Declining Medicare reimbursement in spinal imaging: a 15-year review.

OBJECTIVE: To analyze and quantify the change in United States of America Medicare reimbursement rates for the 30 most commonly performed spinal imaging procedures. MATERIALS AND METHODS: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was utilized to find and extract the 28 most billed spinal imaging procedures. All data was adjusted for inflation and listed in 2020 US dollars. Percent change in reimbursement and Relative Value Units between 2005 and 2020, both unadjusted and adjusted, were calculated and compared. Additionally, percent change per year and compound annual growth rate were calculated and compared. RESULTS: After adjusting for inflation, the average reimbursement for all analyzed spinal imaging procedures between the years 2005 and 2020 decreased by 45.9%. The adjusted reimbursement rate for all procedures decreased at an average 4.3% per year and experienced an average compound annual growth rate (CAGR) of - 4.4%. Magnetic resonance imaging (MRI) had the most substantial adjusted decline of all imaging modalities at - 72.6%, whereas x-ray imaging had the smallest decline at - 27.33%. The average total RVUs per procedure decreased by 50.1%, from 7.96 to 3.97. CONCLUSION: From the years 2005 to 2020, Medicare reimbursement significantly decreased for all advanced imaging modalities involving the most common spinal imaging procedures. Among all practices, imaging procedures may be experiencing some of the largest decreases from Medicare reimbursement cutbacks.

Arthroscopic Management of the Contact Athlete with Anterior Instability.

Anterior glenohumeral instability is one of the most common injuries suffered from sport. Despite padding and conditioning, the shoulder joint remains particularly vulnerable to injury, especially in the setting of contact. The overall rate of anterior instability is reported to be 0.12 injuries per 1000 athlete exposures, although this is increased up to 0.40 to 0.51 in the contact athlete. Successful treatment requires consideration of restoring stability while minimizing loss of glenohumeral motion. Common treatment strategies involve addressing the pathology that results from anterior shoulder dislocation including labral detachment as well as bony defects to the humeral head and glenoid.

Medicaid Reimbursement for Total Hip and Knee Arthroplasty: A State-by-State Analysis Compared With Medicare.

BACKGROUND: Medicare (MCR) reimbursement for arthroplasty procedures has been declining, but little has been reported on Medicaid (MCD) reimbursement. We sought to determine MCD reimbursement rates using state MCD data for nine arthroplasty procedure codes and compare them to MCR rates. METHODS: The Centers for Medicare & Medicaid Services physician fee schedule was used to collect MCR reimbursement rates, and state MCD fee schedules were accessed to collect MCD rates for nine procedures encompassing primary and revision hip and knee arthroplasty surgery. State MCR and MCD rates were compared to determine the mean dollar difference and dollar difference per relative value unit. A cost of living adjustment was performed using the Medicare Wage Index for each state. Coefficients of variation were calculated for each state to determine overall variability between the two systems. RESULTS: The mean reimbursement rates for MCD were lower for eight of the nine codes used in the study. Medicaid reimbursed physicians an average of 11.3% less overall and 23.1% less when adjusted for cost of living. The amount of variability in the MCR rates was low with a consistent coefficient of variation of 0.06, but was higher in the MCD rates with a range of 0.26 to 0.29 in the unadjusted rates and 0.34 to 0.37 in the adjusted rates. There was a mean $6.73 decreased reimbursement per relative value unit for MCD procedures. CONCLUSIONS: For the most common arthroplasty procedures, MCD reimbursed physicians less than MCR on average. MCD also demonstrated increased variability when compared to MCR rates between states.

Medicaid Reimbursement for Common Orthopedic Trauma Procedures is 16.0% Less Compared to Medicare with Substantial Variability Between States.

