitive success.

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

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

Update of pediatric bone tumors: osteogenic tumors and osteoclastic giant cell-rich tumors.

There are numerous bone tumors in the pediatric population, with imaging playing an essential role in diagnosis and management. Our understanding of certain bone tumors has rapidly evolved over the past decade with advancements in next-generation genetic sequencing techniques. This increased level of understanding has altered the nomenclature, management approach, and prognosis of certain lesions. We provide a detailed update of bone tumors that occur in the pediatric population with emphasis on the recently released nomenclature provided in the 5th edition of the World Health Organization Classification of Soft Tissue and Bone Tumours.

Update of pediatric bone tumors-notochordal tumors, chondrogenic tumors, and vascular tumors of the bone.

There are numerous bone tumors in the pediatric population, with imaging playing an essential role in diagnosis and management. Our understanding of certain bone tumors has rapidly evolved over the past decade with advancements in next-generation genetic sequencing techniques. This increased level of understanding has altered the nomenclature, management approach, and prognosis of certain lesions. We provide a detailed update of bone tumors that occur in the pediatric population with emphasis on the recently released nomenclature provided in the 5th edition of the World Health Organization Classification of Soft Tissue and Bone Tumours. In the current manuscript, we address notochordal tumors, chondrogenic tumors, and vascular tumors of the bone.

Mid- and Long-Term Outcomes Are Favorable for Patients With Borderline Dysplasia Undergoing Primary Hip Arthroscopy: A Systematic Review.

PURPOSE: To evaluate midterm outcomes, long-term outcomes, and survivorship in the borderline dysplastic population after primary hip arthroscopy. METHODS: A systematic review of current literature was performed with the following key words: "hip, "arthroscopy," "borderline dysplasia," "borderline hip dysplasia," "developmental dysplasia," "ten-year," "survivorship," "10-year," "5-year," "five year," "mid-term," "long-term," "outcomes," "arthroscopic," and "femoroacetabular impingement" in PubMed, Cochrane, and Scopus in March 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The following information was recorded: title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcomes (PROs), characteristics of patients converting to total hip arthroplasty (THA), and rates of secondary surgeries and conversion to THA were recorded. Survivorship was defined as not converting to THA. Kappa values for the title/abstract and full-text screening were calculated. Forest plots were created for PROs that were included in 3 or more studies. RESULTS: Six articles comprising 413 hips were included in the study. Three studies were Level III evidence, and 3 studies were Level IV evidence. Average follow-up ranged from 5.7 to 12.2 years. One study defined borderline hip dysplasia as lateral center-edge angle 18-25° and 5 defined it as lateral center-edge angle 20-25°. All studies included PROs and reported significant improvement after surgery in at least one PRO. Three studies reported clinical benefit and across the studies at least 70% of patients achieved minimum clinically important difference in at least one PRO. Rates of undergoing revision hip arthroscopy and THA ranged from 2.1% to 7% and 0% to 24%, respectively. Tönnis grade 2, Tönnis angle >15, and Outerbridge Grade IV cartilage damage were identified as predictors of conversion to THA. CONCLUSIONS: Patients with borderline hip dysplasia undergoing primary hip arthroscopy demonstrated significant improvement in PROs at midterm and long-term follow-up. Survivorship at midterm follow-up was 98.2% (328/334 hips) and 76.3% (29/38 hips) at long-term follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

Over One-Third of Patients With Multiligament Knee Injuries and an Intact Anterior Cruciate Ligament Demonstrate Medial Meniscal Ramp Lesions on Magnetic Resonance Imaging.

