Female patients have greater improvement in pain symptoms and physical activity after fasciotomy for treatment of chronic exertional compartment syndrome of the lower leg.

PURPOSE: The purpose of this study was to identify sex differences in postoperative outcomes and return-to-sport rates after fasciotomy for treatment of chronic exertional compartment syndrome (CECS) of the lower leg. It was hypothesised that male CECS patients would have a higher rate of return to sport than female CECS patients. METHODS: A retrospective cohort study was conducted involving patients who underwent primary fasciotomy of one to four leg compartments for treatment of CECS at a single centre from 2010 to 2020. Each affected leg was treated as a separate subject. Postoperative outcomes included CECS pain frequency and severity, return to sport and Tegner activity level. Multivariable regression was used to determine if sex was an independent predictor of outcomes after adjusting for demographic and clinical covariates. p < 0.05 were considered significant. RESULTS: Eighty-one legs (44 M, 37 F) of 47 unique patients (34 of whom had bilateral symptoms) were included with a mean follow-up time of 51.5 ± 31.4 months. Male subjects were older (p < 0.001) and had higher body mass index (p < 0.001) compared to female subjects. Most subjects (84.0%) underwent two- or four-compartment fasciotomies. Female sex was found to be predictive of lower overall postoperative pain severity (p = 0.007), higher odds of return to sport (p = 0.04) and higher postoperative Tegner score (p = 0.005). However, female sex was not predictive of postoperative pain frequency, odds of reoperation or odds of return to sport to at least the presymptomatic level (all p < 0.05). CONCLUSION: Female sex is independently predictive of reduced overall pain severity, higher odds of return to sport and higher postoperative improvement in Tegner score following fasciotomy for treatment of lower-limb CECS. LEVEL OF EVIDENCE: III.

Effect of Spinopelvic Parameters on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: Spinopelvic parameters, including pelvic tilt (PT), sacral slope (SS), and pelvic incidence, have been developed to characterize the relationship between lumbar spine and hip motion, but a paucity of literature is available characterizing differences in spinopelvic parameters among patients with femoroacetabular impingement syndrome (FAIS) versus patients without FAIS, as well as the effect of these parameters on outcomes of arthroscopic treatment of FAIS. PURPOSE: To (1) identify differences in spinopelvic parameters between patients with FAIS versus controls without FAIS; (2) identify associations between spinopelvic parameters and preoperative patient-reported outcomes (PROs); and (3) identify differences in PROs between patients with stiff spines (standing-sitting ΔSS ≤10°) versus those without. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The study enrolled patients ≥18 years of age who underwent primary hip arthroscopy for treatment of FAIS with cam, pincer, or mixed (cam and pincer) morphology. Participants underwent preoperative standing-sitting imaging with a low-dose 3-dimensional radiography system and were matched on age and body mass index (BMI) to controls without FAIS who also underwent EOS imaging. Spinopelvic parameters measured on EOS films were compared between the FAIS and control groups. Patients with FAIS completed the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) before surgery and at 1-year follow-up. Outcome scores were compared between patients with stiff spines versus those without. Associations between spinopelvic parameters and baseline outcome scores were assessed with Pearson correlations. Continuous variables were compared with Student t test and/or Mann-Whitney U test, and categorical variables were compared with Fisher exact test. RESULTS: A total of 50 patients with FAIS (26 men; 24 women; mean age, 36.1 ± 10.7 years; mean BMI, 25.6 ± 4.2) were matched to 30 controls without FAIS (13 men; 17 women; mean age, 36.6 ± 9.5 years; mean BMI, 26.7 ± 3.6). Age, sex, and BMI were not significantly different between the FAIS and control groups (P > .05). Standing PT was not significantly different between stiff and non-stiff cohorts (P = .73), but sitting PT in the FAIS group was more than double that of the control group (36.5° vs 15.0°; P < .001). Incidence of stiff spine was significantly higher in the FAIS group (62.0% vs 3.3%; P < .001). Among FAIS patients, those with stiff spines had a significantly higher prevalence of cam impingement, whereas those with non-stiff spines had a higher prevalence of mixed impingement (P = .04). No significant differences were seen in preoperative mHHS or NAHS scores or pre- to postoperative improvement in scores between FAIS patients with stiff spines versus those without (P > .05), but a greater sitting SS was found to be positively correlated with a higher baseline mHHS (r = 0.36; P = .02). CONCLUSION: Patients with FAIS were more likely to have a stiff spine (standing-sitting ΔSS ≤10°) compared with control participants without FAIS. FAIS patients with stiff spines were more likely to have isolated cam morphology than patient without stiff spines. Although sitting SS was positively correlated with baseline mHHS, no significant differences were seen in 1-year postoperative outcomes between FAIS patients with versus without stiff spine.

