Patients Undergoing Postless Hip Arthroscopy Demonstrate Significantly Better Patient-Reported Outcomes and Clinically Significant Outcomes Compared to Conventional Post-Assisted Hip Arthroscopy at Short-Term Follow-Up.

PURPOSE: To prospectively compare the short-term clinical outcomes of patients undergoing hip arthroscopy with versus without the use of a perineal post. METHODS: A prospective, single-surgeon cohort study was performed on a subset of patients undergoing hip arthroscopy between 2020 and 2022. A post-free hip distraction system was used at 1 center at which the senior author operates, and a perineal post was used at another surgical location. An electronic survey of patient-reported outcome measures (PROMs) was completed by each patient at a minimum of 1 year postoperatively. PROMs included a visual analog scale for pain; University of California, Los Angeles (UCLA) Activity Scale; modified Harris Hip Score (mHHS); Hip Outcome Score-Sports-Specific Subscale (HOS-SSS); and a Single Assessment Numeric Evaluation. Postoperative scores and clinically significant outcomes, including the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state, for each PROM were compared between groups. RESULTS: Sixty-nine patients were reached for follow-up (41 post, 28 postless) of 87 patients eligible for the study (79%). No significant differences were found between groups in terms of sex (post: 61% female, postless: 54% female, P = .54), age (post: 34 years, postless: 29 years, P = .11), body mass index (post: 26, postless: 24, P = .23), or follow-up duration (post: 24.4 months, postless: 21.3 months, P = .16). There was a significantly higher visual analog scale (3.1 vs 1.4, P = .01), a significantly lower UCLA Activity Scale score (7.0 vs 8.4, P = .02), and a significantly lower mHHS (73.7 vs 82.2, P = .03) in the post-assisted group. A significantly higher proportion of patients in the postless group achieved a patient acceptable symptom state for the UCLA (89.3% vs 68.3%, P = .04), mHHS (84.6% vs 61.0%, P = .04), and HOS-SSS (84.0% vs 61.0%, P = .048) and a substantial clinical benefit for HOS-SSS (72.0% vs 41.5%, P = .02). One patient (2.6%) in the post group underwent revision hip arthroscopy, and another was indicated for total hip arthroplasty by the time of follow-up. CONCLUSIONS: Postless hip arthroscopy may result in better clinical outcomes compared with post-assisted hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Following Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Autograft, the Incidence of Anterior Knee Pain Ranges From 5.4% to 48.4% and the Incidence of Kneeling Pain Ranges From 4.0% to 75.6%: A Systematic Review of Level I Studies.

Purpose: To (1) perform a systematic review of level I randomized controlled trials (RCTs) detailing the incidence of anterior knee pain and kneeling pain following anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) autograft and (2) investigate the effect of bone grafting the patellar harvest site on anterior knee and kneeling pain. Methods: A systematic review of level I studies from 1980 to 2023 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome evaluated was the presence of donor site morbidity in the form of anterior knee pain or kneeling pain. A secondary subanalysis was performed to assess for differences in the incidence of postoperative pain between patient groups undergoing ACLR with BPTB receiving harvest site bone grafting and those in whom the defect was left untreated. Results: Following full-text review, 15 studies reporting on a total of 696 patients met final inclusion criteria. Patients were followed for an average of 4.78 years (range, 2.0-15.3), and the mean age ranged from 21.7 to 38 years old. The incidence of anterior knee pain, calculated from 354 patients across 10 studies, ranged from 5.4% to 48.4%. The incidence of postoperative pain with kneeling was determined to range from 4.0% to 75.6% in 490 patients from 9 studies. Patients treated with bone grafting of the BPTB harvest site had no significant difference in incidence of any knee pain compared with those who were not grafted, with incidences of 43.3% and 40.2%, respectively. Conclusions: Based on the current level I RCT data, the incidences of anterior knee pain and kneeling pain following ACLR with BPTB autograft range from 5.4% to 48.4% and 4.0% to 75.6%, respectively. Level of Evidence: Level I, systematic review of RCTs.

The Addition of a Pericapsular Nerve Group Block for Postoperative Pain Control Does Not Result in Less Narcotic Use After Hip Arthroscopy: A Systematic Review.

