Editorial Commentary: Female Patients With Lower Body Mass Index Show the Best Outcomes After Hip Arthroscopy, and Arthroscopic Treatment of Femoroacetabular Impingement in Higher-Body Mass Index Female Patients Results in Improved Outcomes.

Which patients will benefit most from hip arthroscopy? Careful patient selection and conservative indications, such as patients with an alpha angle of 60° or greater or a lateral center-edge angle of 40° or greater who fail a trial of conservative treatment, may benefit from hip arthroscopy for femoroacetabular impingement (FAI). In female patients in particular, a lower body mass index (BMI) will predict the most benefit from arthroscopic treatment. That said, patients with a higher BMI can also substantially improve after treatment of FAI. The true art of medicine is determining indications for an individual patient in addition to providing evidence-based counseling and education. We must not forget that sometimes "any improvement" can be a good outcome for a patient who is in pain.

What is the utility of hip arthroscopy in patients with joint laxity? A contemporary systematic review of patient-reported and surgical outcomes.

INTRODUCTION: The purpose of this study was to systematically review the literature to understand the contemporary outcomes for patients with joint laxity managed with hip arthroscopy. MATERIALS AND METHODS: A search was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement guidelines. All literature related to joint laxity in hip arthroscopy patients was identified. Inclusion criteria consisted of patient-reported outcomes and Beighton and Horan Joint Mobility Index scoring. Study quality was assessed using the Methodological Index of Non-Randomized Studies criteria. RESULTS: Seven articles were identified, including 412 patients (416 hips). Patients were predominantly female (range 83-100%). Mean patient age ranged from 13-69 years. Five studies consisting of 370 hips reported a range of 75 to 100% undergoing labral repair, 0 to 13% labral debridement, 0 to 7% labral reconstruction, 43 to 100% capsular closure, 94 to 99% femoroplasty, 3 to 80% rim resection, and 9 to 50% subspine decompression for surgical management. Post-operative follow-up range was 6-99 months. The mean range of improvement in Hip Outcomes Score Activities of Daily Living, Hip Outcomes Score-Sports Subscale, modified Harris Hip Score, Visual Analog Scale, and 12 item Short Form Health Survey were 17.6-31.3, 31.3-35.1, 22.5-53.8, - 2.79-8, and 12.4-16.9 respectively. CONCLUSION: Generalized ligamentous laxity patients managed with hip arthroscopy were predominantly young women. At short-term follow-up, mean patient-reported outcomes were positive, with improvement postoperatively in activities of daily living, sports, and quality of life.

Magnetic Resonance Imaging Predictors of Chondral Lesions in Patients With Femoroacetabular Impingement: An Analysis of 545 Cases.

PURPOSE: A large prospective cohort was used (1) to evaluate the overall ability of magnetic resonance imaging (MRI) to detect Outerbridge grade III and IV cartilage defects found during surgery and (2) to identify the specific MRI findings most associated with these cartilage defects so that the practicing hip arthroscopist can better predict cartilage injury before surgery. METHODS: All patients undergoing hip arthroscopy between February 2015 and May 2017 at 1 institution were enrolled in a prospective cohort. Intra-articular findings were documented at the time of surgery. MRI reports were retrospectively reviewed for radiologist-reported articular cartilage, osseous, or synovial abnormalities. Sensitivity and specificity of MRI findings were calculated; multivariate logistic regression analysis determined which findings were associated with high-grade chondral damage at the time of arthroscopy and used to create an online risk calculator, https://orthop.washington.edu/hiprisk/. RESULTS: Of 598 patients who underwent hip arthroscopy, 550 had MRI reports available for review (92%). Grade III and IV cartilage injuries were reported on arthroscopy in 70 patients (13%) of average age 33 ± 13 years. On univariate analyses, individual MRI findings were not sensitive in detection of articular cartilage injury (mean 22%; range, 1.4%-46%), but positive findings were highly specific (mean 90%,; range, 76%-99%). Multivariate analysis revealed that older age (odds ratio [OR] 1.09 [1.06-1.11], P < .001) and osseous findings such as subchondral cyst or edema (OR 4.77 [2.51-9.05], P < .001) were most predictive of grade III and IV defects (P < .001). CONCLUSION: MRI was a specific but not sensitive tool in diagnosing articular cartilage injury. Surgeons should be aware that osseous findings such as cysts or edema are highly predictive of full-thickness cartilage loss in FAI. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria (consecutive patients with consistently applied reference standard, no blinding).