PURPOSE: To determine the incidence of ramp lesions and posteromedial tibial plateau (PMTP) bone bruising on magnetic resonance imaging (MRI) in patients with multiligament knee injuries (MLKIs) and an intact anterior cruciate ligament (ACL). METHODS: A retrospective review of consecutive patients surgically treated for MLKIs at 2 level I trauma centers between January 2001 and March 2021 was performed. Only MLKIs with an intact ACL that received MRI scans within 90 days of the injury were included. All MLKIs were diagnosed on MRI and confirmed with operative reports. Two musculoskeletal radiologists retrospectively rereviewed preoperative MRIs for evidence of medial meniscus ramp lesions (MMRLs) and PMTP bone bruises using previously established classification systems. Intraclass correlation coefficients were used to calculate the reliability between the radiologists. The incidence of MMRLs and PMTP bone bruises was quantified using descriptive statistics. RESULTS: A total of 221 MLKIs were identified, of which 32 (14.5%) had an intact ACL (87.5% male; mean age of 29.9 ± 8.6 years) and were included. The most common MLKI pattern was combined injury to the posterior cruciate ligament and posterolateral corner (n = 27, 84.4%). PMTP bone bruises were observed in 12 of 32 (37.5%) patients. Similarly, MMRLs were diagnosed in 12 of 32 (37.5%) patients. A total of 8 of 12 (66.7%) patients with MMRLs demonstrated evidence PMTP bone bruising. CONCLUSIONS: Over one-third of MLKI patients with an intact ACL were diagnosed with MMRLs on MRI in this series. PMTP bone bruising was observed in 66.7% of patients with MMRLs, suggesting that increased vigilance for identifying MMRLs at the time of ligament reconstruction should be practiced in patients with this bone bruising pattern. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Athletes Report Favorable Outcomes at 5-Year Minimum Follow-Up After Primary Hip Arthroscopy: A Systematic Review.

PURPOSE: To evaluate minimum 5-year outcomes and survivorship after primary hip arthroscopy in athletes. METHODS: A systematic review of current literature was performed with the following key words: "hip arthroscopy," "long-term," "outcomes," "ten-year," "survivorship," "10-year," "5-year," "five-year," "midterm," "athlete," "sport," and "femoroacetabular impingement" in PubMed, Cochrane Trials, and Scopus in April 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Study and demographic variables such as title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcome scores, and rates of secondary surgeries and conversion to total hip arthroplasty. Radiographic, intraoperative surgical treatment, and clinical benefit was documented as well. RESULTS: Ten studies that captured data on 691 hips were included in this study. Eight studies reported mean and standard deviation for the modified Harris Hip Score. Significant improvements were reported in all studies with postoperative scores ranging from 83.3 to 94.4 (standardized mean difference [SMD] 1.65; 95% confidence interval [CI] 1.39-1.91, P < .00001). Eight studies reported significant improvement in Hip Outcome Score - Sports Specific Scale with postoperative scores ranging from 59.2 to 94.6 (SMD 1.66; 95% CI 1.33-1.98, P < .00001). Seven studies reported significant improvement in Nonarthritic Hip Score with postoperative scores ranging from 79.6 to 95.3 (SMD 1.41; 95% CI 1.16-1.65, P < .00001). Seven studies also reported significant improvement in VAS with postoperative scores ranging from 0.7 to 3.1 (SMD -1.57; 95% CI -1.88, -1.26, P < .00001). Nine of 10 studies reported achieving at least 1 psychometric threshold at a rate of least 75%. Rates of secondary arthroscopy and conversion to total hip arthroplasty varied from 0% to 15.2% and 0% to 33.3%. CONCLUSIONS: Athletes who underwent primary hip arthroscopy demonstrated favorable outcomes and high rates of clinical benefit at 5-year follow-up. In addition, they demonstrated high rates of survivorship and achieving psychometric thresholds. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

No Difference in Complication or Reoperation Rates Between Arthroscopic and Open Debridement for Lateral Epicondylitis: A National Database Study.

PURPOSE: To compare complication rates and 5-year reoperation rates between open debridement (OD) and arthroscopic debridement (AD) for lateral epicondylitis. METHODS: The PearlDiver MUExtr database (2010-2019) was reviewed for patients diagnosed with lateral epicondylitis (queried by International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision [ICD-10] codes) undergoing OD or AD of the common extensor tendon without repair (queried by Current Procedural Terminology codes). Patients were stratified into 2 cohorts: those who underwent AD and those who underwent OD. Nonoperative treatment modalities were reported for both groups within 1 year before index procedure. The rates of 90-day postoperative complications were compared, and multivariate logistic regression analysis was used to identify risk factors for complications. The 5-year reoperation rates, using laterality-specific ICD-10 codes, were also compared between the 2 groups. RESULTS: In total, 19,280 patients (OD = 17,139, AD = 2,141) were analyzed in this study. The most common nonoperative treatments for patients who underwent OD or AD were corticosteroid injections (49.5% vs 43.2%), physical therapy (24.8% vs 25.7%), bracing (2.8% vs 3.2%), and platelet-rich plasma injections (1.3% vs 1.0%). There were no significant differences in radial nerve injuries, hematomas, surgical site infections, wound dehiscence, and sepsis events between the 2 procedures (P = .50). The 5-year reoperation rate was not significantly different between the AD (5.0%) and OD (3.9%) cohorts (P = .10). CONCLUSIONS: For lateral epicondylitis, both AD and OD of the extensor carpi radialis brevis (without repair) were found to have low rates of 90-day adverse events, with no significant differences between the 2 approaches. Similarly, the 5-year reoperation rate was low and not statistically different for those treated with OD or AD. LEVEL OF EVIDENCE: Level III, cross-sectional study.

