Role of 904 nm superpulsed laser-mediated photobiomodulation on nitroxidative stress and redox homeostasis in burn wound healing.

BACKGROUND: Burn wound healing is delayed due to several critical factors such as sustained inflammation, vascular disorder, neuropathy, enhanced proteolysis, infection, and oxidative stress. Burn wounds have limited oxygen supply owing to compromised blood circulation. Hypoxic burn milieu leads to free radicals overproduction incurring oxidative injury, which impedes repair process causing damage to cell membranes, proteins, lipids, and DNA. Photobiomodulation (PBM) with 904 nm superpulsed laser had shown potent healing efficacy via attenuating inflammation while enhancing proliferation, angiogenesis, collagen accumulation, and bioenergetic activation in burn wounds. METHODS: This study investigated the effects of 904 nm superpulsed laser at 0.4 mW/cm2 average power density, 0.2 J/cm2 total energy density, 100 Hz frequency, and 200 ns pulse width for 10 min daily for seven days postburn injury on nitroxidative stress, endogenous antioxidants status, and redox homeostasis. RESULTS: Photobiomodulation treatment significantly decreased reactive oxygen species, nitric oxide, and lipid peroxidation levels as compared to non-irradiated control. Further, protective action of PBM against protein oxidative damage was evidenced by reduced protein carbonylation and advanced oxidation protein product levels along with significantly enhanced endogenous antioxidants levels of SOD, catalase, GPx, GST, reduced glutathione, and thiol (T-SH, Np-SH, P-SH). Biochemical changes aid in reduction of oxidative stress and maintenance of redox homeostasis, which further well corroborated by significantly up-regulated protein expression of Nrf 2, hemeoxygenase (HO-1), and thioredoxin reductase 2 (Txnrd2). CONCLUSION: Photobiomodulation with 904 nm superpulsed laser led to reduction of nitroxidative stress, induction of endogenous antioxidants, and maintenance of redox homeostasis that could play a vital role in augmentation of burn wound healing.

Effects of Pulsed 810 nm Al-Ga-As Diode Laser on Wound Healing Under Immunosuppression: A Molecular Insight.

BACKGROUND AND OBJECTIVES: Dysregulated inflammation is one of the major contributing factors for the prevalence of non-healing chronic wound in immunosuppressed subjects. Photobiomodulation (PBM) has emerged as a potential non-thermal, light-based therapeutic healing intervention for the treatment of impaired wounds. STUDY DESIGN/MATERIALS AND METHODS: The present study delineates the underlying molecular mechanisms of PBM 810 nm laser-induced full-thickness cutaneous wound repair in immunosuppressed rats at continuous and pulsed wave-mode with power-density of 40 mW/cm 2 , fluence 22.6 J/cm 2 for 10 minutes daily for 7 post-wounding days. Molecular markers were assessed using biochemical, enzyme-linked immunosorbent assay quantification, enzyme kinetics and immunoblots analyses pertaining to inflammation, oxidative stress, cell survival, calcium signaling, and proliferation cascades. RESULTS: Results distinctly revealed that pulsed 810 nm (10 Hz) PBM potentially influenced the cell survival and proliferation signaling pathway by significantly upregulated phospho-protein kinase B(phospho-Akt), phospho-extracellular-signal-regulated kinase 1 (ERK1), transient receptor potential vanilloid-3 (TRPV3), Ca2+ , calmodulin, transforming growth factor-ß1 (TGF-ß1), TGF-ßR3, and Na + /K + -ATPase pump levels. PBM treatment resulted in reduction of exaggerated inflammatory responses evident by significantly repressed levels of interleukin-1ß (IL-1ß), IL-6, cyclooxygenase 2 (COX-2), and substance-P receptor (SPR), as well as inhibited apoptotic cell death by decreasing p53, cytochrome C, and caspase 3 levels (P < 0.05), which, in turn, effectively augment the wound repair in immunosuppressed rats. PBM treatment also lowered 4-hydroxynoneal (HNE) adduct level and NADP/NADPH ratio and upregulated the GRP78 expression, which might culminate into reduced oxidative stress and maintained the redox homeostasis. CONCLUSIONS: Taken together, these findings would be helpful in better understanding of the molecular aspects involved in pulsed 810 nm laser-mediated dermal wound healing in immunosuppressed rats through regulation of cell survival and proliferation via Ca2+ -calmodulin, Akt, ERK, and redox signaling. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Noninvasive red and near-infrared wavelength-induced photobiomodulation: promoting impaired cutaneous wound healing.