Purpose: To perform a systematic review of clinical studies evaluating the pericapsular nerve group (PENG) block in patients undergoing hip arthroscopy. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify comparative studies of patients undergoing the PENG block before hip arthroscopy. The search phrase used was hip arthroscopy pericapsular nerve block. Patients were evaluated based on analgesic consumption, time to discharge from the postanesthesia care unit (PACU), and pain scores (Numeric Rating Scale and visual analog scale). The Modified Coleman Methodology Score was used to evaluate study methodology quality. Results: Five studies (2 Level I, 3 Level III) met inclusion criteria. The 5 studies included the following comparison groups: 0.9% normal saline injection, general anesthesia alone, and general anesthesia with intraoperative pericapsular bupivacaine injection. The 2 randomized controlled trials included in this review reported no significant difference between groups regarding opioid consumption. One of these did not find any statistically significant differences in their secondary outcomes either, including patient satisfaction with analgesia, opioid-related adverse events, or persistent opioid use at 1 week. However, the other 3 studies found significantly lower opioid consumption in patients receiving the PENG block versus the control group intraoperatively, in the PACU, and/or postoperatively. Four studies reported significantly lower pain levels in the PENG block group compared with the control groups, measured differently in each study: 24 hours postoperatively, initial pain score in the PACU, mean score in the PACU, and highest score in the PACU. None of the studies found significantly worse outcomes in the PENG block group compared to the comparison group. Conclusions: Systematic review of randomized controlled trials shows that patients undergoing hip arthroscopy who receive a PENG block do not consume fewer opioids for postoperative pain control than patients who do not receive the block. Level of Evidence: Level III, systematic review of Level I-III studies.

Rotator Cuff Repair With or Without Acromioplasty: A Systematic Review of Randomized Controlled Trials With Outcomes Based on Acromial Type.

BACKGROUND: It is unclear whether the use of concomitant acromioplasty during rotator cuff repair (RCR) improves clinical outcomes and whether the outcomes are affected by acromial type. PURPOSE: To perform a systematic review of randomized controlled trials comparing clinical outcomes of RCR with and without acromioplasty, with a subanalysis of outcomes based on acromial type. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that directly compared outcomes between RCR with versus without acromioplasty. A subanalysis was performed on the studies that provided outcomes based on acromial type. The search phrase used was rotator cuff repair (acromioplasty OR subacromial decompression) randomized. Patients were evaluated based on retear rate, reoperation rate, and patient-reported outcomes (PROs). RESULTS: Application of inclusion criteria yielded 5 studies (2 studies were level 1, and 3 studies were level 2) including a total of 409 patients, with 211 patients undergoing RCR alone (group A) and 198 patients undergoing RCR with acromioplasty (group B). The mean patient age was 58.5 and 58.3 years in groups A and B, respectively. The mean follow-up time was 52.9 months, and the overall percentage of male patients was 54.1%. The rotator cuff tear size was 20.7 mm and 19.8 mm for groups A and B, respectively. No significant differences were found between groups for any of the PROs at final follow-up. Overall retear rates did not significantly differ between groups based on acromial type. Between 2 studies that measured reoperation rate, a significantly higher reoperation rate was found for the nonacromioplasty group (15%) versus the acromioplasty group (4.1%) (P = .031). One of these studies found that 5 of 9 patients (56%) with a type III acromion in the nonacromioplasty group underwent reoperation compared with 0 of 4 patients with a type III acromion in the acromioplasty group. CONCLUSION: There is some evidence that acromioplasty during RCR reduces the risk for later reoperation. This may be particularly true for patients with type III acromions, although further studies with larger sample sizes are needed to corroborate these data.

Microfracture of Acetabular Chondral Lesions Is Not Superior to Other Cartilage Repair Techniques in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review.

PURPOSE: To perform a systematic review to compare clinical outcomes of hip arthroscopy patients undergoing microfracture (MFx) versus other cartilage repair procedures for chondral lesions of the acetabulum. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies that directly compared outcomes between MFx and other cartilage repair procedures for full-thickness chondral lesions of the acetabulum identified during hip arthroscopy. The search phrase used was: hip AND arthroscopy AND microfracture. Patients were evaluated based on reoperation rates and patient-reported outcomes. RESULTS: Six studies (all Level III evidence) met inclusion criteria, including a total of 202 patients undergoing microfracture (group A) and 327 patients undergoing another cartilage repair procedure (group B). Mean patient age ranged from 35.0 to 45.0 years. Mean follow-up time ranged from 12.0 to 72.0 months. Significantly better patient-reported outcomes (PROs) were found in patients undergoing treatment with bone marrow aspirate concentrate, microfragmented adipose tissue concentrate, autologous matrix-induced chondrogenesis, and a combination of autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with MFx. No studies found significantly better postoperative PROs in group A. The reoperation rate ranged from 0% to 34.6% in group A and 0% to 15.9% in group B. Three of 5 studies reporting on reoperation rate found a significantly greater reoperation rate in group A, with no difference in the other 2 studies. CONCLUSIONS: The literature on MFx of acetabular chondral lesions is limited and heterogeneous. Based on the available data, MFx alone results in a greater or equivalent reoperation rate and inferior or equivalent PROs compared with other cartilage repair procedures for acetabular chondral lesions in patients with femoroacetabular impingement syndrome. LEVEL OF EVIDENCE: Level III, systematic review of level III studies.