OBJECTIVES: This study seeks to evaluate the variability of Medicaid reimbursement and compare it to Medicare reimbursement using the 20 most commonly billed orthopedic trauma CPT codes nationwide. The authors anticipate significant variability between states and hypothesize that Medicaid payment will be significantly less than Medicare payment. METHODS: The top 20 most common orthopedic trauma surgery procedural codes were identified from a previous analysis performed by Haglin et al.1 The Centers for Medicare and Medicaid services physician fee schedule was used to determine reimbursement rates from Medicare, and state Medicaid fee schedules were used to determine reimbursement rates for Medicaid. State Medicaid rates were compared to their corresponding Medicare rates to determine a dollar difference. Additionally, the dollar difference for each CPT code was divided by its respective physician relative value unit (RVU). This was utilized to acknowledge the possible variability in the complexity of orthopedic procedures and the related physician effort. The Medicare Wage Index was used to adjust Medicaid rates based on the cost of living for the state as well. Coefficients of variation were calculated to represent overall variability in Medicaid and Medicare reimbursement rates. RESULTS: The mean reimbursement rates for Medicaid were lower for all 20 procedures compared to Medicare. On average, Medicaid reimbursed 16.0% less than Medicare, and 29.6% less when adjusting for cost-of-living. MCD reimbursed at a higher rate than MCR for all procedures in only nine states (Alaska, Arizona, Arkansas, Montana, Nebraska, New Jersey, New Mexico, and North Dakota, and South Dakota) while 38 states reimbursed at a lower rate than MCR, on average. The coefficient of variation ranged from 0.24 to 0.34 for the Medicaid unadjusted group and from 0.35 to 0.46 for the Medicare Wage-Index adjusted group. In contrast, the Medicare group was consistent at 0.06 for all 20 procedures. The average dollar difference across the 20 CPT codes for Medicaid reimbursement compared to Medicare ranged from -$76.89 to -$225.17, and the dollar difference per relative value unit ranged from -$5.96 to -$15.16. CONCLUSION: This study found a high amount of variation between state Medicaid reimbursement rates and average rates that were significantly lower than Medicare reimbursement rates for the top twenty most utilized orthopedic trauma CPT codes as identified by Haglin et al. The discrepancy in reimbursement was increased when Medicaid rates were adjusted for state cost-of-living. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Patellar Resurfacing Is Not a Risk Factor for Postoperative Patella Baja in Total Knee Arthroplasty.

Background: Patella baja is a known complication of total knee arthroplasty (TKA). There is a limited understanding of the association between patellar resurfacing and the incidence of patella baja. We aimed to compare rates of patella baja between unresurfaced and resurfaced patellas in patients undergoing TKA. Methods: A retrospective review of patients who underwent TKA between October 2009 and January 2020 was performed. Patients were included if they had at least one preoperative radiograph and a 1-year follow-up radiograph. Blackburne-Peel index (BPI) and Insall-Salvati ratios (ISRs) were measured on preoperative and 1-year postoperative radiographs and were used to define patella baja vs pseudopatella baja. Statistical analysis was performed using a linear model analysis of variance and the Fisher's exact test. Results: Three hundred eighteen TKAs were included, with 176 being resurfaced and 142 unresurfaced patellas. Of the resurfaced group, 4% (7/176) had true patella baja, compared to 5.6% (8/142) of the unresurfaced patellas. Of the resurfaced patellas, 8% (14/176) had pseudopatella baja, compared to 7% (10/142) in the unresurfaced group. Patellar resurfacing was not associated with a higher incidence of patella baja (P = .60) or pseudopatella baja (P = .83). Lower preoperative ISRs (P = .04) and BPIs (0.03) were highly predictive of a higher incidence of patella baja post-TKA. Conclusions: Patellar resurfacing in TKA is not associated with a higher incidence of patella baja in TKA when compared to unresurfaced patellas. Lower preoperative ISRs and BPIs are highly predictive of a higher incidence of postoperative patella baja.

Patient Interest in Quadriceps Autograft Anterior Cruciate Ligament Reconstruction Is Increasing Over Other Autograft Options: A 12-Year Google Trends Analysis.