Medial quadriceps tendon femoral ligament reconstruction and medial patellofemoral ligament reconstruction have no significant differences in clinical outcomes for treatment of lateral patellar instability: a matched-cohort study.

OBJECTIVES: The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. METHODS: A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. RESULTS: Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p â€‹= â€‹0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p â€‹= â€‹0.47), return to sport (MQTFLR 50%, MPFLR 75%, p â€‹= â€‹0.61), return to work (MQTFLR 100%, MPFLR 88%, p â€‹= â€‹1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p â€‹= â€‹0.31). CONCLUSION: There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. LEVEL OF EVIDENCE: III.

Patient-reported hip pain and function are worse among elite Nordic ski athletes competing in ski jumping versus Nordic combined: a cross-sectional analysis.

OBJECTIVES: Nordic ski athletes are at increased risk of developing hip pain and dysfunction secondary to femoroacetabular impingement syndrome (FAIS), but it is unclear whether hip symptomatology differs between ski jumping (SJ) and Nordic combined (NC) athletes. The purpose of this study was to compare patient-reported hip pain and dysfunction between elite Nordic ski athletes participating in SJ versus NC. METHODS: A cross-sectional study was conducted involving SJ and NC athletes who competed at the international and U.S. national levels during the 2021-2022 season. Subjects were excluded if they had hip surgery within two years prior to enrollment. Subjects were asked to undergo diagnostic workups for FAIS, including physical examination and plain radiographic imaging. Subjects were asked to complete a survey that collected information on athletic and training history and to complete the hip disability and osteoarthritis outcome score (HOOS). Demographics, athletic/training history, and HOOS sub-scores were compared between the SJ and NC groups using the Student's t-test, Wilcoxon rank-sum test, or Fisher's exact test, as appropriate. p-values < 0.05 were considered significant. RESULTS: Twenty-four athletes (13 SJ, 11 NC) were included in the study. There were no statistically significant differences in age, sex, BMI, or age of menarche between the two groups (all p â€‹> â€‹0.05). There were also no statistically significant differences in the number of prior sports participated in, total hours of participation in prior sports, or total hours of training in Nordic specialization (all p â€‹> â€‹0.05). Among the 18 athletes who underwent physical examination (9 SJ, 9 NC), there were no statistically significant inter-group differences in hip range of motion or incidence of positive impingement tests (all p â€‹> â€‹0.05). Among the 19 athletes who underwent imaging (9 SJ, 10 NC), there were no statistically significant inter-group differences in the incidence of cam or pincer morphology in at least one hip (all p â€‹> â€‹0.05). SJ athletes had statistically significantly worse HOOS sub-scores for hip symptoms and stiffness, hip function in sports/recreational activities, and hip-related quality of life compared to NC athletes (all p â€‹< â€‹0.05). CONCLUSION: Elite SJ athletes have worse self-reported hip function compared to elite NC athletes, despite comparable demographics, athletic history, and duration of ski training. LEVEL OF EVIDENCE: IV.

Increased kinesiophobia leads to lower return to sport rate and clinical outcomes following osteochondral allograft transplantation of the knee.

PURPOSE: The purpose of this study is to describe the postoperative psychological state of patients following osteochondral allograft (OCA) transplantation in the knee and to determine whether patient-perceived kinesiophobia is associated with the rate of return to sport (RTS). METHODS: A retrospective review of the electronic medical record at a single institution was conducted for all patients that underwent OCA transplantation from January 2010 to 2020. Patient-reported outcomes including the visual analog scale (VAS), knee injury and osteoarthritis outcome score (KOOS) and the Tampa scale of kinesiophobia-11 (TSK-11) were collected. Patients were surveyed regarding their postoperative RTS status. RESULTS: A total of 38 patients (52.6% female) were included in our analysis. Overall, 24 patients (63.2%) returned to sport with 12 (50%) of these patients returning at a lower level of play. When comparing patients that return to sport to those that did not, patients that return had significantly superior KOOS pain (p = 0.019) and KOOS QOL (p = 0.011). Measures of kinesiophobia (TSK-11) were significantly higher among patients that did not return to sport (p = 0.014), while satisfaction (n.s.) and pain intensity (n.s.) were comparable between groups. Logistic regression models controlling for demographic factors, VAS pain scores and lesion size showed that for every one-point increase in TSK-11 kinesiophobia score, patients were 1.33 times more likely to return to sport at a lower level (p = 0.009). For every one-point increase in TSK-11 scores KOOS QOL decreased by 2.4 points (p < 0.001). CONCLUSION: Fear of reinjury decreases the likelihood that patients will return to their preoperative level of sport after OCA transplantation. Patients that do not return to sport report significantly greater fear of reinjury and inferior clinical outcomes, despite similar levels of satisfaction and pain compared to those that return. LEVEL OF EVIDENCE: Level III.