The innumerable intricacies associated with chronic wounds have made the development of new painless, noninvasive, biophysical therapeutic interventions as the focus of current biomedical research. Red and near-infrared light-induced photobiomodulation therapy appears to emerge as a promising drug-free approach for promoting wound healing, reduction in inflammation, pain and restoration of function owing to penetration power in conjunction with their ability to positively modulate the biochemical and molecular responses. This review will describe the physical properties of red and near-infrared light and their interaction with skin and highlight their efficacy of wound repair and regeneration. Near-infrared (800-830 nm) was found to be the most effective and widely studied wavelength range followed by red (630-680 nm) and 904 nm superpulsed light exhibiting beneficial photobiomodulatory effects on impaired dermal wound healing.

What Factors Predict Conversion to THA After Arthroscopy?

BACKGROUND: Failure of hip preservation to alleviate symptoms potentially subjects the patient to reoperation or conversion surgery to THA, adding recovery time, risk, and cost. A risk calculator using an algorithm that can predict the likelihood that a patient who undergoes arthroscopic hip surgery will undergo THA within 2 years would be helpful, but to our knowledge, no such tool exists. QUESTIONS: (1) Are there preoperative and intraoperative variables at the time of hip arthroscopy associated with subsequent conversion to THA? (2) Can these variables be used to develop a predictive tool for conversion to THA? MATERIALS AND METHODS: All patients undergoing arthroscopy from January 2009 through December 2011 were registered in our longitudinal database. Inclusion criteria for the study group were patients undergoing hip arthroscopy for a labral tear, who eventually had conversion surgery to THA. Patients were compared with a control group of patients who underwent hip arthroscopy for a labral tear but who did not undergo conversion surgery to THA during the same study period. Of the 893 who underwent surgery during that time, 792 (88.7%) were available for followup at a minimum of 2 years (mean, 31.1 ± 8.1 years) and so were considered in this analysis. Multivariate regression analyses of 41 preoperative and intraoperative variables were performed. Using the results of the multivariate regression, we developed a simplified calculator that may be helpful in counseling a patient regarding the risk of conversion to THA after hip arthroscopy. RESULTS: Variables simultaneously associated with conversion to THA in this model were older age (rate ratio, 1.06; 95% CI, 1.03-1.08; p < 0.0001), lower preoperative modified Harris hip score (rate ratio [RR], 0.98; 95% CI, 0.96-0.99; p = 0.0003), decreased femoral anteversion (RR, 0.97; 95% CI, 0.94-0.99; p = 0.0111), revision surgery (RR, 2.4; 95% CI, 1.15-5.01; p = 0.0193), femoral Outerbridge Grades II to IV (Grade II: RR, 2.23 [95% CI, 1.11-4.46], p = 0.023; Grade III: RR, 2.17, [95% CI, 1.11-4.23], p = 0.024; Grade IV: RR, 2.96 [95% CI, 1.34-6.52], p = 0.007), performance of acetabuloplasty (RR, 1.83; 95% CI, 1.03-3.24; p = 0.038), and lack of performance of femoral osteoplasty (RR, 0.62; 95% CI, 0.36-1.06; p = 0.081). Using the results of the multivariate regression, we developed a simplified calculator that may be helpful in counseling a patient regarding the risk of conversion surgery to THA after hip arthroscopy. CONCLUSION: Multiple risk factors have been identified as possible risk factors for conversion to THA after hip arthroscopy. A weighted calculator based on our data is presented here and may be useful for predicting failure after hip arthroscopy for labral treatment. Determining the best candidates for hip preservation remains challenging; careful attention to long-term followup and identifying characteristics associated with successful outcomes should be the focus of further study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does Bony Regrowth Occur After Arthroscopic Femoroplasty in a Group of Young Adolescents?