Purpose: To use Google trends to explore differences in public interest among types of anterior cruciate ligament (ACL) autografts, specifically quadriceps tendon, patellar tendon, and hamstring tendon autografts, between 2008 and 2019. Methods: Data were obtained by querying Google Trends for key terms and phrases for online search data ranging from January 2008 to December 2019. Relative search volumes were created based on searches related to ACL reconstruction with comparative analysis generated for search terms related to quadriceps ACL, patellar tendon ACL, and hamstring ACL autografts. Statistical analysis included linear regression analysis, comparison of quarterly search volume trends over time, and comparison of cumulative annual search volumes for 2008 versus 2019. Results: Linear models for respective search terms were statistically significant for the quadriceps (P < .001) and patellar (P = .007) tendon autograft groups but not the hamstring group (P = .129). The quadriceps autograft group demonstrated a 12-year search volume trend change of 0.56, which was significantly greater than the hamstring (0.07; P < .001) and patellar tendon (0.168; P < .001) groups. There was no significant difference in the trend change between hamstring and patellar tendon groups (P = .20). Percent change in cumulative relative annual search volumes between 2008 and 2019 was 112% for the quadriceps tendon group, 12.9% for the hamstring group, and 18.6% for the patellar tendon group. Conclusions: This study indicates a consistently increasing public interest in quadriceps tendon autograft for ACL reconstruction. The quadriceps autograft group demonstrated a significantly greater 12-year online search volume, greater linear correlation, and larger percent change between 2008 and 2019 compared with patellar tendon or hamstring autograft groups. Clinical Relevance: Awareness of patient perceptions has value in informing shared decision-making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.

Arthroscopic Posterior Capsular Release Improves Range of Motion and Outcomes for Flexion Contracture After Anterior Cruciate Ligament Reconstruction in Athletes.

Purpose: To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction. Methods: A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow-up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications. Results: Eighteen athletes with minimum 2 years of follow-up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years' follow-up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension. Conclusions: For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient-reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels. Level of Evidence: Level IV, therapeutic case series.

Pseudoparalysis and Pseudoparesis of the Shoulder: Definitions, Management, and Outcomes.

Loss of shoulder function can be a complex condition to manage. Specifically, the definition between the terms pseudoparalysis and pseudoparesis remains inconsistent in the literature based on various factors including chronicity, present pathology, and the role of pain in the loss of function. There is also debate as to the optimal management strategies for these challenging conditions. In the setting of advanced glenohumeral arthritis or arthropathy in the correct patient, arthroplasty provides consistent and reliable results. However, in younger patients or the patient without arthritis, arthroplasty may not be the best option. In some cases, addressing pain with biceps procedures, balloon spacer placement, débridement, or others may be appropriate. However, other instances may require attempts at improving shoulder kinematics with procedures such as rotator cuff repair, superior capsular reconstruction, and tendon transfer. In this review, we discuss current definitions for pseudoparalysis and pseudoparesis, in addition to reviewing the indications for the various treatment options and their respective outcomes.

Risk Versus Reward: Hospitals Incentivized More Than Surgeons to Care for Riskier Arthroplasty Patients.

BACKGROUND: The purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA). METHODS: The "2021 Medicare Physician and Other Provider" and "2021 Medicare Inpatient Hospitals" files were used. Patient comorbidity profiles were collected, including the mean patient hierarchal condition category (HCC) risk score. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all such inpatient episodes. Surgeon and hospital reimbursements were collected. All episodes were split into a "sicker cohort" with an HCC risk score of 1.5 or more and a "healthier cohort" with HCC risk scores less than 1.5. Variables were compared across cohorts. RESULTS: In 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < .001). Meanwhile, for the hospital analysis, 112,012 Medicare TJA patients were admitted as inpatients and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < .001). CONCLUSIONS: This study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients.

Low Risk of Periprosthetic Joint Infection After Aseptic Revision Total Knee Arthroplasty With Intraosseous Vancomycin.

