Single-cell transcriptomic profiling reveals distinct mechanical responses between normal and diseased tendon progenitor cells.

Regenerative medicine approaches utilizing stem cells offer a promising strategy to address tendinopathy, a class of common tendon disorders associated with pain and impaired function. Tendon progenitor cells (TPCs) are important in healing and maintaining tendon tissues. Here we provide a comprehensive single cell transcriptomic profiling of TPCs from three normal and three clinically classified tendinopathy samples in response to mechanical stimuli. Analysis reveals seven distinct TPC subpopulations including subsets that are responsive to the mechanical stress, highly clonogenic, and specialized in cytokine or growth factor expression. The single cell transcriptomic profiling of TPCs and their subsets serves as a foundation for further investigation into the pathology and molecular hallmarks of tendinopathy in mechanical stimulation conditions.

Concomitant Osteotomy Reduces Risk of Reoperation Following Cartilage Restoration Procedures of the Knee: A Matched Cohort Analysis.

OBJECTIVE: The objective of this study is to compare the (1) reoperation rates, (2) 30-day complication rates, and (3) cost differences between patients undergoing isolated autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation (OCA) procedures alone versus patients with concomitant osteotomy. STUDY DESIGN: Retrospective cohort study, level III. DESIGN: Patients who underwent knee ACI (Current Procedural Terminology [CPT] 27412) or OCA (CPT 27415) with minimum 2-year follow-up were queried from a national insurance database. Resulting cohorts of patients that underwent ACI and OCA were then divided into patients who underwent isolated cartilage restoration procedure and patients who underwent concomitant osteotomy (CPT 27457, 27450, 27418). Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using ICD-9-CM codes. The cost per patient was calculated. RESULTS: A total of 1,113 patients (402 ACI, 67 ACI + osteotomy, 552 OCA, 92 OCA + osteotomy) were included (mean follow-up of 39.0 months). Reoperation rate was significantly higher after isolated ACI or OCA compared to ACI or OCA plus concomitant osteotomy (ACI 68.7% vs. ACI + osteotomy 23.9%; OCA 34.8% vs. OCA + osteotomy 16.3%). Overall complication rates were similar between isolated ACI (3.0%) and ACI + osteotomy (4.5%) groups and OCA (2.5%) and OCA + osteotomy (3.3%) groups. Payments were significantly higher in the osteotomy groups at day of surgery and 9 months compared to isolated ACI or OCA, but costs were similar by 2 years postoperatively. CONCLUSIONS: Concomitant osteotomy at the time of index ACI or OCA procedure significantly reduces the risk of reoperation with a similar rate of complications and similar overall costs compared with isolated ACI or OCA.

Double Tension Slide Technique as a Novel Repair for Distal Biceps Tendon Tear: A Biomechanical Evaluation.

Background A comparative biomechanical analysis of two distal biceps tendon repair techniques was performed: a single suture tension slide technique (TST) and two suture double tension slide (DTS) technique. Methodology Ten matched pairs of fresh frozen human cadaveric elbows (20 elbows) were randomly separated into two cohorts for distal biceps tendon repair. One cohort underwent the TST, and the other underwent the DTS technique. The tendon was preconditioned with cyclic loading from 0° to 90° at 0.5 Hz for 3,600 cycles with a 50 N load. The specimens were then loaded to failure at a rate of 1 mm/s. The difference in the load to failure between the groups was analyzed using the Student's t test. The mode of failure was compared between groups using the chi-square test. All p-values were reported with significance set at p < 0.05. Results Overall, 77.8% of the included matched pairs demonstrated greater load to failure in the DTS group. The mean load to failure in the DTS group was 383.3 ± 149.3 N compared to 275.8 ± 98.1 N in the TST group (p = 0.13). The DTS specimens failed at the tendon (5/9), suture (3/9), and bone (1/9). The TST specimens failed at the tendon (4/9) and suture (5/9) only. There was no significant difference in failure type between groups (p = 0.76). Conclusions DTS demonstrates a similar to greater load to failure compared to TST with a trend towards statistical significance. The redundancy provided by the second suture has an inherent advantage without compromising the biomechanical testing.

Worse Preoperative Pain and Higher Activity Levels Predict Patient Choice of Formal Physical Therapy After Primary Anterior Total Hip Arthroplasty.