A Superolateral Cam Lesion Location Increases Odds of Total Hip Arthroplasty 5 Years After Hip Arthroscopy.

PURPOSE: To determine if radiographic cam location is associated with hip survivorship and postoperative patient-reported outcomes (PROs) at 5-year follow-up. METHODS: We conducted a review of prospectively collected data of patients with cam lesions who underwent hip arthroscopy for femoroacetabular impingement syndrome. Cam lesions were categorized into 3 locations: superolateral, anterolateral, or anterior. Conversion to total hip arthroplasty (THA), revision rates, and reoperation rates were assessed. Patient-reported outcome measures, including modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS), were collected preoperatively and at 5-year follow-up. RESULTS: Of the 156-patients, 125 met the final criteria (80.1%). Mean age was 41.1 ± 12.7 years. Seventy-one patients (56.8%) had superolateral cam lesions, 41 (32.8%) had anterolateral lesions, and 13 (10.4%) had anterior lesions. Revision rates within 5 years were 7.7% for anterior, 24.4% for anterolateral, and 14.1% for superolateral lesions; conversions to THAs were 15.4% for anterior), 7.3% for anterolateral, and 8.5% for superolateral. Reoperations were 23.1% for anterior, 29.3% for anterolateral, and 21.1% for superolateral. The superolateral cohort was younger than the anterior and anterolateral cohorts (anterior, 46.6 ± 12.2 years; anterolateral, 44.7 ± 12.2 years; superolateral, 38.1 ± 12.3 years; P = .006). Multivariable analysis showed the anterolateral group was significantly predictive of lower odds of undergoing THA compared to the superolateral group (odds ratio, 0.01; 95% CI, <0.01-0.72; P = .03). There were no differences in the 5-year improvement in mHHS (anterior, 32.4; anterolateral, 36.8; superolateral, 33.0; P = .29) or NAHS (anterior, 34.8; anterolateral, 39.0; superolateral, 37.3; P = .65). CONCLUSIONS: A superolateral cam lesion increases the odds of conversion to THA within 5 years of hip arthroscopy compared to those with anterolateral lesions on multivariable analysis. Those with superolateral lesions were significantly younger compared to those with anterior or anterolateral lesions. Cam lesion location did not affect improvement in PROs at 5-year follow-up. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Global Acetabular Retroversion Is Not Associated With Differences in Outcomes After Primary Hip Arthroscopy Among Patients With Femoroacetabular Impingement Syndrome: A Matched Cohort Study With Minimum 5-Year Follow-Up.

PURPOSE: To compare hip survivorship and patient-reported outcome measures (PROMs) after primary hip arthroscopy at 5-year follow-up between patients with femoroacetabular impingement syndrome (FAIS) with radiographic signs of global acetabular retroversion and those without. METHODS: A retrospective matched-cohort study was conducted using a single-surgeon hip arthroscopy database. Patients were included if they underwent primary hip arthroscopy for treatment of FAIS, had preoperative hip x-rays, and had a minimum 5-year follow-up. Global retroversion was defined as the presence of ischial spine sign, posterior wall sign, and crossover sign on anteroposterior view. Patients with FAIS with global retroversion were matched 1:1 on age, sex, and body mass index to FAIS controls. The modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were administered preoperatively and at follow-up. Hip survivorship and PROMs were compared between the 2 groups using the paired t test, Wilcoxon signed rank test, and/or Cochran-Mantel-Haenszel test as appropriate. P values <.05 were considered significant. RESULTS: Thirty-eight patients with global retroversion (mean age 40.6 ± 10.8 years, 60.5% female) were matched to 38 controls (mean age 41.3 ± 13.6 years, 60.5% female). Reoperation rates were the same in both groups (5.3%). On average, both groups reported significant pre- to postoperative improvement in mHHS (P < .001) and NAHS (P < .001), and there was no significant intergroup differences in the change in mHHS (P = .86) or NAHS (P = .90). Achievement rates for the patient acceptable symptom state on the mHHS were higher among males compared to females (P = .04) in both the global retroversion group (93.3% vs 73.9%) and the control group (93.3% vs 73.9%). CONCLUSIONS: Patients with FAIS with and without global acetabular retroversion had no significant difference in outcomes after primary hip arthroscopy at a minimum 5-year minimum follow-up. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Patient Satisfaction with Postoperative Telemedicine Versus In-Office Visits Following Primary Hip Arthroscopy: A Prospective Observational Study Before and During the COVID-19 Pandemic.