Screw Fixation for the Latarjet Procedure May Reduce Risk of Recurrent Instability but Increases Reoperation Rate Compared to Suture-Button Fixation: A Systematic Review.

PURPOSE: To perform a systematic review to compare clinical outcomes, complications, and reoperation rates of patients undergoing the Latarjet procedure with screw vs suture-button fixation. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies directly comparing screw vs suture-button fixation for the Latarjet procedure. The search terms used were shoulder screw suture button. Patients were evaluated based on reoperation rate, complication rate, recurrent instability, radiologic outcomes, and patient-reported outcomes. Graft and screw position were assessed via computed tomography. RESULTS: Seven studies (1 Level II, 6 Level III) met inclusion criteria, with 845 patients undergoing the Latarjet procedure with screw fixation (screw group) and 279 patients with suture-button fixation (suture-button group). Mean patient age ranged from 21.2 to 29.6 years. Mean follow-up time ranged from 6.0 to 40.8 months. The recurrent instability rate ranged from 0% to 2.5% in the screw group and 0% to 8.3% in the suture-button group. The reoperation rate ranged from 0% to 7.7% in the screw group compared to 0% to 1.9% in the suture-button group. One study reported significantly lower visual analog scale pain scores in the suture-button group compared with the screw group (1.5 vs 1.2, P = .003). No other studies reported significant differences in any patient-reported outcomes. There was no significant difference in horizontal or vertical graft position, graft union rate, or complication rate between groups in any study. CONCLUSIONS: The Latarjet procedure with screw fixation may result in a lower risk of recurrent instability compared to suture-button fixation, although screw fixation may also have a higher reoperation rate due to hardware-related complications. LEVEL OF EVIDENCE: Level III, systematic review of Level II to III studies.

Orthopaedic Surgeons Should Consider Online and E-publication Resources for the Most Current Evidence-Based Medicine Following the COVID-19 Pandemic.

Purpose: To compare the time to publication of accepted manuscripts and content in orthopaedic sports medicine journals during the first 2 years of the COVID-19 pandemic. Methods: A convenience sample of articles published in January, May, and September during the years 2019-2021 was taken from Arthroscopy, American Journal of Sports Medicine (AJSM), and Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA). The duration between the aspects of the article publication process was compared between journals and years. Results: Overall, 826 journal articles were included. Arthroscopy demonstrated no significant differences in the time from manuscript submission to journal publication from 2019 to 2021, a significant decrease in time from acceptance to e-Pub (140 vs 74 vs 16 days; P < .001), but an increase from e-Pub to journal publication (23 vs 74 vs 130 days; P < .001). In AJSM, there was an overall increase in time from submission to journal publication significant between 2019 and 2021 (P = .05) and 2020 and 2021 (P = .001). KSSTA demonstrated the longest timelines in 2020. There was a trend toward a greater number of systematic reviews and meta-analyses. Conclusion: Changes in various aspects of the time to publication and journal content occurred in orthopaedic sports medicine journals in the years surrounding the peak of the COVID-19 pandemic in 2020. Although it is not possible to know whether these delays are caused by journal or author-related factors, orthopaedic surgeons should be aware of the possible delay in time to publication and consider online and e-publication resources for the most current evidence-based medicine, while journals may take this information into account to consider ways of improving the publication process and when determining journal content. Clinical Relevance: It is important to understand the impact the COVID-19 pandemic had on the publications which orthopaedic sports medicine surgeons rely on for clinical knowledge and the practice of evidence-based medicine.

Isolated Osteotomy Versus Combined Osteotomy and Cartilage Repair for Osteoarthritis or Focal Chondral Defects of the Medial Compartment of the Knee Joint: A Systematic Review.