Interchangeability of CT and 3D "pseudo-CT" MRI for preoperative planning in patients with femoroacetabular impingement.

OBJECTIVE: To determine whether a 3D magnetic resonance imaging (MRI) sequence with postprocessing applied to simulate computed tomography (CT) ("pseudo-CT") images can be used instead of CT to measure acetabular version and alpha angles and to plan for surgery in patients with femoroacetabular impingement (FAI). MATERIALS AND METHODS: Four readers retrospectively measured acetabular version and alpha angles on MRI and CT images of 40 hips from 20 consecutive patients (9 female patients, 11 male patients; mean age, 26.0 ± 6.5 years) with FAI. 3D models created from MRI and CT images were assessed by 2 orthopedic surgeons to determine the need for femoroplasty and/or acetabuloplasty. Interchangeability of MRI with CT was tested by comparing agreement between 2 readers using CT (intramodality) with agreement between 1 reader using CT and 1 using MRI (intermodality). RESULTS: Intramodality and intermodality agreement values were nearly identical for acetabular version and alpha angle measurements and for surgical planning. Increases in inter-reader disagreement for acetabular version angle, alpha angle, and surgical planning when MRI was substituted for CT were - 2.1% (95% confidence interval [CI], - 7.7 to + 3.5%; p = 0.459), - 0.6% (95% CI, - 8.6 to + 7.3%; p = 0.878), and 0% (95% CI, - 15.1 to + 15.1%; p = 1.0), respectively, when an agreement criterion ≤ 5° was used for angle measurements. CONCLUSION: Pseudo-CT MRI was interchangeable with CT for measuring acetabular version and highly favorable for interchangeability for measuring alpha angle and for surgical planning, suggesting that MRI could replace CT in assessing patients with FAI.

Trends in Hip Arthroscopic Labral Repair: An American Board of Orthopaedic Surgery Database Study.

PURPOSE: The purpose of this study is to evaluate the trends in labral repair in American Board of Orthopaedic Surgery Part II candidates performing hip arthroscopy. METHODS: Candidates who performed arthroscopic hip surgery between 2011 and 2015 during their American Board of Orthopaedic Surgery Part II board collection period were identified using Current Procedural Terminology codes (29860, 29861, 29862, 29863, 29914, 29915, 29916). The proportion of hip arthroscopy cases including labral repair (Current Procedural Terminology code 29916) were calculated for each year and analyzed by fellowship training experience. Trends in labral repair utilization were calculated using univariate and regression analyses, with significance set at P < .05. RESULTS: During the study period, 1,606 hip labral repair cases were performed, with a 35% increase in utilization between 2011 and 2015. Overall, labral repair was performed in 64.8% (1,606/2,480) of hip arthroscopy cases, with a significant increase between 2011 and 2015 (47.4% vs 79.2%; P < .001). Of the hip arthroscopy cases including labral repair, 80.4% (1,291/1,606) were performed by candidates with sports medicine fellowship training. The proportion of hip arthroscopy cases including labral repair was highest for surgeons with sports medicine fellowship training compared with those without sports medicine fellowship training (66.1% vs 59.8%; P = .007). Candidates with sports medicine training performing at least 1 labral repair each year increased from 68% to 89% over the study period (P = .0007). The average number of labral repairs per candidate increased significantly over the duration of the study period (P = .0072). CONCLUSIONS: Labral repair utilization during hip arthroscopy procedures nearly doubled from 2011 to 2015 for American Board of Orthopaedic Surgery Part II candidates, reflecting a significant change in practice. Current data suggest that nearly 80% of hip arthroscopy procedures include labral repair. These trends may reflect the current practice patterns at academic institutions with sports medicine fellowships.

A posterior labral cyst associated with an anterior labral tear of the hip.