Abstract Background: The purpose of this study was to compare satisfaction with postoperative telemedicine visits versus in-office visits among patients undergoing primary hip arthroscopy. Methods: A prospective cohort study was conducted involving subjects ≥18 years old undergoing primary hip arthroscopy at a single center from January 2020 to February 2021. Subjects chose between a telemedicine or in-office visit for 6-week follow-up. Patient satisfaction after the 6-week visit was assessed using an electronic survey. The primary outcome was satisfaction on a scale from 0 to 10. Intergroup comparisons of outcomes were performed using Student's t-test, Mann-Whitney U test, or Fisher's exact test. p-Values <0.05 were considered significant. Results: Seventy-five patients (28M and 47F) were enrolled in the study with mean age 41.2 ± 12.7 years. Forty-four patients (58.7%) attended in-office visits and 31 (41.3%) attended telemedicine visits. There were no significant intergroup differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) classification (p > 0.05). There were no significant intergroup differences in satisfaction with overall care (in-office 9.6 vs. telemedicine 9.3, p = 0.08) or the 6-week visit (in-office 9.0 vs. telemedicine 8.0, p = 0.06). The telemedicine group more frequently reported visits taking <20 min (p = 0.002) and spending >10 min with their surgeon (p = 0.01). However, 51.6% of the telemedicine group and 74.7% of the entire cohort expressed a retrospective preference for in-office visits. Conclusions: There were no significant differences in satisfaction scores between hip arthroscopy patients assigned to telemedicine versus in-office visits for 6-week follow-up, but most patients expressed a preference for in-office visits.

Five-Year Outcomes of Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Among Female Patients: Higher Body Mass Index Is Associated With Reduced Clinically Significant Outcomes.

PURPOSE: To evaluate the impact of age, body mass index (BMI), and symptom duration on 5-year clinical outcomes among females following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: We conducted a retrospective review of a prospectively collected database of hip arthroscopy patients with a minimum 5-year follow-up. Patients were stratified by age (<30, 30-45, ≥45 years), BMI (<25.0, 25.0-29.9, ≥30.0), and preoperative symptom duration (<1 vs ≥1 year). Patient-reported outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Pre- to postoperative improvement in mHHS and NAHS was compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Hip survivorship rates and minimum clinically important difference (MCID) achievement rates were compared with Fisher exact test. Predictors of outcomes were identified using multivariable linear and logistic regression. P values <.05 were considered significant. RESULTS: In total, 103 patients were included in the analysis with a mean age of 42.0 ± 12.6 years (range, 16-75) and mean BMI of 24.9 ± 4.8 (range, 17.2-38.9). Most patients had symptoms of duration ≥1 year (60.2%). Six patients (5.8%) had arthroscopic revisions, and 2 patients (1.9%) converted to total hip arthroplasty by 5-year follow-up. Patients with BMI ≥30.0 had significantly lower postoperative mHHS (P = .03) and NAHS (P = .04) than those with BMI <25.0. Higher BMI was associated with reduced improvement in mHHS (ß = -1.14, P = .02) and NAHS (ß = -1.34, P < .001) and lower odds of achieving the mHHS MCID (odds ratio [OR] = 0.82, P = .02) and NAHS MCID (OR = 0.88, P = .04). Older age was predictive of reduced improvement in NAHS (ß = -0.31, P = .046). Symptom duration ≥1 year was predictive of higher odds of achieving the NAHS MCID (OR = 3.98, P = .02). CONCLUSIONS: Female patients across a wide range of ages, BMIs, and symptom durations experience satisfactory 5-year outcomes following primary hip arthroscopy, but higher BMI is associated with reduced improvement in patient-reported outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Borderline Hip Dysplasia Is Not Associated With Significant Differences in Hip Survivorship or Patient-Reported Outcomes Following Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Cohort Study.