BACKGROUND: The purpose of this randomized controlled trial is (1) to compare the efficacy of supervised formal physical therapy (PT) and self-directed home exercises and (2) to identify independent predictors of transitioning from self-directed home exercises to supervised formal PT following total hip arthroplasty (THA) via an anterior approach. METHODS: After Institutional Review Board approval, 147 patients undergoing primary unilateral THA through anterior approach were enrolled and randomized to receive either clinic or home-based PT. Surveys with Hip Disability Osteoarthritis Outcome Scores (HOOS) and Short Form-12 Health Survey scores for both groups were obtained before surgery and at 6, 14, and 24 weeks after surgery. Patients had the option to transition into the other study group at their 6-week follow-up visit. RESULTS: Of the 147 patients enrolled, final analysis included scores for 136 patients. Forty-two (63.6%) of the 66 patients randomized to the supervised formal PT group crossed over to self-directed home exercise group and 12 (17.1%) of the 70 patients randomized to the self-directed home exercise group crossed over to supervised formal PT group. There were no significant (P > .05) differences between groups at all time points for the overall HOOS and Short Form-12 Health Survey. Subjects with worse preoperative pain scores (P = .005) and higher HOOS preoperative activity of daily living scores (P = .015) were more likely to transition from the home exercise group to formal PT group. CONCLUSION: There were no significant outcome score differences between subjects undergoing supervised formal PT and self-directed home exercises. However, patients reporting worse preoperative pain and higher preoperative activity levels may prefer supervised formal PT compared to self-directed home exercises after undergoing primary anterior THA.

Relationship of the Medial Patellofemoral Ligament Origin on the Distal Femur to the Distal Femoral Physis: A Systematic Review.

BACKGROUND: The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies. PURPOSE: To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants. STUDY DESIGN: Systematic review. METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean ± SD. Categorical variable data were reported as frequency with percentage. RESULTS: Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 ± 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 ± 2.4 mm. CONCLUSION: The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.

Comparison of Autologous Chondrocyte Implantation and Osteochondral Allograft Transplantation of the Knee in a Large Insurance Database: Reoperation Rate, Complications, and Cost Analysis.

OBJECTIVE: To compare (1) the reoperation rates, (2) risk factors for reoperation, (3) 30-day complication rates, and (4) cost differences between autologous chondrocyte implantation (ACI) and osteochondral allograft transplantation (OCA) of the knee in a large insurance database. DESIGN: Subjects who underwent knee ACI (Current Procedural Terminology [CPT] code 27412) or OCA (CPT code 27415) with minimum 2-year follow-up were queried from a national insurance database. Reoperation was defined by ipsilateral knee procedure after index surgery. Multivariate logistic regression models were built to determine the effect of independent variables (age, sex, tobacco use, obesity, diabetes, and concomitant osteotomy) on reoperation rates. The 30-day complication rates were assessed using ICD-9-CM codes. The cost of the procedures per patient was calculated. Statistical comparisons were made. All P values were reported with significance set at P < 0.05. RESULTS: A total of 909 subjects (315 ACI and 594 OCA) were included (mean follow-up 39.2 months). There was a significantly higher reoperation rate after index ACI compared with OCA (67.6% vs. 40.4%, P < 0.0001). Concomitant osteotomy at the time of index procedure significantly reduced the risk for reoperation in both groups (odds ratio [OR] 0.2, P < 0.0001 and OR 0.2, P = 0.009). The complication rates were similar between ACI (1.6%) and OCA (1.2%) groups (P = 0.24). Day of surgery payments were significantly higher after ACI compared with OCA (P = 0.013). CONCLUSIONS: Autologous chondrocyte implantation had significantly higher reoperation rates and cost with similar complication rates compared with OCA. Concomitant osteotomy significantly reduced the risk for reoperation in both groups.

Superior Capsular Reconstruction: A Systematic Review of Surgical Techniques and Clinical Outcomes.