Paralabral cysts are often associated with labral and other intraarticular hip pathology; MRI as well as diagnostic ultrasound can assist in diagnosis. Although often considered a coincidental finding, paralabral cysts can be a separate pain generator about the hip through compression of surrounding anatomy. They can also be initially mistaken for malignancy or other pathology by providers unfamiliar with their appearance. We present the case of an active 33-year-old female with right hip pain secondary to a large symptomatic posterior acetabular paralabral cyst with concomitant anterior labral tear. Following diagnosis on MRI, treatment included ultrasound-guided aspiration of the cyst, followed by arthroscopic anterior labral repair and separate cyst decompression from a posterior portal. The patient had complete resolution of her symptoms.

Epidemiology and Detrimental Impact of Opioid Use in Patients Undergoing Arthroscopic Treatment of Femoroacetabular Impingement Syndrome.

PURPOSE: To determine the prevalence of preoperative opioid use in patients with femoroacetabular impingement (FAI) syndrome and to define how opioid use influences preoperative hip pain and function at a single center. METHODS: Between February 2015 and September 2016, patients undergoing hip arthroscopy at a single Midwest institution for FAI syndrome were retrospectively reviewed. Patients undergoing arthroscopy for non-FAI conditions and those with undocumented preoperative opioid use were excluded. Baseline validated measures (Hip Disability and Osteoarthritis Outcome Score [HOOS] pain and physical function; University of California, Los Angeles, activity scores; Veterans RAND 12 Item Health Survey) of health were collected at the time of surgery. Articular cartilage status was documented at the time of surgery. Opioid use was extracted from the electronic medical record retrospectively, and patients were designated current users, past users, or nonusers. Analysis of variance and 2-tailed Student's t-tests were used to detect differences between groups according to preoperative opioid use, and significance was set to P < .05. RESULTS: During the study period 321 patients underwent arthroscopic hip surgery for FAI and met the inclusion criteria (75 were excluded). Preoperatively, 55 patients (17%) were current opioid users, 89 (28%) were past users (not within 3 months of surgery), and 177 (55%) were opioid naive. Current opioid use was associated with significantly worse measures of joint and general health including HOOS-Pain (15.3 point difference, P < .001), HOOS-Physical Function (13.6 point difference, P < .001), University of California, Los Angeles, activity score (1.7 point difference, P < .001), and Veterans RAND 12 Item Health Survey mental component score (5.5 point difference, P < .001). Outerbridge cartilage grading and presence or length of labral tears were not worse in opioid users (P = .2-.61). CONCLUSIONS: Preoperative opioid use is common prior to arthroscopy for FAI and has detrimental impacts on hip pain and function. The present data also suggest cessation of opioid medication for 3 months prior to surgery may have meaningful impacts on baseline measures of hip and general health. LEVEL OF EVIDENCE: Level III, prognostic.

Assessing the Readability of Online Information About Hip Arthroscopy.

PURPOSE: To investigate the current readability of online information pertaining to hip arthroscopy. METHODS: The terms "hip arthroscopy" and "hip scope" were entered into the advanced search functions of Google, Yahoo!, and Bing on March 25, 2017, and results from the first 3 pages were analyzed. Results were required to be unique, accessible websites with information about hip arthroscopy conveyed primarily via analyzable text. Two reviewers applied inclusion criteria to the initial 97 results, discussing to reach consensus in cases of disagreement. Overall, 60 unique results were reviewed with 48 meeting inclusion criteria. Websites were categorized as physician-sponsored, academic, commercial, governmental and nonprofit organization (NPO), or unspecified. Readability was measured via 6 different indices: the Flesch-Kincaid grade level (FKGL), Flesch Reading Ease (FRE), Gunning Fog Score, SMOG Index, Coleman-Liau Index (CLI), and Automated Readability Index (ARI) along with an average grade level and readability classification score. RESULTS: Forty-eight unique websites were assessed for readability, with physician-sponsored webpages composing the majority (47.92%) followed by academic sources (35.42%). The webpages' average grade level, incorporating information from all 6 metrics, was 12.79 ± 1.98. CONCLUSIONS: The current readability of online information pertaining to hip arthroscopy is at an inappropriately high reading level compared with the sixth-grade level recommended by the American Medical Association and National Institutes of Health, thus introducing significant barriers to understanding for many patients. Online materials should be edited to reduce word and sentence length and complexity, use simpler terms, and minimize use of passive voice to facilitate patient knowledge acquisition and understanding of online information about hip arthroscopy. CLINICAL RELEVANCE: This study shows that the current readability of online information on hip arthroscopy exceeds the suggested sixth-grade reading level. It also emphasizes the need for simplifying written materials and offers specific suggestions on doing so to increase accessibility of information for patients.