Patients Undergoing Primary Hip Arthroscopy Report Favorable Outcomes at Minimum 10 Year Follow-Up: A Systematic Review.

PURPOSE: (1) To evaluate minimum 10-year PROs (patient-reported outcomes) and survivorship after primary hip arthroscopy and (2) to identify predictors of failure for secondary arthroscopy and conversion to total hip arthroplasty (THA). METHODS: A systematic review of the literature was conducted with the following key words: "hip arthroscopy," "long-term," "outcomes," "ten-year," "survivorship," "10-year," "15-year," "fifteen-year," 20-year," "twenty-year," and "femoroacetabular impingement" in PubMed and Embase in March 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Level I to Level IV evidence was included and reported on minimum 10-year outcomes or greater after primary hip arthroscopy. Long-term studies were defined as minimum 10-year follow-up in accordance with established standards in the literature. Case reports, review articles, technique articles, and opinion articles were excluded. Articles not in English were excluded. Title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, PROs, predictors of failure for THA, and rates of secondary surgeries were recorded. Survivorship was defined as a nonconversion to THA. P < .05 was defined as statistical significance. RESULTS: Twelve studies met the inclusion criteria. In total, 4 studies were Level III, and 8 studies were Level IV. A total of 1,344 hips were included, and follow-up ranged from 10 to 20 years. Femoroacetabular impingement syndrome was the most common indication for hip arthroscopy. Ten of the 12 studies reported on PROs, and 8 studies reported significant improvement after hip arthroscopy at long-term follow-up. The remaining 2 studies reported favorable outcomes that satisfied clinical benefit thresholds at minimum 10-year follow-up. Five studies reported clinical benefit where each patient cohort achieved 80% minimal clinically important difference and 75% patient acceptable symptomatic state for at least one PRO. Rates of secondary arthroscopy ranged from 4.5% to 24%, and rates of conversion to THA varied from 0% to 44.1%. Older age and chondral damage were the most commonly cited predictors for conversion to THA. CONCLUSIONS: At long-term follow-up, patients who underwent primary hip arthroscopy demonstrated favorable outcomes and variable rates of secondary surgeries. Patients undergoing hip arthroscopy within the last 20 years with Tönnis grade <1 and labral repair experienced greater than 90% survivorship. Chondral damage and older age were the most cited predictors for conversion to THA. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

Over 50% of Studies Report Low-Back Pain Is Associated With Worse Outcomes After Hip Arthroscopy When Compared With a Control Group: A Systematic Review.

PURPOSE: To review outcomes of patients with low-back pathology undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement (FAI) syndrome. METHODS: The PubMed, Cochrane Trials, and Scopus databases were queried in June 2022 to conduct this systematic review using the following terms: ("hip" OR "femoroacetabular impingement") AND ("arthroscopy" OR "arthroscopic") AND ("spine" OR "lumbar" OR "sacral" OR "hip-spine" OR "back") AND ("outcomes"). Articles were included if they reported on patient-reported outcomes (PROs) and/or clinical benefit of patients undergoing hip arthroscopy with concomitant low-back pathology. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Case reports, opinion articles, review articles, and technique articles were excluded from this study. Forest plots were created to analyze preoperative and postoperative outcomes among patients with low-back pathology. RESULTS: Fourteen studies were included in the review. There were 750 hips with low-back pathology and FAI (hip-spine syndrome) and 1,800 hips with only FAI (no hip-spine syndrome). All 14 studies reported PROs. In 4 studies in the group with hip-spine syndrome and 8 studies in the group with FAI without low-back pathology, the respective cohorts were reported to achieve the minimal clinically important difference in at least 1 PRO at a rate of 80%. Eight studies reported that patients with low-back pathology were associated with inferior outcomes or clinical benefit compared with patients without low-back pathology. CONCLUSIONS: Patients undergoing primary hip arthroscopy with concomitant low-back pathology can expect favorable outcomes, but outcomes are superior in patients undergoing hip arthroscopy for FAI alone compared with FAI with concomitant low-back pathology. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to Level IV studies.