PURPOSE: To evaluate surgical techniques and clinical outcomes of arthroscopic superior capsular reconstruction (SCR) for the treatment of massive irreparable rotator cuff tears. METHODS: A systematic review was registered with PROSPERO and performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Scopus, and Cochrane databases were searched. Studies investigating SCR with reported surgical techniques were included. Animal studies, cadaveric studies, review studies, and letters to the editor were excluded. The technical aspects of the surgical techniques for SCR were analyzed in each article, which included graft type, glenoid fixation method, greater tuberosity fixation method, graft passage technique, suture management, margin convergence, concomitant procedures, and postoperative rehabilitation protocol. Clinical outcomes, when available, were also analyzed. RESULTS: We screened 365 articles, of which 29 described surgical techniques for SCR. According to the Modified Coleman Methodology Score, 24 articles were rated as poor (score < 55), 4 were rated as fair (score between 55 and 69), and 1 was rated as good (score between 70 and 84), with an average score of 25.8 ± 20.9. The most commonly performed technique for SCR used the following: an acellular dermal allograft, 2 biocomposite suture anchors for glenoid fixation, transosseous-equivalent double-row suture anchor fixation for greater tuberosity fixation with 2 biocomposite medial-row anchors and 2 biocomposite lateral-row anchors, the double-pulley technique combined with an arthroscopic grasper and/or pull suture to pass the graft into the shoulder, the performance of both anterior and posterior margin convergence, and a native rotator cuff repair when possible. Only 8 studies reported clinical outcomes, and they showed that SCR provides significant improvement in patient-reported outcomes, significant improvement in shoulder range of motion, variable graft failure rates, low complication rates, and variable reoperation rates. There were no studies comparing outcomes among the various surgical techniques. CONCLUSIONS: Many surgical techniques exist for arthroscopic SCR. However, no superior technique was shown because there were no studies comparing clinical outcomes among these various techniques. LEVEL OF EVIDENCE: Level V, systematic review of Level III, IV, and V studies.

Platelet-Rich Plasma Augmentation for Isolated Arthroscopic Meniscal Repairs Leads to Significantly Lower Failure Rates: A Systematic Review of Comparative Studies.

BACKGROUND: Studies have reported relatively high failure rates of isolated meniscal repairs. Platelet-rich plasma (PRP) has been suggested as a way to increase growth factors that enhance healing. PURPOSE: To compare (1) meniscal repair failures and (2) patient-reported outcomes after isolated arthroscopic meniscal repair augmented with and without PRP. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Multiple databases were searched for studies that compared outcomes of isolated arthroscopic meniscal repair augmented with PRP versus without PRP in human patients. Failures and patient-reported outcome scores were reported for each study and compared between groups. Study heterogeneity was assessed using I 2 for each outcome measure before meta-analysis. Study methodological quality was analyzed. Continuous variable data were reported as mean and standard deviation from the mean. Categorical variable data were reported as frequency with percentage. All P values were reported with significance set at P < .05. RESULTS: Five articles were analyzed (274 patients [110 with PRP and 164 without PRP]; 65.8% male; mean age, 29.1 ± 4.6 years; mean follow-up, 29.2 ± 22.1 months). The risk of meniscal repair failure ranged from 4.4% to 26.7% for PRP-augmented repairs and 13.3% to 50.0% for repairs without PRP. Meniscal repairs augmented with PRP had significantly lower failure rates than repairs without PRP (odds ratio, 0.32; 95% CI, 0.12-0.90; P = .03). One of the 5 studies reported significantly higher outcomes in the PRP-augmented group versus the no-PRP group for the International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee injury and Osteoarthritis Outcome Score (KOOS) (P < .05 for all). The remaining 4 studies reported no significant difference between groups with regard to outcomes for the IKDC, Lysholm knee scale, visual analog scale for pain, or Tegner activity level. CONCLUSION: Although the studies were of mostly of low quality, isolated arthroscopic meniscal repairs augmented with PRP led to significantly lower failure rates (10.8% vs 27.0%; odds ratio, 0.32; P = .03) as compared with repairs without PRP. However, most studies reported no significant differences in patient-reported outcomes.

Validation of Self-Reported Smoking Status Among Orthopedic Hip Surgery Patients.