Outcomes After Diagnostic Hip Injection.

PURPOSE: To provide a comprehensive review of outcomes associated with local anesthetic (LA) or LA and corticosteroid (CS) diagnostic hip injections, and how well response predicts subsequent operative success. METHODS: A systematic review from database (PubMed, Medline, Scopus, Embase) inception to January 2015 for English-language articles reporting primary patient outcomes data was performed, excluding studies with >50% underlying osteoarthritis. Studies were assessed by 2 reviewers who collected pertinent data. RESULTS: Seven studies were included, reporting on a total 337 patients undergoing diagnostic hip injection. The mean age was 34.4 years, with 5 studies reporting 94 (35.2%) males and 173 (64.8%) females. One study examined the rate of pain relief with LA (92.5%); 2 CS studies reported relief on a scale from 0% to 100% (no to complete relief), ranging from 61% to 82.3%; and 3 studies used 10-point pain scales, with a CS study noting a pain score of 1.0, an LA study with a score of 3.03, and 1 study using either CS or LA scores of 3 to 5.6. Duration of pain relief was 9.8 (CS) and 2.35 days (LA). By pathology, greatest relief was achieved in acetabular chondral injury (93.3%) and least in cam impingement (81.6%), with clinical and imaging findings being unreliable predictors of relief. One study showed nonresponse to be a strong predictor of negative surgical outcome for femoroacetabular impingement. CONCLUSIONS: Diagnostic hip injections provide substantial pain relief for patients with various hip pathologies, with limited data to suggest greatest relief for those with chondral injury. Clinical and imaging findings are unreliable predictors of injection response, and nonresponse to injection is a strong negative predictor of surgical outcome. Future research should focus on elucidating differences by underlying pathology and predicting future operative success. LEVEL OF EVIDENCE: Level IV, systematic review.

Adolescent Femoroacetabular Impingement: Gender Differences in Hip Morphology.

PURPOSE: To compare the hip morphology of adolescent male patients and female patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) and determine if gender differences exist. METHODS: We retrospectively reviewed the records of 177 adolescents, aged 13 to 18 years, who were treated for FAI with hip arthroscopy. We examined and analyzed preoperative magnetic resonance imaging (MRI) scans and plain radiographs, measuring the lateral center-edge angle, Tönnis angle, and alpha angle. The intraclass correlation coefficient between readers was calculated. We created multiple linear regression models incorporating age, gender, and body mass index (BMI) with the radiographic measurements. Intraoperative findings using the Outerbridge grading system, as well as procedure performed, were documented. We compared these findings with our preoperative imaging measurements using the χ2 test and the Wilcoxon rank sum test. RESULTS: The intraclass correlation coefficient showed moderate to strong agreement between the 3 image readers. The BMI- and age-adjusted mean alpha angle was higher in male patients than female patients on both plain radiographs (55.9° vs 45.2°, P < .0001) and axial oblique MRI scans (54.1° vs 42.5°, P < .0001). An alpha angle greater than 55° was found in 38.9% of male patients compared with only 1% of female patients (P < .0001). The lateral center-edge angle and Tönnis angle on MRI scans and plain radiographs displayed no statistically significant differences between genders after we controlled for BMI and age. Male patients were more likely to have chondral damage intraoperatively than female patients (56.3% vs 32.5%, P = .0041). CONCLUSIONS: Distinct differences between genders were seen both on preoperative imaging and at the time of hip arthroscopy. We found that male patients with FAI displayed a larger mean alpha angle, and therefore a more severe cam-type deformity, than female patients. Our study also found that male patients were more likely to show evidence of chondral damage than female patients at the time of surgery. LEVEL OF EVIDENCE: Level IV.

Development and psychometric evaluation of a cardiovascular risk and disease management knowledge assessment tool.