PURPOSE: To evaluate femoral head-neck bone regrowth and PROs in skeletally immature patients that underwent arthroscopic femoroplasties over a minimum 2-year period. METHODS: Eleven skeletally immature hips (10 patients) with open femoral head physes underwent femoroplasty between October 2008 and November 2013. Inclusion criteria were minimum 2-year follow-up with patient-reported outcomes (PROs) and radiographs preoperatively, at 2 weeks, and at a minimum of 2 years postoperatively. Exclusion criteria were >16 years of age, preoperative Tönnis grade >1 and previous hip conditions. Preoperative radiographs were used to assess skeletal immaturity, which was indicated by a Risser score ≤4 and femoral head physis >1 mm. Alpha angles were measured preoperatively, at 2 weeks, and at a minimum of 2 years postoperatively. PROs, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) score, were measured preoperatively and at the latest follow-up. RESULTS: Mean age at surgery was 14.7 years (range: 13.2-15.9). Mean follow-up was 35.7 months (range: 23.3-61.4). All hips tested positive for anterior impingement preoperatively. The mean preoperative alpha angle was 61.8°, which decreased to 41.5° postoperatively (P < .0001) and was 40.7° at a minimum of 2 years postoperatively. No bony regrowth was documented at the latest follow-up. Mean improvements in scores were as follows: mHHS = 58.5 to 79.8 (P < .0001), NAHS = 56.8 to 87.1 (P = .008), HOS-SSS = 34.3 to 78.3 (P = .004), and VAS score = 7.5 to 1.3 (P < .0001). Mean patient satisfaction was 8.7 ± 1.7. One hip (9.0%) required revision arthroscopy at 31.1 months. No postoperative complications were reported. CONCLUSIONS: Bony regrowth of the femoral head-neck region did not occur in this study of skeletally immature females who underwent arthroscopic femoroplasty. In this group of patients, hip arthroscopic treatment of FAI and labral tears is a safe and favorable intervention because of its high patient satisfaction and outcome scores and absence of postoperative complications. LEVEL OF EVIDENCE: Level IV, prognostic study.

Survey mode influence on patient-reported outcome scores in orthopaedic surgery: telephone results may be positively biased.

PURPOSE: Patient-reported outcome (PRO) scores are used to evaluate treatment modalities in orthopaedic surgery. The method of PRO collection may introduce bias to reported surgical outcomes due to the presence of an interviewer. This study evaluates post-operative PROs for variation of outcomes between survey methods-in-person, online, or telephone. METHODS: From 2008 to 2011, 456 patients underwent arthroscopic surgical treatment for acetabular labral tears. All pre-operative surveys were completed in the clinic during pre-operative visit. Two-year follow-up questionnaires were completed by 385 (84 %) patients. The PRO data were prospectively collected pre- and post-operatively using five tools: modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADLS), Hip Outcome Score Sports-Specific Subscale (HOS-SSS), Non-Arthritic Hip Score (NAHS), and visual analog scale. Patients were grouped according to method of 2-year follow-up: in-person during follow-up visit (102 patients, 26 %), online by email prompt (138 patients, 36 %), or telephone with an interviewer (145 patients, 38 %). RESULTS: Pre-operative baseline PRO scores demonstrated no statistically significant difference between groups for mHHS, HOS-ADLS, HOS-SSS, and NAHS. Two-year post-operative PRO scores obtained by telephone were statistically greater than scores obtained in-person or online for mHHS (p < 0.001), HOS-ADLS (p < 0.001), and HOS-SSS (p < 0.01). CONCLUSION: This study demonstrates higher patient-reported outcome scores and greater improvement by telephone surveys compared to in-person or online. The variation of results between collection methods is indicative of a confounding variable. Clinically, it is important to understand these confounding variables in order to assess patient responses and guide treatment. LEVEL OF EVIDENCE: IV.

Outcomes of Revision Hip Arthroscopy: 2-Year Clinical Follow-up.

PURPOSE: To evaluate clinical outcomes, pain, and patient satisfaction following revision hip arthroscopy with a minimum 2-year follow-up. METHODS: From April 2008 to October 2011, data were prospectively collected on all patients undergoing revision hip arthroscopy. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures: the modified Harris hip score (mHHS), nonarthritic hip score (NAHS), hip outcome score-activities of daily living (HOS-ADL), and hip outcome score-sport-specific subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. The number of patients who underwent subsequent revision arthroscopy or total hip arthroplasty during the study period is also reported. RESULTS: Eighty-seven patients underwent revision hip arthroscopy during the study period. Seventy (80.5%) patients were included in our study. Average follow-up time was 28 months (range, 20 to 47.4 months). In terms of residual femoroacetabular impingement morphology, 45.7% of patients had preoperative alpha angles ≥ 55°, and 7.14% of patients had a lateral center-edge angle ≥ 40°. The score improvement from preoperative to 2-year follow-up was 57.84 to 73.65 for mHHS, 62.79 to 83.04 for HOS-ADL, 37.33 to 54.93 for HOS-SSS, and 55.65 to 70.79 for NAHS. VAS decreased from 6.72 to 4.08. All scores demonstrated statistically significant improvement (P < .001). Overall patient satisfaction was 7.67. Our success rate was 74.58%. Ten (14.29%) patients underwent total hip arthroplasty during the study period. Our hip survivorship was 85.7%. Five (7.14%) patients underwent secondary revision hip arthroscopy during the study period. We found an overall minor complication rate of 10%. CONCLUSIONS: Revision hip arthroscopy for all procedures performed on aggregate has improved clinical outcomes for all PROs, high survivorship, and high patient satisfaction scores at short-term follow-up. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty and the potential for revision surgery. LEVEL OF EVIDENCE: Level IV retrospective case series.