Purpose The purpose of this study was to determine the accuracy of self-reported non-smoking status in subjects undergoing elective orthopedic surgery as confirmed by serum cotinine levels. Methods Institutional Review Board approval was obtained for this retrospective review of consecutive subjects that underwent elective orthopedic surgery by a single fellowship-trained orthopedic surgeon. All patients provided smoking history (active, former, or non-smoker). Serum cotinine levels defined each subject as "non-smoker", "passive tobacco exposure", or "active smoker". Self-reported non-smokers were eligible for inclusion. Subjects were excluded if they failed to provide smoking history, reported themselves as "smokers", and/or had unavailable serum cotinine levels. Self-reported non-smoking status accuracy was determined by dividing the total number of included subjects by the number of subjects that were defined as "non-smoker" or "passive tobacco exposure" on their serum cotinine test. Results A total of 378 patients (mean age of 42.5 (13-78) years and 68% female) self-reported as non-smokers and were included. A total of 369 subjects had serum cotinine levels consistent with "non-smoking" resulting in a self-reported non-smoking status accuracy of 97.6%. None of the former smokers had cotinine levels consistent with active smoker status. Conclusion Subjects undergoing elective orthopedic surgery self-report as non-smokers with an accuracy of 97.6%. This suggests that routine serum cotinine testing of non-smokers in this patient population may not be necessary.

Systematic Review: Is Intradiscal Injection of Bone Marrow Concentrate for Lumbar Disc Degeneration Effective?

Current studies evaluating the outcomes of an intradiscal injection of bone marrow concentrate (BMC) for lumbar disc degeneration are limited. The purpose of this review was to determine if an intradiscal injection of BMC for lumbar disc degeneration results in a statistically significant improvement in clinical outcomes. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Levels I-IV investigations of intradiscal BMC injections in symptomatic lumbar disc degeneration were included in the analysis. Modified Coleman Methodology Scores (MCMS) were used to analyze study methodological quality. Only outcome measurements used by more than 50% of included studies, with a minimum follow-up of 12 months, were eligible for final data analysis. Pre-injection and post-injection visual analog scale (VAS) and Oswestry disability index (ODI) were compared using two-sample Z-tests. Seven articles (97 subjects (47 males, 38 females, 12 unspecified), mean age 33.9 ± 14.3 years, mean follow-up 44.4 ± 25.4 months) were analyzed. Six articles were level IV evidence and one article was level II. Mean MCMS was 56.6 ± 9.1. All subjects received single injections into the nucleus pulposus of one or more affected discs. VAS (66.0 mm to 20.9 mm; p<0.001) and ODI (44.4 to 19.1; p<0.001) significantly improved following the intradiscal BMC injection. One patient (1.0%) experienced herniated nucleus pulposus (HNP) following treatment. No other complications or re-injections were reported. In conclusion, despite our skepticism regarding the efficacy of the procedure, intradiscal injection of BMC for lumbar disc degeneration resulted in statistically significant improvement in VAS and ODI with low re-injection and complication rates in the studies assessed. Given that this study is limited to level IV evidence, the findings suggest that further randomized controlled studies may be worthwhile to evaluate the true efficacy of this treatment.

Reoperation Rates Following Meniscus Transplantation Using the Truven Database.

PURPOSE: The purpose of this study was to determine the (1) reoperation rate and (2) 30-day complication rate in a large insurance database. METHODS: The Truven Database was queried for subjects that underwent meniscus allograft transplantation (Current Procedural Terminology code 29868) in the outpatient setting with minimal 2-year follow-up. Patients without confirmed laterality and patients that underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using International Classification of Diseases, 9th Revision, Clinical Modification codes. RESULTS: A total of 284 patients (mean age of 26.2 ± 10.4 years; 49.6% females) were included in this study with mean follow up of 43.2 ± 19.2 months. One hundred and sixty-seven subjects (58.8%) undergoing meniscus allograft transplantation underwent reoperation at an average of 11.9 ± 12.2 months postoperatively. There was a low number of subjects that required ipsilateral unicompartmental knee arthroplasty and total knee arthroplasty postoperatively (0.7% and 1.1%, respectively). The overall 30-day complication rate following meniscus allograft transplantation was 1.4%. CONCLUSIONS: Patients undergoing meniscus allograft transplantation have a 58.8% reoperation rate at final follow up with low (1.4%) 30-day complication rates in a large insurance database. LEVEL OF EVIDENCE: Level IV, case series.