PURPOSE: This article describes the systematic construction and psychometric analysis of a knowledge assessment instrument for phase II cardiac rehabilitation (CR) patients measuring risk modification disease management knowledge and behavioral outcomes derived from national standards relevant to secondary prevention and management of cardiovascular disease. METHODS: First, using adult curriculum based on disease-specific learning outcomes and competencies, a systematic test item development process was completed by clinical staff. Second, a panel of educational and clinical experts used an iterative process to identify test content domain and arrive at consensus in selecting items meeting criteria. Third, the resulting 31-question instrument, the Cardiac Knowledge Assessment Tool (CKAT), was piloted in CR patients to ensure use of application. Validity and reliability analyses were performed on 3638 adults before test administrations with additional focused analyses on 1999 individuals completing both pretreatment and posttreatment administrations within 6 months. RESULTS: Evidence of CKAT content validity was substantiated, with 85% agreement among content experts. Evidence of construct validity was demonstrated via factor analysis identifying key underlying factors. Estimates of internal consistency, for example, Cronbach's α = .852 and Spearman-Brown split-half reliability = 0.817 on pretesting, support test reliability. Item analysis, using point biserial correlation, measured relationships between performance on single items and total score (P < .01). Analyses using item difficulty and item discrimination indices further verified item stability and validity of the CKAT. CONCLUSIONS: A knowledge instrument specifically designed for an adult CR population was systematically developed and tested in a large representative patient population, satisfying psychometric parameters, including validity and reliability.

Surgeon Performance as a Predictor for Patient-Reported Outcomes After Arthroscopic Partial Meniscectomy.

Background: Surgeon performance has been investigated as a factor affecting patient outcomes after orthopaedic procedures to improve transparency between patients and providers. Purpose/Hypothesis: The purpose of this study was to identify whether surgeon performance influenced patient-reported outcomes (PROMs) 1 year after arthroscopic partial meniscectomy (APM). It was hypothesized that there would be no significant difference in PROMs between patients who underwent APM from various surgeons. Study Design: Case-control study; Level of evidence, 3. Methods: A prospective cohort of 794 patients who underwent APM between 2018 and 2019 were included in the analysis. A total of 34 surgeons from a large multicenter health care center were included. Three multivariable models were built to determine whether the surgeon-among demographic and meniscal pathology factors-was a significant variable for predicting the Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain subscale, the Patient Acceptable Symptom State (PASS), and a 10-point improvement in the KOOS-Pain at 1 year after APM. Likelihood ratio (LR) tests were used to determine the significance of the surgeon variable in the models. Results: The 794 patients were identified from the multicenter hospital system. The baseline KOOS-Pain score was a significant predictor of outcome in the 1-year KOOS-Pain model (odds ratio [OR], 2.1 [95% CI, 1.77-2.48]; P < .001), the KOOS-Pain 10-point improvement model (OR, 0.57 [95% CI, 0.44-0.73), and the 1-year PASS model (OR, 1.42 [95% CI, 1.15-1.76]; P = .002) among articular cartilage pathology (bipolar medial cartilage) and patient-factor variables, including body mass index, Veterans RAND 12-Item Health Survey-Mental Component Score, and Area Deprivation Index. The individual surgeon significantly impacted outcomes in the 1-year KOOS-Pain mixed model in the LR test (P = .004). Conclusion: Patient factors and characteristics are better predictors for patient outcomes 1 year after APM than surgeon characteristics, specifically baseline KOOS-Pain, although an individual surgeon influenced the 1-Year KOOS-Pain mixed model in the LR test. This finding has key clinical implications; surgeons who wish to improve patient outcomes after APM should focus on improving patient selection rather than improving the surgical technique. Future research is needed to determine whether surgeon variability has an impact on longer-term patient outcomes.

Functional outcomes used to compare single radius and multiradius of curvature designs in total knee arthroplasty.