Bacterial photodynamic inactivation mediated by methylene blue and red light is enhanced by synergistic effect of potassium iodide.

The inexorable increase of antibiotic resistance occurring in different bacterial species is increasing the interest in developing new antimicrobial treatments that will be equally effective against multidrug-resistant strains and will not themselves induce resistance. One of these alternatives may be photodynamic inactivation (PDI), which uses a combination of nontoxic dyes, called photosensitizers (PS), excited by harmless visible light to generate reactive oxygen species (ROS) by type 1 (radical) and type 2 (singlet oxygen) pathways. In this study, we asked whether it was possible to improve the efficacy of PDI in vitro and in vivo by addition of the inert salt potassium iodide (KI) to a commonly investigated PS, the phenothiazinium dye methylene blue (MB). By adding KI, we observed a consistent increase of red light-mediated bacterial killing of Gram-positive and Gram-negative species in vitro and in vivo. In vivo, we also observed less bacterial recurrence in wounds in the days posttreatment. The mechanism of action is probably due to formation of reactive iodine species that are produced quickly with a short lifetime. This finding may have a relevant clinical impact by reducing the risk of amputation and, in some cases, the risk of death, leading to improvement in the care of patients affected by localized infections.

Outcomes of hip arthroscopy in patients aged 50 years or older compared with a matched-pair control of patients aged 30 years or younger.

PURPOSE: Age has been suggested as a negative prognostic factor for hip arthroscopy. The purpose of this study was to compare patient characteristics and outcomes after hip arthroscopy in patients aged 50 years or older with a matched control group of patients aged 30 years or younger at a minimum postoperative follow-up of 2 years. METHODS: Between September 2008 and March 2010, data were prospectively collected on all patients aged 50 years or older undergoing primary hip arthroscopy. Fifty-two patients met our inclusion and matching criteria, of whom all 52 (100%) were available for follow-up at a minimum of 2 years. This cohort was compared with a matched-pair control group of patients aged 30 years or younger who underwent similar procedures. RESULTS: The mean age of the study group was 54.8 years (range, 50 to 69 years), and that of the control group was 20.3 years (range, 13 to 30 years). The groups were matched at a 1:1 ratio, including 18 male patients (34.6%) and 34 female patients (65.4%) in each group, with a mean follow-up period of 32 months (range, 24 to 54 months). In the younger control group, the score improvement from preoperatively to 2 years' follow-up was 62.9 to 84.2 for the modified Harris Hip Score, 60.5 to 84.2 for the Non-Arthritic Hip Score, 63.1 to 86.5 for the Hip Outcome Score-Activities of Daily Living, and 42.2 to 72.7 for the Hip Outcome Score-Sport-Specific Subscale. In the older study group, the score improvement from preoperatively to 2 years' follow-up was 61.2 to 82.2 for the modified Harris Hip Score, 59.9 to 80.4 for the Non-Arthritic Hip Score, 63.9 to 83 for the Hip Outcome Score-Activities of Daily Living, and 41.2 to 64.6 for the Hip Outcome Score-Sport-Specific Subscale. All improvements in both groups were statistically significant at the 2-year postoperative follow-up (P < .001). There was no significant difference for all patient-reported outcome (PRO) scores at final follow-up between both groups. When we compared the change in PRO scores (Δ) from preoperatively to 2 years postoperatively, there was no significant difference between both groups. The overall survivorship rate was 98.1% for the younger control group and 82.7% for the older study group. CONCLUSIONS: Survivors aged 50 years or older show similar improvement to patients aged 30 years or younger in PRO and patient satisfaction scores. The 2-year survivorship rate was 98.1% for the younger control group and 82.7% for the older study group. Therefore we believe that hip arthroscopy should be considered a valid treatment option when treating hip pain in patients aged 50 years or older with a Tönnis arthritic grade of 0 or 1. Older patients should be counseled on the possibility of later conversion to total hip arthroplasty. Future work may include development of a decision-making tool to assess for prognosis to better delineate the indications for hip arthroscopy in the older population. LEVEL OF EVIDENCE: Level III, therapeutic case-control study.