Humeral Head Osteochondral Allograft Reconstruction with Arthroscopic Anterior Shoulder Stabilization at a Long-Term Follow-Up: A Case Report.

CASE: The authors report a case of recurrent anterior shoulder instability in a 19-year-old man. Intraoperative arthroscopic examination identified Bankart and engaging Hill-Sachs lesions. The patient was treated with humeral head osteochondral allograft reconstruction and concomitant arthroscopic anterior stabilization. At the 14-year follow-up, there was no recurrent instability. CONCLUSION: Humeral head osteochondral allograft reconstruction combined with an arthroscopic anterior stabilization procedure can be successful for recurrent shoulder instability and engaging Hill-Sachs lesion.

Linked Double-Row Equivalent Arthroscopic Rotator Cuff Repair Leads to Significantly Improved Patient Outcomes.

BACKGROUND: Biomechanical studies have demonstrated that arthroscopic rotator cuff repair using a linked double-row equivalent construct results in significantly higher load to failure compared with conventional transosseous-equivalent constructs. PURPOSE: To determine the patient-reported outcomes (PROs), reoperation rates, and complication rates after linked double-row equivalent rotator cuff repair for full-thickness rotator cuff tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients who underwent linked double-row equivalent arthroscopic rotator cuff repair with minimum 2-year follow-up were included. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score at final follow-up. Secondary outcomes included the Simple Shoulder Test (SST), shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, visual analog scale (VAS), reoperations, and complications. Clinical relevance was defined by the minimally clinically important difference (MCID). Comparisons on an individual level that exceeded MCID (individual-level scores) were deemed clinically relevant. Comparisons between preoperative and postoperative scores were completed using the Student t test. All P values were reported with significance set at P < .05. RESULTS: A total of 42 shoulders in 41 consecutive patients were included in this study (21 male patients [51.2%]; mean age, 64.5 ± 11.9 years; mean follow-up, 29.7 ± 4.5 months). All patients (100%) completed the minimum 2-year follow-up. The rotator cuff tear measured on average 15.2 ± 8.9 mm in the coronal plane and 14.6 ± 9.8 mm in the sagittal plane. The ASES score improved significantly from 35.5 ± 18.2 preoperatively to 93.4 ± 10.6 postoperatively (P < .001). The QuickDASH (P < .001), SST (P < .001), and VAS (P < .001) scores also significantly improved after surgery. All patients (42/42 shoulders; 100%) achieved clinically relevant improvement (met or exceeded MCID) on ASES and SST scores postoperatively. There were no postoperative complications (0.0%) or reoperations (0.0%) at final follow-up. CONCLUSION: Arthroscopic repair of full-thickness rotator cuff tears with the linked double-row equivalent construct results in statistically significant and clinically relevant improvements in PRO scores with low complication rates (0.0%) and reoperation rates (0.0%) at short-term follow-up.

Comparing Meniscectomy and Meniscal Repair: A Matched Cohort Analysis Utilizing a National Insurance Database.

BACKGROUND: Meniscal repair leads to improved patient outcomes compared with meniscectomy in small case series. PURPOSE: To compare the reoperation rates, 30-day complication rates, and cost differences between meniscectomy and meniscal repair in a large insurance database. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A national insurance database was queried for patients who underwent meniscectomy (Current Procedural Terminology [CPT] code 29880 or 29881) or meniscal repair (CPT code 29882 or 29883) in the outpatient setting and who had a minimum 2-year follow-up. Patients without confirmed laterality and patients who underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The cost of the procedures per patient was calculated. Propensity score matching was utilized to create matched cohorts with similar characteristics. Statistical comparisons of cohort characteristics, reoperations, postoperative complications, and payments were made. All P values were reported with significance set at P < .05. RESULTS: A total of 27,580 patients (22,064 meniscectomy and 5516 meniscal repair; mean age, 29.9 ± 15.1 years; 41.2% female) were included in this study with a mean follow-up of 45.6 ± 21.0 months. The matched groups were similar with regard to characteristics and comorbidities. There were significantly more patients who required reoperation after index meniscectomy compared with meniscal repair postoperatively (5.3% vs 2.1%; P < .001). Patients undergoing meniscectomy were also significantly more likely to undergo any ipsilateral meniscal surgery (P < .001), meniscal transplantation (P = .005), or total knee arthroplasty (P = .001) postoperatively. There was a significantly higher overall 30-day complication rate after meniscal repair (1.2%) compared with meniscectomy (0.82%; P = .011). The total day-of-surgery payments was significantly higher in the repair group compared with the meniscectomy group ($7094 vs $5423; P < .001). CONCLUSION: Meniscal repair leads to significantly lower rates of reoperation and higher rates of early complications with a higher total cost compared with meniscectomy in a large database study.