Background: The extent to which concomitant cartilage repair provides an improvement in clinical outcomes after osteotomy is unclear. Purpose: To compare studies reporting clinical outcomes after isolated osteotomy with or without cartilage repair for osteoarthritis (OA) or focal chondral defects (FCDs) of the knee joint. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, Cochrane Library, and Embase databases. The search was done to identify comparative studies that directly compared outcomes between isolated osteotomy-high tibial osteotomy or distal femoral osteotomy-and osteotomy with concomitant cartilage repair for OA or FCDs of the knee joint. Patients were evaluated based on reoperation rate, magnetic resonance observation of cartilage repair tissue score, macroscopic International Cartilage Regeneration & Joint Preservation Society score, and patient-reported outcomes. Results: In total, 6 studies-level 2 evidence (n = 2);, level 3 evidence (n = 3);, and level 4 evidence (n = 1)-met the inclusion criteria, including a total of 228 patients undergoing osteotomy alone (group A) and 255 patients undergoing osteotomy with concomitant cartilage repair (group B). The mean patient age was 53.4 and 54.8 years, respectively, and the mean preoperative alignment was 6.6° and 6.7° of varus in groups A and B, respectively. The mean follow-up time was 71.5 months. All studies assessed medial compartment lesions with varus deformity. One study compared osteotomy alone for patients with medial compartment OA versus osteotomy with autologous chondrocyte implantation for patients with FCDs of the medial compartment. Three other studies included a heterogeneous cohort of patients with OA and FCDs in both groups. Only 1 study isolated its comparison to patients with medial compartment OA and 1 study isolated its comparison to patients with FCDs. Conclusion: There is limited evidence with substantial heterogeneity between studies on clinical outcomes after osteotomy alone versus osteotomy with cartilage repair for OA or FCDs of the knee joint. At this time, no conclusion can be made regarding the role of additional cartilage procedures in treating medial compartment OA or FCDs. Further studies are needed that isolate specific disease pathology and specific cartilage procedures.

Tommy John: Elbow Ulnar Collateral Ligament Allograft Reconstruction With Internal Brace.

Injuries of the medial ulnar collateral ligament (UCL) of the elbow have previously been career ending for overhead athletes, with gymnasts and baseball pitchers being highly affected. The majority of UCL injuries in this population are chronic, overuse injuries and may be amenable to surgical intervention. The original reconstruction technique, pioneered by Dr. Frank Jobe in 1974, has undergone many modifications over the years. Most notable is the modified Jobe technique developed by Dr. James R. Andrews, which has resulted high rates of return to play and increased career longevity. However, the lengthy recovery time is still problematic. As a way to address the lengthy recovery time, a UCL repair with an internal brace technique improved the time to return to play but has limited applicability to the young patient with an avulsion injury and good tissue quality. Furthermore, there is considerable variety in other published techniques including surgical approach, repair, reconstruction, and fixation. We present here a technique for a muscle splitting, ulnar collateral ligament reconstruction with allograft to provide collagen for longevity and internal brace for immediate stability, early rehabilitation, and return to play.

Postless Arthroscopic Hip Preservation Can be Adequately Performed Using Published Techniques.

Purpose: To identify and evaluate techniques used for postless hip arthroscopy. Methods: A narrative review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify surgical technique articles or clinical studies describing techniques for the use of postless hip arthroscopy. Specific items sought for analysis included hip arthroscopy for femoroacetabular impingement including cam or pincer-type lesions, surgical time, traction time, traction force, bed Trendelenburg angle, intraoperative techniques, and postoperative outcomes, including complications. Exclusion criteria included any postless techniques used for open hip surgeries such as periacetabular osteotomy, sports hernia, peritrochanteric work, gluteus medius repair, ischiofemoral impingement, hamstring repair, or need for intraoperative conversion from postless to posted technique. Results: Ten studies (1 Level III, 3 Level IV, 6 Level V), published from 2007 to 2021, were analyzed (1,341 hips, 51.5% male, mean age ranged from 16.0 to 66.0 years). In 4 studies, Trendelenburg position with a foam pad (The Pink Pad; Xodus Medical, Inc.) was used at 5 to 20°. Six of 10 studies contained no clinical results. The average traction force and time ranged from 65.0 to 88 pounds and 31.0 to 73.5 minutes, respectively. The remaining studies used the yoga mat technique, the Tutankhamun technique, the beanbag technique, and the Hip Arthroscopy Post-less Procedure Impingement technique. There was only one incident of pudendal neurapraxia, which resolved spontaneously at 6 weeks without complication. Sufficient distraction was able to be obtained using postless traction in all cases. Conclusions: Postless hip arthroscopy may adequately be performed with a variety of techniques. Obtaining adequate traction and countertraction may be achieved through these postless methods. Clinical Relevance: Given the potential serious complications that may result from use of a perineal post, it is important for surgeons to be aware of postless techniques that may be used effectively for hip arthroscopy.