Clinical results of hip arthroscopy for labral tears: a comparison between intraoperative platelet-rich plasma and bupivacaine injection.

PURPOSE: The purpose of this prospective comparative study was to evaluate the effect of intraoperative platelet-rich plasma (PRP) injection on the outcomes of patients undergoing hip arthroscopy for labral treatment. METHODS: During the period from November 2010 through March 2012, all patients undergoing hip arthroscopy for labral tears were considered for this study. The study group received intra-articular PRP at the end of the operation, and the control group received an intra-articular injection of 0.25% bupivacaine. Selection for the study group was based on the day of the week on which the patient underwent surgery. The protocol included administration of 4 hip-specific patient-reported outcome tools. Patients also reported their pain score on a visual analog scale from 0 to 10. Scores were recorded at the preoperative visit and at 3 months and 2 years postoperatively. RESULTS: A minimum of 2 years' follow-up was available for 306 patients. Thirteen patients (4.2%) underwent conversion to total hip arthroplasty and 24 patients (7.8%) underwent revision hip arthroscopy, which left 91 patients in the study group and 180 patients in the control group. The study group had slightly higher pain scores than the control group (3.4 v 2.5) 2 years after surgery (P = .005). No difference in pain scores was identified at 3 months postoperatively. The 2-year modified Harris Hip Score was slightly lower in the study group (78.6) than in the control group (82.6) (P = .049). No significant difference was observed for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, or Non-Arthritic Hip Score at any time point. There was no significant difference between groups for conversion to total hip arthroplasty or revision surgery. CONCLUSIONS: On the basis of the results of this study, intraoperative PRP injection does not appear to improve the clinical results of patients undergoing hip arthroscopy for labral treatment. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Labral injury: radiographic predictors at the time of hip arthroscopy.

PURPOSE: The purpose of this study was to investigate the influence of multiple demographic and radiographic findings on the size of labral tears identified at the time of hip arthroscopy. METHODS: Data were prospectively collected for patients treated with arthroscopic labral repair or debridement from February 2008 to August 2011. Preoperative radiographic and demographic data were collected for 392 patients during the study period. Exclusion criteria included revision surgery and previous hip conditions. An anteroposterior pelvic view, 45° Dunn view, and false-profile view were used to measure Tönnis grade, neck-shaft angle, alpha angle, lateral center edge angle (LCEA), anterior center edge angle (ACEA), acetabular inclination, and the extent of crossover sign when present. At the time of surgery, labral tear size and location were documented for all patients, using traditional acetabular clock face nomenclature for sizing. A multiple linear regression analysis was then performed to assess the correlation of radiographic and demographic findings with the size of the labral tear. RESULTS: Regression analysis displayed statistical significance for sex (P < .0001), age (P < .0001), and alpha angle (P = .005) with labral tear size. For female patients, Tönnis grade (P = .0004) and neck-shaft angle (P = .004) correlated with labral tear size. This model accounted for only 26% of variation in labral tear size. CONCLUSIONS: Preoperative risk factors for the extent of labral tear size are male sex, increasing age, and increasing alpha angle. Labral tears were larger in female patients with higher Tönnis grades and lower neck-shaft angles. Measurements of acetabular coverage and version showed no correlation with labral tear size. The majority of labral tear size variation was not accounted for in this model. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Concomitant Hip Arthroscopy and Periacetabular Osteotomy.