A recent development to better recreate joint kinematics has been a change from a multiradius (MR) design to a single radius (SR) design. We analyzed 559 primary total knee arthroplasty (TKA) procedures which used either a SR (n = 426 Triathlon; Stryker Orthopaedics, Mahwah, NJ) or MR of curvature knee system (n = 133 Duracon; Stryker Orthopaedics, Mahwah, NJ) (79.3% follow-up; 705 total TKA procedures identified). Patients were administered a modification of the Knee Society score (KSS) (3.9 years average follow-up). The SR design showed improvements over the MR design in pain (p = 0.021), stability (p = 0.002), flexion (p = 0.006), ability to completely straighten the knee (p = 0.025), stair climbing (p = 0.0001), walking (p = 0.0001), use of assistive devices (p = 0.0005), postoperative knee score (p = 0.0005), and postoperative function (p < 0.0001). Analysis of the change in KSS knee (p = 0.002) and function scores (p = 0.002) from preoperative visit to postoperative follow-up favored the SR design as well. These data support the use of SR implants and provide evidence of improved outcomes in terms of function, stability, and pain.

Intra-articular Hip Injuries in National Basketball Association Players: A Descriptive Epidemiological Study.

Background: Since the most recent epidemiologic study of injuries in National Basketball Association (NBA) players was completed in 2012, the understanding and diagnosis of intra-articular hip injury has advanced. Purpose: To report the epidemiology of intra- versus extra-articular hip injuries in NBA players with regard to missed games, risk factors for injury, and treatment types. Study Design: Cohort study; Level of evidence, 3. Methods: The NBA injury database was queried for all reported hip and groin injuries from 2013 to 2017. The injuries were then divided into intra-articular and extra-articular types. Variables compared between injury types included player age, NBA tenure, season schedule (preseason or offseason), onset type, injury mechanism, roster position, games missed, time to return to play, and need for surgery. Results: A total of 224 athletes sustaining 353 total hip pathologies were identified. Of these injuries, 216 (61.2%) were sustained during game competition and affected 156 (69.6%) of the athletes. Intra-articular injuries represented 39 (11.0%) cases and involved 36 (16.1%) players. The time to return to play was significantly longer after intra-articular versus extra-articular injury (44.6 ± 96.0 vs 11.8 ± 32.0 days; P = .03), and the number of games missed was significantly greater after intra-articular versus extra-articular injury (8.0 ± 18.7 vs 1.54 ± 4.9 games; P = .03). Patients with intra-articular hip injuries were more likely to undergo surgery (odds ratio, 5.5 [95% CI, 1.8-16.7]; P = .005). There was no statistically significant difference in the number of games missed due to surgery (35.2 ± 8.3 [intra-articular] vs 35.4 ± 11.6 [extra-articular]; P = .42) or nonoperative treatment (4.2 ± 3.4 [intra-articular] vs 1.3 ± 0.5 [extra-articular]; P = .11). Years of NBA tenure were not significantly different between intra-articular and extra-articular injuries (7.1 ± 3.7 vs 6.3 ± 4.0 years). For both types of hip injury, there was no correlation between player age and either days to return to play or number of games missed (R 2 = 0.014). Conclusion: NBA players with intra-articular hip injuries underwent surgery more frequently and had a longer return-to-play time compared with those with extra-articular hip injuries. NBA tenure and player age were not correlated with the risk of developing hip injury or the need for surgery.

Opioid Use After Simple Arthroscopic Knee Surgery.

BACKGROUND: Evidence-based prescribing guidelines are lacking for opioids after most orthopaedic surgical procedures. HYPOTHESIS: Opioids are commonly overprescribed after simple knee arthroscopy. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A cohort of 174 patients who underwent simple arthroscopic knee surgery were prospectively evaluated using data from the Outcome Management and Evaluation database. All patients received 10 combined hydrocodone 5 mg and acetaminophen 325 mg pills postoperatively. Patients were excluded if they (1) had revision surgery, (2) had concomitant complex surgery (eg, ligament surgery, osteotomy), (3) had current opioid use, (4) had open surgery for removal of hardware, (5) or had bilateral knee surgery. Total opioid consumption was reported at the first postoperative visit, and a distribution was created based on patient response. Based on the distribution, patients were separated into low (0-2 pills) versus high (3 or more pills) opioid consumption groups for evaluating risk factors for opioid use. The risk factors included were age, body mass index, smoking status, education level, baseline pain (Knee injury and Osteoarthritis Outcome Score pain subscale [KOOS Pain]), and baseline mental health (Veterans RAND 12-Item Health Survey Mental Component Score), as well as intraoperative findings such as synovial characteristics and extent of osteoarthritis in the multivariate model. RESULTS: Total opioid consumption ranged from 0 to 19 pills. The median pill count was 2 (25th; 75th interquartile range, 0; 4). Of total patients, 59% were categorized as having low opioid consumption, and the remaining 41% were in the high opioid consumption group. Only 23 patients (13.2%) took 6 or more pills. Preoperative pain as measured by KOOS Pain score was a significant predictor of high opioid consumption postoperatively (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .003). CONCLUSION: The clinically relevant conclusion is that opioids are overprescribed after simple arthroscopic knee surgery. Based on distribution, the authors recommend that 4 pills be prescribed after simple arthroscopic knee surgery. After accounting for confounding variables, preoperative pain was associated with higher postoperative opioid consumption.