Effects of Running on the Development of Knee Osteoarthritis: An Updated Systematic Review at Short-Term Follow-up.

Background: Some studies have suggested that running increases the risk of knee osteoarthritis (OA), while others believe it serves a protective function. Purpose: To perform an updated systematic review of the literature to determine the effects of running on the development of knee OA. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies evaluating the effect of cumulative running on the development of knee OA or chondral damage based on imaging and/or patient-reported outcomes (PROs). The search terms used were "knee AND osteoarthritis AND (run OR running OR runner)." Patients were evaluated based on plain radiographs, magnetic resonance imaging (MRI), and PROs (presence of knee pain, Health Assessment Questionnaire-Disability Index, and the Knee injury and Osteoarthritis Outcome Score). Results: Seventeen studies (6 level 2 studies, 9 level 3 studies, and 2 level 4 studies), with 7194 runners and 6947 nonrunners, met the inclusion criteria. The mean follow-up time was 55.8 months in the runner group and 99.7 months in the nonrunner group. The mean age was 56.2 years in the runner group and 61.6 years in the nonrunner group. The overall percentage of men was 58.5%. There was a significantly higher prevalence of knee pain in the nonrunner group (P < .0001). Although 1 study found a significantly higher prevalence of osteophytes in the tibiofemoral (TF) and patellofemoral (PF) joints within the runner group, multiple studies found no significant differences in the prevalence of radiographic knee OA (based on TF/PF joint-space narrowing or Kellgren-Lawrence grade) or cartilage thickness on MRI between runners and nonrunners (P > .05). One study found a significantly higher risk of knee OA progressing to total knee replacement among nonrunners (4.6% vs 2.6%; P = .014). Conclusion: In the short term, running is not associated with worsening PROs or radiological signs of knee OA and may be protective against generalized knee pain.

Cartilage Repair of the Tibiofemoral Joint With Versus Without Concomitant Osteotomy: A Systematic Review of Clinical Outcomes.

Background: The extent to which concomitant osteotomy provides an improvement in clinical outcomes after cartilage repair procedures is unclear. Purpose: To review the existing literature to compare clinical outcomes of patients undergoing cartilage repair of the tibiofemoral joint with versus without concomitant osteotomy. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify studies that directly compared outcomes between cartilage repair of the tibiofemoral joint alone (group A) versus cartilage repair with concomitant osteotomy (high tibial osteotomy [HTO] or distal femoral osteotomy [DFO]) (group B). Studies on cartilage repair of the patellofemoral joint were excluded. The search terms used were as follows: osteotomy AND knee AND ("autologous chondrocyte" OR "osteochondral autograft" OR "osteochondral allograft" OR microfracture). Outcomes in groups A and B were compared based on reoperation rate, complication rate, procedure payments, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale [VAS] for pain, satisfaction, and WOMAC). Results: Included in the review were 5 studies (1 level 2 study, 2 level 3 studies, 2 level 4 studies) with 1747 patients in group A and 520 patients in group B. The mean patient ages were 34.7 and 37.5 years in groups A and B, respectively, and the mean lesion sizes were 4.0 and 4.5 cm2, respectively. The mean follow-up time was 44.6 months. The most common lesion location was the medial femoral condyle (n = 999). Preoperative alignment averaged 1.8° and 5.5° of varus in groups A and B, respectively. One study found significant differences between groups in KOOS, VAS, and satisfaction, favoring group B. The reoperation rates were 47.4% and 17.3% in groups A and B, respectively (P < .0001). Conclusion: Patients undergoing cartilage repair of the tibiofemoral joint with concomitant osteotomy might be expected to experience greater improvement in clinical outcomes with a lower reoperation rate compared with those undergoing cartilage repair alone. Surgeons preparing for cartilage procedures of the knee joint should pay particular attention to preoperative malalignment of the lower extremity to optimize outcomes.

Editorial Commentary: For Surgical Treatment of Elbow Lateral Epicondylitis, Arthroscopic Treatment Is Recommended for Surgeons With Elbow Arthroscopy Training.