PURPOSE: To detail our early experience using concomitant hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of acetabular dysplasia. METHODS: We prospectively collected and retrospectively reviewed the surgical and outcome data of 17 patients who underwent concomitant hip arthroscopy and PAO between October 2010 and July 2013. Preoperative and postoperative range of motion, outcome and pain scores, and radiographic data were collected. Intraoperative arthroscopic findings and postoperative complications were recorded. RESULTS: The group consisted of 3 male and 14 female patients with a mean follow-up period of 2.4 years. Three patients had undergone previous surgery on the affected hip. Chondrolabral pathology was identified in all 17 patients. Twelve patients underwent labral repair, and five patients underwent partial labral debridement. No patient was converted to total hip arthroplasty or required revision surgery at short-term follow-up. All 4 patient-reported outcome scores showed statistically significant changes from baseline to latest follow-up (P < .001). An excellent outcome was obtained in 82% of patients (13 of 16). The lateral center-edge angle averaged 11° preoperatively and 29° postoperatively. The acetabular inclination averaged 18° preoperatively and 3° postoperatively. The anterior center-edge angle averaged 7° preoperatively and 27° postoperatively. At most recent radiographic follow-up, 1 patient had progression of arthritic changes but remained asymptomatic. No other patient showed any radiographic evidence of progression of arthritis. Complications included 3 superficial wound infections, 1 pulmonary embolism, and 1 temporary sciatic neurapraxia. CONCLUSIONS: Our initial experience with concomitant hip arthroscopy and PAO has been favorable. We noted that all our patients have evidence of chondrolabral damage at the time of PAO when the joint is distracted and evaluated. All patients in this series had intra-articular pathology treated arthroscopically and showed satisfactory mean clinical improvement. Hip arthroscopy with PAO did not appear to introduce complications beyond the PAO alone. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

A matched-pair controlled study of microfracture of the hip with average 2-year follow-up: do full-thickness chondral defects portend an inferior prognosis in hip arthroscopy?

PURPOSE: This study compared 2-year clinical outcomes in hip arthroscopy patients treated with microfracture to a matched control group without full-thickness chondral damage. METHODS: During the study period between June 2008 and July 2011, data were collected on all patients treated with hip arthroscopy who underwent microfracture. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures. Pain was estimated on the visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. A matched-pair group of patients who did not undergo microfracture was selected in a 1:2 ratio. Matching criteria were age within 5 years, sex, surgical procedures, and radiographic findings. RESULTS: Average follow-up for the study was 26.66 months (17.29 to 48.89 months). Forty-nine hips were included in the microfracture group and 98 hips were in entered in the nonmicrofracture group, with no significant difference in PRO scores preoperatively between the groups. Both groups had statistically significant postoperative improvement in all scores, and the average amount of change from preoperative to postoperative scores between the 2 groups was not statistically significantly different for any of the PRO scores. Most importantly, there was no statistically significant difference in postoperative PRO scores between the microfracture and control groups. Patient satisfaction was 6.9 for the microfracture group and 7.84 for the nonmicrofracture group, which was statistically significant (P < .05). When comparing patients who received acetabular microfracture to those who received femoral microfracture, both groups had similar preoperative and postoperative PRO scores, with no significant difference in the magnitude of change (delta) at final follow-up. CONCLUSIONS: Our study found that patients undergoing microfracture during hip arthroscopy did not show a statistically significant difference in PRO scores when compared with a matched-pair control group at an average of 2 years of follow-up. Both groups showed significant improvement in all PRO scores. LEVEL OF EVIDENCE: Level III, matched case-control study.

Arthroscopic Treatment of Labral Tears in Patients Aged 60 Years or Older.

PURPOSE: The purpose of this study was to (1) evaluate the clinical outcomes of a series of patients aged 60 years or older who underwent hip arthroscopy for labral tears with minimum 2-year follow-up and (2) identify risk factors for conversion to total hip arthroplasty (THA). METHODS: Outcome data were prospectively collected and retrospectively reviewed in patients aged 60 years or older who underwent hip arthroscopy between April 2008 and May 2012. Four patient-reported outcome (PRO) scores, pain scores, and satisfaction ratings were collected. Conversion to THA and revision surgery rates were recorded. A subgroup analysis compared survivors with patients requiring THA. RESULTS: Minimum 2-year follow-up was available for 30 patients with a mean age of 63.9 years. The 2-year survivorship rate was 70%, with 9 patients undergoing conversion to THA at a mean of 1.1 years after hip arthroscopy. Two patients required additional surgery during the study period, for a reoperation rate of 37% (11 of 30 patients). The remaining cohort showed mean improvements in all PRO scores. All scores, except the sports-related PRO (P = .12), improved significantly from the preoperative baseline scores. Visual analog scale scores for pain decreased from a mean of 5.0 preoperatively to 2.7 postoperatively (P = .003). Patients who required conversion to THA had lower preoperative modified Harris Hip Scores (P = .015), lower preoperative Hip Outcome Score-Activity of Daily Living values (P = .01), higher pain scores (P = .05), greater acetabular inclination (P = .023), and more severe chondral damage (P = .033). CONCLUSIONS: Arthroscopic treatment of labral tears in patients aged 60 years or older should be approached with caution. Patients in this age group had an overall 2-year survivorship rate of 70% and should be counseled before surgery on the possibility of subsequent conversion to THA. Patients aged 60 years or older with poor preoperative PRO scores, high pain scores, radiographic evidence of borderline dysplasia, and severe chondral damage may be poor candidates for hip arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Best Practices During Hip Arthroscopy: Aggregate Recommendations of High-Volume Surgeons.