Evaluation of Differences Between Non-Hispanic White and African American Patients With Sports Medicine-Related Hip Disabilities.

BACKGROUND: Racial disparities within the field of orthopaedics are well-documented in the spinal surgery, knee arthroplasty, and hip arthroplasty literature. Not much is known about racial differences in patients with sports medicine-related hip disabilities. PURPOSE: To investigate whether differences exist between African American and non-Hispanic White (White) patients evaluated for hip disabilities. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a multicenter retrospective cohort study of 905 patients who were evaluated over a 1-year period for hip-related orthopaedic concerns. Patient demographic data, disability characteristics, and hip radiographic findings were obtained from electronic medical records. We also obtained data on whether patients were offered physical therapy, magnetic resonance imaging (MRI), and/or surgery. Comparisons by race and insurance status were evaluated using univariate and multivariate analyses. RESULTS: African Americans comprised a significantly lower proportion of the patients evaluated for hip-related disabilities compared with Whites (6.5% vs 93.5%; P < .001). A significantly smaller proportion of African Americans with hip disabilities was recommended for surgery than White patients (35.6% vs 54.6%; P = .007). Cam deformities were more common in White vs African American patients (39.7% vs 23.7%; P = .021), as were labral tears (54.1% vs 35.6%; P = .009). Logistic regression demonstrated that neither race nor insurance status were significant determinants in surgery recommendations. Conversely, race was a determinant of whether an MRI was performed, as White patients were 2.74 times more likely to have this procedure. There were no differences with respect to obtaining an MRI between private and Medicaid insurance. CONCLUSION: Compared with White patients, there were differences in both the proportion of African Americans evaluated for hip-related disabilities and the proportion receiving a surgery recommendation. African Americans with sports medicine-related hip issues were also less likely to obtain an MRI. With regard to observed pathology, African American patients were less likely to have cam deformities and labral tears than White patients.

Posteromedial Tibial Bone Bruise After Anterior Cruciate Ligament Injury: An MRI Study of Bone Bruise Patterns in 208 Patients.

Background: Bone bruise patterns after anterior cruciate ligament (ACL) rupture may predict the presence of intra-articular pathology and help explain the mechanism of injury. Lateral femoral condyle (LFC) and lateral tibial plateau (LTP) bone bruises are pathognomic to ACL rupture. There is a lack of information regarding medial tibial plateau (MTP) and medial femoral condyle (MFC) bone bruises. Purpose: To summarize the prevalence and location of MTP bone bruises with acute ACL rupture and to determine the predictors of MTP bone bruises. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Inclusion criteria were patients who underwent ACL reconstruction between February 2015 and November 2017, magnetic resonance imaging (MRI) within 90 days of injury, and participation in the database. Exclusion criteria included previous ipsilateral surgery, multiligamentous injuries, and incomplete imaging. Due to the large number of cases remaining (n = 600), 150 patients were selected randomly from each year included in the study, for a total of 300 patients. Two readers independently reviewed injury MRI scans using the Costa-Paz bone bruise grading system. Logistic regression was used to identify factors associated with MTP bone bruises. Results: Included were 208 patients (mean age, 23.8 years; mean body mass index, 25.6). The mechanism of injury was noncontact in 59% of injuries, with over half from soccer, basketball, and football. The median time from injury to MRI scan was 12 days. Of the 208 patients, 98% (203/208) had a bone bruise, 79% (164/208) had an MTP bone bruise, and 83% (172/208) had bruises in both medial and lateral compartments. The most common pattern, representing 46.6% of patients (97/208), was a bruise in all 4 locations (MFC, LFC, MTP, and LTP). Of the 164 MTP bruises, 160 (98%) involved the posterior third of the plateau, and 161 were grade 1. The presence of an MFC bruise was the only independent risk factor for an MTP bruise (odds ratio, 3.71). The resulting nomogram demonstrated MFC bruise, sport, and mechanism of injury were the most important predictors of an MTP bruise. Conclusion: MTP bruise after acute ACL rupture was as prevalent as lateral bruises. The presence of a posterior MTP bruise suggested anterior tibial translation at the time of injury and could portend more medial compartment pathology at the time of injury than previously recognized.