Lateral epicondylitis is a commonly encountered and persistent problem in the active, middle-aged population, with a reported annual incidence as high as 3.4%. Lateral epicondylitis is often treated successfully with conservative measures but may necessitate surgical intervention in refractory cases. Most of the review literature has failed to definitively identify arthroscopic or open debridement as the superior surgical approach. We favor the arthroscopic approach because it allows for the examination and treatment of concomitant intra-articular pathologies, which may be underappreciated on magnetic resonance imaging, and for minimal disruption of the superficial extensors to access the pathologic structures. In addition, this approach often allows for a quick resolution of symptoms and expeditious return to work and sport with a low rate of complications or revisions. For surgeons who are not experienced in elbow arthroscopy, the option of open debridement remains a reasonable approach. However, our preferred management of surgically indicated tennis elbow is arthroscopic repair of the affected extensor tendons along with addressing any concomitant pathology, when present. In our opinion, this leads to optimized long-term outcomes.

A Prospective Comparison of Groin-Related Complications After Hip Arthroscopy With and Without a Perineal Post.

BACKGROUND: Previous studies have demonstrated various groin-related nerve and soft tissue complications in patients undergoing hip arthroscopy with a perineal post. PURPOSE: To prospectively compare groin-related nerve and soft tissue complications between patients undergoing hip arthroscopy with and without the use of a perineal post. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective single-surgeon cohort study was performed on all patients undergoing hip arthroscopy by the senior author between January 2020 and March 2022. A post-free hip distraction system was used at 1 center in which the senior author operates, and a system with a large padded perineal post was used at another surgical location. Patients completed a survey at the first postoperative visit (7-10 days) to determine if they had experienced any groin-related complications after surgery (groin numbness, sexual/urinary dysfunction, skin tears). Patients with a positive survey response repeated the survey at each follow-up visit (6 weeks, 3 months, 6 months) until the symptoms resolved. The rate and duration of groin-related complications were then compared between the groups. RESULTS: A total of 87 patients were included in the study who underwent hip arthroscopy: 53 with a perineal post and 34 without. No differences were found between the post and postless groups in terms of age at surgery, sex, body mass index, or traction time. We found that 16 patients (30%) in the perineal post group experienced groin numbness versus 0 (0%) in the postless group (P < .0001). On average, groin numbness lasted 5 ± 3 days (mean ± SD) in the perineal post group. Three patients in the perineal post group experienced sexual dysfunction for a mean 7 days, as compared with none in the postless group. Seventeen patients (32%) in the perineal post group experienced foot numbness versus 4 (12%) in the postless group (P = .04). One patient in the perineal post group reported a superficial skin tear. CONCLUSION: Postless hip arthroscopy resulted in no risk of groin-related complications as compared with traditional hip arthroscopy with a perineal post.

Improved Pain and Perioperative Outcomes After Hip Arthroscopy With the Pericapsular Nerve Group Block.

PURPOSE: To compare early postoperative pain in patients undergoing hip arthroscopy with versus without the pericapsular nerve group (PENG) block. METHODS: A retrospective chart review of prospectively collected data was performed to identify patients who underwent hip arthroscopy at a single institution between May 2019 and October 2021. Patients were included if they received general anesthesia and were opioid naive. Patients who received the PENG block were compared with patients who did not. Opioid, benzodiazepine, and antiemetic medication administration was recorded both intraoperatively and for the duration of the patient's stay in the postanesthesia care unit (PACU). Opioids administered were converted to morphine milligram equivalents (MMEs). Pain was assessed with a visual analog scale. Time to discharge (in minutes) and complications were recorded. RESULTS: A total of 53 patients were identified for inclusion, of whom 28 received the PENG block and 25 did not. Opioid consumption was significantly lower in the PENG block group both intraoperatively (16.9 ± 14.1 MMEs vs 40.6 ± 18.3 MMEs, P < .001) and in the PACU (14.4 ± 11.4 MMEs vs 31.2 ± 20.1 MMEs, P < .001). The highest recorded PACU pain score was significantly greater in the no-PENG block group (7.0 ± 1.9 vs 5.3 ± 2.1, P = .004). Within the PENG block group, fewer patients required antiemetics (0 vs 4, P = .043). There was a greater time to discharge in the no-PENG block group (161 ± 50 minutes vs 129 ± 34 minutes, P = .008). No complications, including postoperative falls, were noted in either group. CONCLUSIONS: The PENG block improves perioperative outcomes by decreasing pain, opioid consumption, time to discharge, antiemetic requirements, and benzodiazepine requirements after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Current Trends in the Use of Postless Hip Arthroscopy: A Survey of the International Society for Hip Arthroscopy Membership.