BACKGROUND: Aseptic revisions are the most common reason for revision total knee arthroplasty (rTKA). Previous literature reports early periprosthetic joint infection (PJI) rates after aseptic rTKA to range from 3 to 9.4%. Intraosseous (IO) regional administration of vancomycin has previously been shown to produce high local tissue concentrations in primary and rTKA. However, no data exist on the effect of prophylactic IO vancomycin on early PJI rates in the setting of aseptic rTKA. The aim of this study was to determine the following: (1) what is the rate of early PJI during the first year after surgery in aseptic rTKA performed with IO vancomycin; and (2) how does this compare to previously published PJI rates after rTKA. METHODS: A consecutive series of 117 cases were included in this study who underwent rTKA between January 2016 and March 2022 by 1 of 2 fellowship-trained adult reconstruction surgeons and received IO vancomycin at the time of surgery in addition to standard intravenous antibiotic prophylaxis. Rates of PJI at 3 months, 1 year, and the final follow-up were evaluated and compared to prior literature. RESULTS: Follow-up at 3 months was available for 116 of the 117 rTKAs, with 1 lost to follow-up. The rate of PJI was 0% at 3 months postoperatively. Follow-up at 1 year was obtained for 113 of the 117 rTKAs, and the PJI rate remained 0%. The rate of PJI at the final follow-up of ≥ 1 year was 0.88% (95% confidence interval: -0.84 to 2.61). Previous literature reports PJI rates in aseptic rTKA to range from 3 to 9.4%. CONCLUSIONS: Dual prophylactic antibiotics with IO vancomycin in conjunction with intravenous cephalosporins or clindamycin were associated with a substantial reduction in early PJI compared to prior published literature. These data supplement the early evidence about the potential clinical benefits of IO vancomycin for infection prevention in high-risk cases. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Patients Say About Their Orthopaedic Hand and Wrist Surgeons: A Qualitative Analysis of Negative Reviews on Yelp.

Background Patients often turn to online reviews as a source of information to inform their decisions regarding care. Existing literature has analyzed factors associated with positive online patient ratings among hand and wrist surgeons. However, there is limited in-depth analysis of factors associated with low patient satisfaction for hand and wrist surgeons. The focus of this study is to examine and characterize extremely negative reviews of hand and wrist surgeons on Yelp.com. Methods A search was performed using the keywords "hand surgery" on Yelp.com for eight major metropolitan areas including Washington DC, Dallas, New York, Phoenix, Los Angeles, San Francisco, Boston, and Seattle. Only single-star reviews (out of a possible 5 stars) of hand and wrist surgeons were included. The complaints in the 1-star reviews were then categorized into clinical and nonclinical categories. Result A total of 233 single-star reviews were included for analysis, which resulted in 468 total complaints. Of these complaints, 81 (18.8%) were clinically related and 351 (81.3%) were nonclinical in nature. The most common clinical complaints were for complication (24 complaints, 6%), misdiagnosis (16 complaints, 4%), unclear treatment plan (16 complaints, 4%), and uncontrolled pain (15 complaints, 3%). The most common nonclinical complaints were for physician bedside manner (93 complaints, 22%), financially related (80 complaints, 19%), unprofessional nonclinical staff (61 complaints, 14%), and wait time (46 complaints, 11%). The difference in the number of complaints for surgical and nonsurgical patients was statistically significant ( p < 0.05) for complication and uncontrolled pain. Clinical Relevance Patient satisfaction is dependent on a multitude of clinical and nonclinical factors. An awareness of online physician ratings is essential for hand and wrist surgeons to maintain and improve patient care and patient satisfaction. We believe the results of our study could be used to further improve the quality of care provided by hand and wrist surgeons.

Lower Income and Nonheterosexual Orientation Are Associated With Poor Access to Care in Patients With Knee Osteoarthritis.