PURPOSE: To survey surgeons who perform a high volume of hip arthroscopy procedures regarding their operative technique, type of procedure, and postoperative management. METHODS: We conducted a cross-sectional survey of 27 high-volume orthopaedic surgeons specializing in hip arthroscopy to report their preferences and practices related to their operative practice and postoperative rehabilitation protocol. All participants completed the survey in person in an anonymous fashion during a meeting of the American Hip Institute. RESULTS: All surgeons perform hip arthroscopy with the patient in the supine position, accessing the central compartment of the hip initially, using intraoperative fluoroscopy. All surgeons perform labral repair (100%), with the majority performing labral reconstructions (77.8%) and gluteus medius repairs (81.5%). There is variability in the type of anchors used during labral repair. Most surgeons perform capsular closure in most cases (88.9%), inject either intra-articular cortisone or platelet-rich plasma at the conclusion of the procedure (59%), and prescribe a postoperative hip brace for some or all patients (59%). There is considerable variability in rehabilitation protocols. All surgeons routinely prescribe postoperative heterotopic ossification prophylaxis to their patients, with most surgeons (88.9%) prescribing a nonsteroidal anti-inflammatory medication for 3 weeks. Forty percent of the respondents use the modified Harris Hip Score as the most important outcome measure. CONCLUSIONS: Consistent practices such as use of intraoperative fluoroscopy, heterotopic ossification prophylaxis, and labral repair skills were identified by surveying 27 hip arthroscopy surgeons at high-volume centers. Most of the surgeons performed routine capsular closure unless underlying conditions precluded capsular release or plication. The survey identified higher variability between surgeons regarding postoperative rehabilitation protocols and use of intra-articular pharmacologic injections at the end of the procedure. These data may provide surgeons with a set of aggregate trends that may help guide training, clinical practice, and research in the evolving field of hip arthroscopy.

The learning curve associated with robotic-assisted total hip arthroplasty.

There are no reports examining the learning curve during the adoption of robotic assisted THA. The purpose of this study was to examine the learning curve of robotic assisted THA as measured by component position, operative time, and complications. The first 105 robotic-assisted THAs performed by a single surgeon were divided into three groups based on the order of surgery. Component position, operative time, intra-operative technical problems, and intra-operative complications were recorded. There was a decreased risk of acetabular component malpositioning with experience (P<0.05). Operative time appeared to decrease with increasing surgical experience (P<0.05). A learning curve was observed, as a decreased incidence of acetabular component outliers and decreased operative time were noted with increased experience.

Does Robotic-Assisted Computer Navigation Affect Acetabular Cup Positioning in Total Hip Arthroplasty in the Obese Patient? A Comparison Study.

Obese populations present challenges for acetabular cup placement during total hip arthroplasty (THA). This study examines the accuracy of acetabular cup inclination and version in the obese patient with robotic-assisted computer navigation. A total of 105 patients underwent robotic-assisted computer navigation THA with a posterior approach. Groups were divided on body mass index (BMI, kg/m(2)) of <30, 30-35, and >35. There was no statistical difference between the BMI <30 (n=59), BMI 30-35 (n=34) and BMI >35 (n=12) groups for acetabular inclination (P=0.43) or version (P=0.95). Robotic-assisted computer navigation provided accurate and reproducible placement of the acetabular cup within safe zones for inclination and version in the obese patient.

Antimicrobial blue light therapy for multidrug-resistant Acinetobacter baumannii infection in a mouse burn model: implications for prophylaxis and treatment of combat-related wound infections.