Background: Previous studies have demonstrated the risks of pudendal nerve and/or soft tissue complications due to the use of a perineal post during hip arthroscopy. Recently, various postless hip arthroscopy techniques have been described in the literature. Purpose: To assess the current international trends in the use of postless hip arthroscopy among hip preservation specialists. Study Design: Cross-sectional study. Methods: An anonymous 11-item survey was sent by email to all members of the International Society for Hip Arthroscopy (ISHA) in January 2022. Surgeons were asked various questions regarding their current use of post-assisted or postless hip arthroscopy, if they had changed their setup technique during their career and the reason for that change, and their perceived rate of pudendal nerve and/or perineal soft tissue injuries using their current technique. Descriptive statistics were used to report the results of each question. The Student t test was used to compare the number of years in practice between post-assisted and postless users. Fisher exact tests were performed to compare categorical rates of pudendal nerve and soft tissue complications between post-assisted and postless users. Results: A total of 126 surveys were completed from 431 ISHA members (29.2%). Sixty-one percent of the surgeons currently use a perineal post, while 33% use a postless technique. Seventy-five percent of the perineal post users and 98% of the postless users self-reported a rate of pudendal nerve and/or soft tissue injury of <1% (P = .015). Among 41 respondents who indicated changing their technique at some point, 59% reported doing so because of pudendal nerve and/or soft tissue complications. Among surgeons who switched from a perineal post to a postless setup, 71% indicated they have noticed a decrease in the rate of pudendal nerve and/or soft tissue complications. Conclusion: Although use of a perineal post is still a more common setup technique among hip arthroscopists, approximately one-third of surgeons use a postless technique. Surgeons who have switched to a postless technique often did so because of perineal complications, with the majority noticing a subjective decrease in these complications with the use of postless hip arthroscopy.

The Most Common Rehabilitation Protocol After Matrix-Assisted Autologous Chondrocyte Implantation Is Immediate Partial Weight-Bearing and Continuous Passive Motion.

Purpose: To perform a systematic review of postoperative rehabilitation protocols for third-generation autologous chondrocyte implantation (ACI) of the knee joint. Methods: A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials that described a rehabilitation protocol following third-generation ACI of the knee joint. The search terms used were: "autologous" AND "chondrocyte" AND "randomized". Data extracted from each study included various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, the use of continuous passive motion (CPM), the time to return to sports, and physical therapy (PT) modalities used and the timing of their initiation. Results: Twenty-five studies (22 Level I, 3 Level II) met inclusion criteria, including a total of 905 patients undergoing treatment with ACI. The average patient age ranged from 29.1 to 54.8 years, and the mean follow-up time ranged from 3 months to 10.0 years. The average lesion size ranged from 1.9 to 5.8 cm2, and the most common lesion location was the medial femoral condyle (n = 494). Twenty studies allowed partial WB postoperatively with all studies permitting full WB within 12 weeks. Twenty studies used CPM in their rehabilitation protocols and initiated its use within 24 hours postoperatively. Among 10 studies that reported time to return to sport, 9 (90%) allowed return by 12 months. While most protocols used strength training as well as the inclusion of proprioceptive training, there was disagreement on the timing and inclusion of specific PT modalities used during the rehabilitation process. Conclusions: Based on the included studies, most rehabilitation protocols for third-generation ACI initiate CPM within 24 hours postoperatively and allow partial WB immediately following surgery with progression to full WB within 12 weeks. There is variation of the PT modalities used as well as the timing of their initiation. Level of Evidence: Level II, systematic review of Level I-II studies.

Autograft and Nonirradiated Allograft for Anterior Cruciate Ligament Reconstruction Demonstrate Similar Clinical Outcomes and Graft Failure Rates: An Updated Systematic Review.

Purpose: To perform an updated systematic review comparing the clinical outcomes of autograft versus nonirradiated allograft for anterior cruciate ligament reconstruction (ACLR). Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of primary ACLR with autograft versus nonirradiated allograft with a minimum 2-year follow-up. The search terms used were: "anterior cruciate ligament" AND autograft AND allograft AND (irradiation OR non-irradiated). Patients were evaluated based on graft failure rates, the Objective International Knee Documentation Committee (IKDC) score, anteroposterior laxity, and patient-reported outcomes (Subjective IKDC score, the visual analog scale [VAS], the Cincinnati Knee Rating System, Lysholm, and Tegner scores). Risk of bias was assessed using the ROBINS-I and Cochrane Collaboration's risk of bias tool for non-randomized and randomized studies, respectively. Results: Sixteen studies (3 Level I, 7 Level II, 6 Level III) met inclusion criteria, including a total of 15,502 patients undergoing ACLR with autograft and 1,577 with nonirradiated allograft. The average follow-up ranged from 24.0 to 132.0 months. Graft failure ranged from 0% to 9.4% of patients in the autograft group and 0% to 26.5% in the allograft group. Two studies showed greater failure rates among younger patients in the allograft group. There were no significant differences between the Objective IKDC score, anteroposterior laxity, or patient-reported outcomes between the groups within any of the included studies (P > .05). Conclusions: Autograft and nonirradiated allograft for primary ACLR demonstrate similar patient-reported outcomes and graft failure rates. Level of Evidence: III, systematic review of level I-III studies.