Background: Social determinants of health are implicated in the experience of knee osteoarthritis, a key component of which is access to care and healthcare utilization. The objective of this study was to describe difficulties in access to care and healthcare utilization in the United States knee osteoarthritis population. Methods: The publicly available All of Us Database was utilized to conduct a retrospective cohort study. Patients with a diagnosis of knee osteoarthritis were included and matched to a control group who did not have knee osteoarthritis. The association of knee osteoarthritis and patient-specific demographic features with self-reported domains of access to care was analyzed. Results: Among 15,718 patients with knee osteoarthritis, 27.6% reported delayed care (n = 4343), 25.6% reported inability to afford care (n = 4015), 12.8% reported skipped medications (n = 2011), and 1.6% reported not seeing a healthcare provider in over 1 year (n = 247). Patients with knee osteoarthritis were more likely to be unable to afford care (odds ratio 1.21, P < .001) or skip medications (odds ratio 1.12, P = .004) in comparison to matched patients without knee osteoarthritis. Among the knee osteoarthritis cohort, low income and nonheterosexual orientation were both associated with increased rates of delayed care and an inability to afford care. Conclusions: Patients with knee osteoarthritis report significant challenges with delayed care, affordability of care, and medication adherence. Among patients with knee osteoarthritis, patients who are younger age, female sex, low-income, low-education, nonheterosexual orientation, or have poor physical and mental health are at increased risk of having decreased access to treatment.

Acute Patellar Tendon Ruptures: An Update on Management.

Patellar tendon ruptures can be debilitating injuries. When incomplete, partial tears can be managed nonsurgically with immobilization and progressive rehabilitation. Although complete ruptures remain a relatively uncommon injury, they portend a high level of morbidity. Ruptures typically result from an acute mechanical overload to the extensor mechanism, such as with forced quadriceps contraction and knee flexion. However, chronically degenerated tendons are also predisposed to failure from low-energy injuries. Diagnosis can often be made clinically with recognition of a palpable defect to the tendon, localized patellar tendon tenderness, and inability to actively extend the knee. Diagnosis and surgical planning can be established with radiograph, ultrasonography, or magnetic resonance imaging. Surgical repair is the mainstay of treatment, and there have been many recent advances in repair technique, optimal reconstruction strategies, and supplemental fixation. Time to surgery for complete tears remains the most important prognosticator for success. Direct primary repair can be completed with transosseous tunnels, suture anchor repair, or end-to-end repair. Tendon reconstruction can be achieved with or without mechanical or biologic augments. Rehabilitation programs vary in specifics, but return to sport can be expected by 6 months postoperatively.

Editorial Commentary: Tuberoplasty Is a Reliable Option to Address Pain in Massive Irreparable Rotator Cuff Tears.

The massive irreparable rotator cuff tear remains a challenging condition for which there are many reported treatment options, including biceps tenotomy or tenodesis, subacromial decompression, cuff debridement, partial or augmented rotator cuff repair, bursal acromial reconstruction, balloon spacer placement, superior capsular reconstruction, reverse total shoulder arthroplasty, and tendon transfer, among others. Optimally treating the condition relies on paying attention to several patient factors, including correctly identifying whether function loss is driven by pain or compromised shoulder kinematics. If pain is the primary limiting factor, then tuberoplasty, or "reversed subacromial decompression," seems to be a reliable option that can afford encouraging results in terms of pain and range of motion in correctly indicated individuals. It is important to note, however, that these results should not be expected in the patient with anterior-superior humeral escape or pseudoparalysis, in whom a kinematic-restoring option may be more appropriate. Considering a history of inconsistent terminology and definitions when it comes to defining massive tears, when they are irreparable, and when the patient has pseudoparesis versus pseudoparalysis, it is paramount to accurately describe patient factors, including preoperative function, in ongoing research.

Hamstring Tendon Autograft Is Associated With Increased Knee Valgus Moment After Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis.

BACKGROUND: There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone-patellar tendon-bone autograft at 6 months postoperatively in an adolescent population. The authors' hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used. STUDY DESIGN: Controlled laboratory study. METHODS: Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb. RESULTS: A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg (P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10-2 vs -35 × 10-2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10-2 vs -4 × 10-2 N·m/kg, respectively; P = .0426). Both the QT with bone block (-12 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0265) and QT (-13 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group. CONCLUSION: The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft. CLINICAL RELEVANCE: This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.