In this study, we investigated the utility of antimicrobial blue light therapy for multidrug-resistant Acinetobacter baumannii infection in a mouse burn model. A bioluminescent clinical isolate of multidrug-resistant A. baumannii was obtained. The susceptibility of A. baumannii to blue light (415 nm)-inactivation was compared in vitro to that of human keratinocytes. Repeated cycles of sublethal inactivation of bacterial by blue light were performed to investigate the potential resistance development of A. baumannii to blue light. A mouse model of third degree burn infected with A. baumannii was developed. A single exposure of blue light was initiated 30 minutes after bacterial inoculation to inactivate A. baumannii in mouse burns. It was found that the multidrug-resistant A. baumannii strain was significantly more susceptible than keratinocytes to blue light inactivation. Transmission electron microscopy revealed blue light-induced ultrastructural damage in A. baumannii cells. Fluorescence spectroscopy suggested that endogenous porphyrins exist in A. baumannii cells. Blue light at an exposure of 55.8 J/cm(2) significantly reduced the bacterial burden in mouse burns. No resistance development to blue light inactivation was observed in A. baumannii after 10 cycles of sublethal inactivation of bacteria. No significant DNA damage was detected in mouse skin by means of a skin TUNEL assay after a blue light exposure of 195 J/cm(2).

The effect of liposomal bupivacaine injection during total hip arthroplasty: a controlled cohort study.

BACKGROUND: Multimodal analgesia following total hip arthroplasty has been shown to improve patient satisfaction, participation with physical therapy, and allow early return to self care. Liposomal bupivacaine is a formulation of local anesthetic which has the potential to provide anesthesia for up to 72 hours following administration. The purpose of this study was to compare the effectiveness of liposomal bupivacaine with bupivacaine following total hip arthroplasty. METHODS: A retrospective chart review was performed on 28 patients undergoing total hip arthroplasty or hip resurfacing who received intraoperative administration of liposomal bupivacaine. A control group of 30 patients who had previously undergone total hip arthroplasty or hip resurfacing and had received intraoperative administration of bupivacaine also underwent a chart review. Length of stay, post-operative opioid use, and pain scores were compared for both groups. RESULTS: The average length of stay in the study group was 1.93 days and the control group length of stay was 2.47 days (p ≤ 0.05). Morphine equivalent use was less in the study group during the first 24 hours compared to the control group (p ≤0.05). During the second and third 24 hours the morphine equivalent use difference was not statistically significant. Visual analogue scores were not significantly different between groups at any time point. CONCLUSION: Liposomal bupivacaine administration during total hip arthroplasty appears to decrease the need for opioid use post operatively and decrease length of stay. The results of this study justify the need for a well-designed randomized controlled trial utilizing liposomal bupivacaine as part of multimodal analgesia during THA.

Nerve proximity during bicortical drilling for subpectoral biceps tenodesis: a cadaveric study.

PURPOSE: The long head of the biceps can develop tendonitis and tendinosis, which can lead to pain in the bicipital groove. The use of bicortical button fixation allows for a smaller defect in the humerus compared with tenodesis screws, reducing the risk of fracture. Our objective is to evaluate the exit location of our bicortical button and its relation to relevant posterior nervous structures. METHODS: We performed anatomic dissection of 6 fresh-frozen cadaveric upper extremities. At the level of the inferior border of the pectoralis major tendon, the musculotendinous junction of the long head of the biceps was identified. At the base of the bicipital groove, a 3.2-mm guidewire was advanced perpendicularly through both the anterior and posterior cortex. Posteriorly, the radial and axillary nerves were carefully dissected. For each dissection, we recorded the closest distance from the posterior cortical hole created by our drill to both the axillary and radial nerves using digital calipers. RESULTS: The mean distance from the axillary nerve to the posterior drill hole was 25.1 mm (95% confidence interval, 21.6 to 28.6 mm). The mean distance from the radial nerve to the posterior drill hole was 30.3 mm (95% confidence interval, 27.2 to 33.4 mm). CONCLUSIONS: With placement of the tenodesis at the inferior aspect of the bicipital groove in conjunction with the musculotendinous junction, open subpectoral tenodesis of the long head of the biceps can be performed using bicortical button fixation without risk to the posterior nervous structures. CLINICAL RELEVANCE: This cadaveric study suggests that posterior proximal humerus nervous structures can be avoided with proper tenodesis placement.