Umbilical Cord-Derived Stem Cells for the Treatment of Knee Osteoarthritis: A Systematic Review.

Background: The use of mesenchymal stem cells (MSCs) for the treatment of knee osteoarthritis (OA) has gained recent interest in the orthopaedics community. Purpose: To review the literature to evaluate the efficacy of umbilical cord-derived MSCs in the treatment of OA of the knee joint. Study Design: Systematic review; Level of evidence, 4. Methods: We searched the PubMed, Cochrane Library, and Embase databases to identify studies with evidence levels from 1 to 4 that evaluated the clinical efficacy of human umbilical cord-derived MSC (hUC-MSC) injections for knee OA. The search phrase used was "umbilical cord knee osteoarthritis." In the studies reviewed, patients were assessed based on the macroscopic International Cartilage Regeneration & Joint Preservation Society (ICRS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and the subjective International Knee Documentation Committee (IKDC) score. Results: A total of 7 studies met inclusion criteria, including 385 patients undergoing injection of hUC-MSCs (mean age, 59.7 years). The mean follow-up was 23.4 months. Weighted averages of the WOMAC, macroscopic ICRS, subjective IKDC, and VAS scores all showed improvement from before to after treatment. No severe adverse reactions were recorded. Conclusion: Patients undergoing treatment of knee OA with hUC-MSCs might be expected to experience improvements in clinical outcomes. Additional high-quality randomized studies are needed to better determine the efficacy of hUC-MSC for the treatment of knee OA.

Improved Outcomes with Arthroscopic Bone Marrow Aspirate Concentrate and Cartilage-Derived Matrix Implantation versus Chondroplasty for the Treatment of Focal Chondral Defects of the Knee Joint: A Retrospective Case Series.

Purpose: To compare the outcomes of patients undergoing treatment of focal chondral defects (FCDs) of the knee joint with chondroplasty versus bone marrow aspirate concentrate (BMAC) and cartilage-derived matrix (CDM) implantation. Methods: A retrospective chart review was performed for patients diagnosed with Outerbridge grade 3-4 FCDs. Patients were included if they were treated arthroscopically with BMAC/CDM implantation or chondroplasty alone between March 2016 and May 2019 and had more than 1-year follow-up. Postoperative outcomes included the visual analog scale (VAS) for pain; University of California, Los Angeles (UCLA) activity scores; Knee Outcome Survey (KOS) Activities of Daily Living (ADL) and Sports subscores; postoperative corticosteroid or hyaluronic acid injections; subsequent surgeries; and conversion to total knee arthroplasty. Results: A total of 98 patients were identified with a mean follow-up in BMAC/CDM of 24 months (range 13-41 months) and in chondroplasty of 44 months (range 34-55 months). A subanalysis was performed to control for significant differences in age, which yielded 39 patients, ages 40-60 years. Within the subanalysis group, mean VAS scores were significantly lower in the BMAC/CDM group (1.7 vs 4.4; P = .005) and mean UCLA scores were significantly greater (7.1 vs 5.0; P = .002). Mean improvement in VAS and UCLA scores were similar between the BMAC/CDM and chondroplasty groups (-3.7 vs -1.3; P = .71, 1.9 vs 0.1; P = .14, respectively). Mean KOS ADL and Sports subscores were significantly greater among patients in the BMAC/CDM group (87% vs 55%; P = .001, 71% vs 41%; P = .002, respectively). There were no differences in postoperative injections, subsequent surgeries, or conversion to total knee arthroplasty between the BMAC/CDM and chondroplasty groups. Conclusions: Patients with grade 3-4 FCDs of the knee had improved postoperative outcomes when treated with BMAC/CDM implantation versus chondroplasty alone, as evidenced by a significant improvement in VAS and UCLA scores and significantly greater postoperative KOS ADL, and KOS Sport subscores. Level of Evidence: IV, therapeutic case series.