All-Arthroscopic Falciform Portal Biceps Tenodesis.

Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra-articular biceps pathology. In this report we describe an all-arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation.

Editorial Commentary: Extreme Hip Labral Size (Both Small and Large) Shows Inferior Outcomes After Arthroscopic Labral Repair With Femoroacetabular Impingement Treatment.

Arthroscopic management of hip femoroacetabular impingement shows reliable improvement in pain and patient-reported outcomes, high survivorship, and low conversion to total hip arthroplasty, particularly in the absence of dysplasia. Concomitant labral repair-or augmentation versus reconstruction when indicated- consistently shows better results than labral debridement. The effect of labral size on outcomes has been studies in several series. Some studies show that smaller labra show inferior outcomes after repair, others show labral size makes no difference in outcomes, and one showed that patients large labra actually had worse outcomes. Perhaps labral size at either extreme does worse. Labral size is likely to remain one of many factors worth evaluating when prognosticating repair outcomes or indicating when advanced reconstructive options are warranted.

Surgical Management of Massive Irreparable Cuff Tears: Superior Capsule Reconstruction and Rotator Cable Reconstruction.

PURPOSE OF REVIEW: Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations. RECENT FINDINGS: Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns. SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures.

Editorial Commentary: One- and 2-Year Outcomes Are Clinically Similar After Rotator Cuff Repair: What Are We Waiting For?

Research standards require reliable data from which we can draw accurate conclusions. For short-term outcome studies, one measure recommended by journals is preferring at least 2 years' minimum follow-up. In some cases, this is important to avoid false conclusions because of follow-up too short to detect either failure or complete improvement. However, although intended to prevent an incomplete picture, this mandate may not always add clinical utility. Recent data suggest that for rotator cuff repair outcomes, 1-year follow-up is clinically sufficient, making the 2-year recommendation an inconvenient and unnecessary standard. The widely accepted 2-year benchmark may be arbitrary and promotes a one-size-fits all approach; the approach can be evidence-based refined.

Medial Collateral Ligament Pie-Crusting for Isolated Medial Meniscal Root Repair Is Associated With Improved Clinical Outcomes with Minimum 2-Year Follow-Up.

PURPOSE: To determine clinical and radiographic outcomes of medial collateral ligament (MCL) pie-crusting during isolated medial meniscal root repair. METHODS: A retrospective review was conducted between August 2013 and December 2019 in patients undergoing isolated medial meniscal root repair. Outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, re-tears, MCL laxity, and conversion to total knee arthroplasty (TKA), were compared between pie crust (PC) and non-pie crust (NPC) cohorts. Other assessments included subjective instability or stiffness, infection, and intra-operative chondromalacia. Additionally, radiographic outcomes were compared to determine progression of medial compartment arthrosis. RESULTS: Final analysis included 97 knees, 45 in the PC, and 52 in the NPC group. IKDC and Lysholm scores were similar between both groups preoperatively and 3 months postoperatively. However, at the 6,12, and 24-month follow up, the PC group had a significantly higher measured IKDC and Lysholm scores than the NPC group. PASS percentages for the IKDC score were significantly higher in the PC group at 6 months, 1 year, and 2 years (96.2%; P = .02) follow-up compared to the NPC group. MCID percentages for the IKDC score were also significantly higher at the 1- and 2-year (100%; P = .05) follow-up in the PC group compared to the NPC group. There was also a significantly higher rate of recurrent medial meniscal root tears in the NPC group (4 [8.9%]) compared to the PC group (0 [P = .03]). No MCL laxity was observed at 6 months follow-up. CONCLUSIONS: MCL pie-crusting during isolated medial meniscal root repair can be used as an alternative surgical technique, as it leads to improved clinical and patient outcomes compared to patients who do not undergo MCL pie-crusting in the short term. Additionally, those that underwent MCL pie-crusting had a lower incidence of recurrent tears, and no patients experienced MCL laxity at 6 months. LEVEL OF EVIDENCE: Level III, retrospective cohort/comparative study.