Systemic Review: Is an Intradiscal Injection of Platelet-Rich Plasma for Lumbar Disc Degeneration Effective?

Current studies evaluating the outcomes of intradiscal platelet-rich plasma (PRP) injections in degenerative disc disease (DDD) are limited. The purpose of this review was to determine if an intradiscal injection of PRP for degenerative discs results in a statistically significant improvement in clinical outcomes. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Level I-IV investigations of intradiscal PRP injections in DDD were sought in multiple databases. The Modified Coleman Methodology Score (MCMS) was used to analyze the methodological quality of the study. Only the outcome measurements used by more than 50% of the studies were included in the data analysis. The study heterogeneity and nature of evidence (mostly retrospective, non-comparative) precluded meta-analysis. Pre and post-injection pain visual analog scales (VAS) were compared using two sample Z-tests. Five articles (90 subjects, mean age 43.6 ± 7.7 years, mean follow-up 8.0 ± 3.6 months) were analyzed. Four articles were level IV evidence and one article was level II. Mean MCMS was 56.0 ± 10.3. There were 43 males and 37 females (10 unidentified). Pain VAS significantly improved following lumbar intradiscal PRP injection (69.7 mm to 43.3 mm; p<0.01). Two patients (2.2%) experienced lower extremity paresthesia after treatment. One patient (1.1%) underwent re-injection. No other complications were reported. In conclusion, intradiscal injection of PRP for degenerative discs resulted in statistically significant improvement in VAS with low re-injection and complication rates in this systematic review. It is unclear whether the improvements were clinically significant given the available evidence. The low level of evidence available (level IV) does not allow for valid conclusions regarding efficacy; however, the positive results suggest that further higher-quality studies might be of value.

Distal Biceps Tendon Repair Using a Double Tension Slide Technique.

Distal biceps tendon ruptures are thought to be secondary to an acute forceful eccentric load on a degenerative tendon. Nonoperative treatment following rupture leads to significantly decreased forearm supination and elbow flexion strength. There are several techniques described in the literature for repair. This article describes, with video illustration, distal biceps tendon repair using a double tension slide technique with 2 No. 2 high-tension nonabsorbable composite sutures.

Progression of Hamate Hook Stress Reactions in Elite Baseball Players.

BACKGROUND: Hamate hook fractures can occur as a result of repetitive contact with the knob of the bat used in the sport of baseball. Hamate hook excision has resulted in excellent outcomes and return to sport (RTS) in elite baseball players. The ideal treatment for hamate stress response before the development of a fracture line is unknown. PURPOSE: To report the outcomes of elite baseball players with hamate bone edema. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We reviewed the medical records of all elite baseball players with hamate bone edema consistent with a stress response at 2 institutions. Players were eligible for inclusion if they played collegiate or professional baseball at the time of initial injury, had magnetic resonance imaging (MRI) showing hamate bone edema, and had no radiographic evidence of acute fracture lines at initial presentation. RESULTS: A total of 4 players with a mean age of 22.8 years were included. All injuries occurred in the nondominant hand. All athletes had normal initial wrist radiographs and MRI showing hamate edema but no fracture line. Patients returned to play as tolerated and developed an acute injury at an average of 25.8 days (range, 10-56 days) from the initial presentation. Repeat radiographs demonstrated acute hamate hook fractures in all 4 (100%) athletes. All 4 athletes underwent hamate hook excision. There were no postoperative complications. All athletes returned to sport at their previous level of competition at a mean of 5.3 weeks (range, 3.6-7.3 weeks). CONCLUSION: There is a high rate of hamate bone edema progression to acute hamate hook fracture in elite baseball players, with 100% RTS at preinjury level after hamate hook excision. We therefore recommend against prolonged rest. Continuation of play with hamate bone edema followed by hamate hook excision for acute fracture limits the time missed and obtains a faster RTS in elite baseball players.