Evaluation of Health Care Disparities in Patients With Anterior Cruciate Ligament Injury: Does Race and Insurance Matter?

Background: It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR). Hypothesis: Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS). Results: The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear. Conclusion: There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear.

Improvements in cognitive function following cardiac rehabilitation for older adults with cardiovascular disease.

Cognitive impairment is common in persons with cardiovascular disease (CVD). Cardiac rehabilitation (CR) improves many aspects of CVD linked to cognitive impairment. The current study explored whether CR may improve cognitive function. Potential mechanisms for cognitive changes were also examined through exploratory analyses, including changes in cardiovascular fitness and cerebral blood flow. Fifty-one older adults with CVD underwent neuropsychological assessment at baseline and discharge from a 12-week CR program. Cardiovascular fitness (i.e., metabolic equivalents [METs]) was estimated from a symptom-limited volitional stress test. Transcranial doppler quantified mean cerebral blood flow velocity and pulsatility indexes for the middle cerebral artery and anterior cerebral artery (ACA). Repeated measures ANOVA showed improvements in global cognition, attention-executive-psychomotor function, and memory. Exploratory analyses revealed improvement in METs and changes in ACA flow velocity, but only improvement in METs was related to improved verbal recall. CVD patients exhibited improvements in multiple cognitive domains following a 12-week CR program, suggesting that cognitive impairment is modifiable in this population. Although other studies are needed to elucidate underlying mechanisms, exploratory analyses suggest that cognitive improvements may be better explained by physiological processes other than improved cardiovascular fitness and cerebral blood flow.

Adherence to prescribed exercise and diet regimens two months post-cardiac rehabilitation.

BACKGROUND: Adherence to diet and exercise regimens significantly limits morbidity and mortality for cardiac patients. Research at six and 12 months post CR program indicates that healthy behaviours learned in CR are not sustained. However, little is known about the extent of adherence in the immediate program completion period. PURPOSE: To determine CR participants' knowledge of their diet and exercise prescription and the degree of adherence two months after completing CR, and to examine demographic and clinical variables to identify relationships to adherence behaviours. METHODS: Participants (n = 174) were recruited from Phase II CR over a one-year period. The Diet Habit Survey (DHS) and Duke Activity Status Index (DASI) scores were administered at admission, discharge, and two months post discharge. Structured telephone interviews were conducted to evaluate adherence behaviours. Spearman correlation was used to determine relationships between demographic and clinical variables and adherence behaviours. RESULTS: Repeated measures ANOVA showed DHS and DASI scores were significantly higher at discharge (p < 0.001) without significant drift at two months post program (p < 0.09). These scores were in contrast with low self-report of knowledge of dietary and exercise recommendations and adherence to dietary and exercise instructions. Lower knowledge about diet and exercise were correlated with employment (diet, p < 0.001; exercise, p < 0.025). Decreased dietary adherence was correlated with BMI (p < 0.005). Exercise adherence was correlated with gender (p < 0.021) and marital status (p < 0.042). CONCLUSION: Although CR participants gain and retain knowledge about necessary dietary changes and improve their exercise activity tolerance during CR, most fail to translate the information into health promoting behaviour changes beginning in the immediate discharge period. Research to identify methods that transform knowledge into lasting behaviour change post CR is needed.