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

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

Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials.

PURPOSE: To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR). METHODS: PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups. RESULTS: Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.). CONCLUSION: ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events. LEVEL OF EVIDENCE: Level I.

Poorer functional Outcomes in Patients with Multi-Ligamentous Knee Injury with Concomitant Patellar Tendon Ruptures at 5 years Follow-Up.

PURPOSE: Multi-ligamentous knee injuries (MLKIs) are high-energy injuries that may infrequently present with concomitant patellar tendon rupture. There is limited information in the literature regarding these rare presentations, with even less information regarding clinical outcomes. Using propensity-score matching, the purpose of this study was to compare the outcomes of MLKIs with and without patellar tendon ruptures and to investigate the overall predictors of these outcomes. METHODS: Twelve patients who underwent surgical repair for combined MLKI and patellar tendon rupture from 2011 to 2020 with minimum 1-year follow-up data were identified from two separate institutions. Patients were propensity-score matched with a 1:1 ratio with controls based on age, body mass index (BMI), gender, and time from surgery. Patient-reported outcomes included International Knee Documentation Committee (IKDC) Subjective Knee Form, Lysholm and Tegner scores. RESULTS: Twelve MLKIs with concomitant patellar tendon injuries were identified out of a multicenter cohort of 237 (5%) patients sustaining MLKI and were case matched 1:1 with 12 MLKIs without extensor mechanism injuries. The average follow-up was 5.5 ± 2.6 years. There were no differences in Schenck Classification injury patterns. There were significant differences found across IKDC (Patellar Tendon mean: 53.1 ± 24.3, MLKI mean 79.3 ± 19.6, P < 0.001) and Lysholm scores (Patellar Tendon mean: 63.6 ± 22.3, MLKI mean 86.3 ± 10.7, P < 0.001) between the two, illustrating poorer outcomes for patients with concomitant patellar tendon ruptures. CONCLUSION: In the setting of MLKI, patients who have a concomitant patellar tendon rupture have worse functional outcomes compared to those without. This information will be important for patient counseling and might be considered to be added to Schenck classification, reflecting its prognostic value. LEVEL OF EVIDENCE: Level IV.

Factors associated with humeral stem revision in anatomic to reverse total shoulder arthroplasty revision.

BACKGROUND: Recent advances in implant technology have allowed for modular or platform humeral stem insertion during initial anatomic total shoulder arthroplasty (TSA). These systems allow for humeral stem retention during conversion to reverse TSA (RTSA). However, some patients still require humeral stem revision when undergoing revision to RTSA. The purpose of this study was to evaluate the association between patient-specific factors and radiographic parameters with humeral stem revision vs. retention during conversion from TSA to RTSA. METHODS: Retrospective chart review was conducted for patients who underwent a revision TSA to RTSA between January 2010 and May 2022 at a single institution. Patients were included if their prosthesis included a convertible humeral stem. Patient demographic information, surgical details, and postoperative outcomes and complications were collected. Radiographic parameters were measured by 2 graders on radiographs taken prior to the revision procedure. The need for humeral stem revision and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores (preoperative and 2 years) were also noted. Statistical analysis was performed using chi-square test for categorical variables and t test for continuous variables. RESULTS: One hundred seven patients were included, with 52 undergoing humeral stem revision. Patients were revised an average of 51.0 ± 54 months after primary TSA. Younger patient age (63.6 vs. 68.5 years, P = .017) and use of a lateralized glenosphere (1.6 mm vs. 0.4 mm, P < .001) were significantly associated with need for humeral stem revision. Glenoid to humeral head cut distance (28.3 mm vs. 26.3 mm, P = .076) approached significant association with the need for humeral stem revision. All other measurements were not associated with the need for humeral stem revision. Improvement of ASES scores at 2 years' follow-up was higher in the nonrevised group (increase of 33.4 points) than the revision group (23.3), but this did not reach significance (P = .149). Estimated blood loss and surgical time were significantly higher in the stem revision group than the non-revised group (P = .048 and P < .001, respectively). CONCLUSION: Younger patients and those receiving a lateralized glenosphere were more likely to undergo humeral stem revision during conversion from TSA to RTSA. Glenoid to the humeral head cut distance should be studied further as a potential indication for humeral stem revision, as it correlates with the space available for a revision implant. This information can guide surgeons with preoperative planning for a revision arthroplasty.