Sham Surgery Studies in Orthopaedic Surgery May Just Be a Sham: A Systematic Review of Randomized Placebo-Controlled Trials.

PURPOSE: To determine the limitations of randomized sham surgery-controlled trials in orthopaedic sports medicine and fidelity of the trials' conclusions. METHODS: Randomized placebo surgery-controlled trials in orthopaedic sports medicine were included in this Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review. Several aspects of investigation design and conduct were analyzed: genetic analysis for propensity to placebo response, equipoise of informed consent process, geography of trial subjects, percentage of eligible subjects willing to be randomized, changes from protocol publication to results publication, and perioperative complications. RESULTS: Seven sham surgery-controlled trials (845 subjects [370 knees, 449 shoulders, 26 elbows]; 5 from Europe, 1 from North America, and 1 from Australia; all superiority model, efficacy design) were analyzed. There were consistent methodologic deficiencies across studies. No studies reported genetic analysis of susceptibility to placebo response. Three studies (43%) were underpowered. Crossover rates ranged from 8% to 36%, which led to un-blinding in up to 100% of subjects. There were low enrollment rates of eligible subjects (up to 57% refused randomization). Follow-up was short term (2 years or less in all but one study). Complication rates ranged from 0% to 12.5%, with complications occurring in both groups (no significant difference between groups in any study). CONCLUSIONS: Randomized sham-controlled studies in orthopaedic sports medicine have significant methodologic deficiencies that may invalidate their conclusions. Randomized trial design (with or without placebo control) may be optimized through the inclusion of per-protocol analysis, blinding index, equivalence or noninferiority trial design, and a nontreatment group. LEVEL OF EVIDENCE: Level II Systematic Review of Level II studies.

Gender-Specific Sexual Activity After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Position Matters.

BACKGROUND: There is limited evidence on the safety of return to sexual activity after hip arthroscopy. AIM: To determine the positional safety of sexual activity after hip arthroscopy relative to hip instability and/or impingement risk. STUDY DESIGN: This study is an observational study. METHODS: 12 common sexual positions were identified based on previous research. Gender-specific hip motion was then assessed for the possibility of postarthroscopic hip instability (due to disruption of iliofemoral ligament [interportal capsulotomy] repair) and/or impingement (labral or capsular compressive stress with disrupted repair) for all 12 positions (both right and left hips; 15 unique male and 14 unique female positions). Instability risk was defined as greater than 0° hip extension, greater than 30° external rotation (ER), or greater than 30° abduction. Impingement risk was defined as greater than 90° hip flexion, greater than 10° internal rotation, and greater than 10° adduction. OUTCOMES: A majority of both male and female sexual positions caused either instability or impingement, with only 4 positions in women and 4 positions in men deemed "safe" by avoiding excessive hip motion. RESULTS: Return to sexual activity after hip arthroscopy may cause instability in 10/15 of male positions and 5/14 female positions. Most male positions (6/10) were at risk for instability because of excessive ER. 2 positions were unstable because of a combination of ER and extension, one was due to extension, and one abduction. In female instability positions, all 5 were unstable because of excessive abduction. Impingement may be observed in 5 of 15 male positions and 6 of 14 female positions. In male impingement positions, all were due to excessive adduction. 4 female positions risked impingement due to excessive flexion and 2 positions due to internal rotation. CLINICAL IMPLICATIONS: This study demonstrates risks that should be considered when counseling patients preoperatively and postoperatively regarding sexual activity. STRENGTHS & LIMITATIONS: This study closely models a hip preservation patient population by using 2 young and otherwise healthy individuals. The most significant limitation of this investigation was its basis with only 2 young healthy volunteers (one male, one female) in a single motion capture session using surface-based spherical retroreflective markers from a previous investigation. CONCLUSION: After hip arthroscopy, patients need to be made aware of the possibility of hip instability (10 of 15 men; 5 of 14 women) and impingement (5 of 15 men; 6 of 14 women) due to excessive hip motion that may compromise their outcome. Morehouse H, Sochacki KR, Nho SJ, et al. Gender-Specific Sexual Activity After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Position Matters. J Sex Med 2020;17:658-664.