PURPOSE: To compare hip survivorship and patient-reported outcomes after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients with versus without comorbid borderline hip dysplasia (BHD) at 2-year follow-up. METHODS: A retrospective matched-cohort study was conducted involving patients who underwent primary hip arthroscopy for FAIS with a single surgeon from 2010 to 2019. BHD was defined as lateral center edge angle (LCEA) of 20 to 25°. Subjects with BHD were matched 1:2 to controls without BHD on age, sex, body mass index, and preoperative modified Harris Hip Score (mHHS). Alpha angle, LCEA, Tönnis angle, and acetabular retroversion signs were measured on preoperative and/or postoperative hip radiographs. Patient-reported outcomes were assessed using the mHHS and the Non-Arthritic Hip Score. Hip survivorship, outcome scores, and achievement of the minimum clinically important difference were compared between groups using the Mann-Whitney U test or Fisher exact test, as appropriate. P values <.05 were considered significant. RESULTS: Thirty-one BHD subjects (mean age 36.8 years, 71.0% female) and 62 controls (mean age 38.0 years, 71.0% female) were included. There were no significant intergroup differences in demographics or preoperative radiographic measurements besides LCEA and Tönnis angle (all P > .05). Intraoperatively, subjects with BHD were found to have significantly shorter labral tears (mean 2.6 vs 2.8 clock-face hours, P = .048), but there were no significant intergroup differences in acetabular or femoral cartilage status (all P > .05). Postoperatively, there were no significant intergroup differences in rates of revision arthroscopy (BHD 6.5% vs control 11.3%) or conversion to total hip arthroplasty (BHD 9.7% vs control 1.6%), in 2-year improvement of the mHHS and Non-Arthritic Hip Score, or in minimum clinically important difference achievement rates (all P > .05). CONCLUSIONS: BHD is not associated with a significant difference in hip survivorship or patient-reported outcomes following primary hip arthroscopy for FAIS. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Paresthesia Is Predictive of Symptom Recurrence After Fasciotomy for Exertional Compartment Syndrome of the Leg.

BACKGROUND: Exertional compartment syndrome (ECS) is an underdiagnosed cause of lower extremity pain among athletes. The condition can be managed operatively by fasciotomy to relieve excess compartment pressure. However, symptom recurrence rates after fasciotomy are considerable, ranging from 3% to 17%. HYPOTHESIS: Leg paresthesia and its distribution during ECS episodes would be a significant predictor of outcomes after fasciotomy. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: We conducted a retrospective chart review of patients who underwent fasciotomy for ECS at our center from 2010 to 2020 (institutional review board no. 21-00107). We measured postoperative outcomes including pain frequency and severity, Tegner activity level, and return to sport. Significant predictors of outcomes were identified using multivariable linear and logistic regression. P values <0.05 were considered significant. RESULTS: A total of 78 legs (from 42 male and 36 female participants) were included in the study with average follow-up of 52 months (range, 3-126 months); 33 participants (42.3%) presented with paresthesia. Paresthesia was an independent predictor of worse outcomes, including more severe pain at rest (P = 0.05) and with daily activity (P = 0.04), reduced postoperative improvement in Tegner scores (P = 0.04), and lower odds of return to sport (P = 0.05). Those with paresthesia symptoms in the tibial nerve distribution had worse outcomes than those without paresthesia in terms of preoperative-to-present improvement in pain frequency (P < 0.01), pain severity at rest (P < 0.01) and with daily activity (P = 0.04), and return to sport (P = 0.04). CONCLUSION: ECS patients who present with paresthesia have worse pain and activity outcomes after first-time fasciotomy, but prognosis is worst among those with tibial nerve paresthesia. CLINICAL RELEVANCE: Paresthesia among ECS patients is broadly predictive of more severe recurrent leg pain, reduced activity level, and decreased odds of return to sport after fasciotomy.

Decreased Hip Labral Width Measured on Preoperative Magnetic Resonance Imaging Is Associated With Greater Revision Rate After Primary Arthroscopic Labral Repair for Femoroacetabular Impingement Syndrome at 5-Year Follow-Up.

PURPOSE: To examine the associations between hip labral width and patient-reported outcomes, clinical threshold achievement rates, and rate of reoperation among patients with femoroacetabular impingement syndrome (FAIS) who underwent hip arthroscopy and labral repair at minimum 5-year follow-up. METHODS: Patients were identified from a prospective database who underwent primary hip arthroscopy for treatment of labral tears and FAIS. Modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) were recorded preoperatively and at 5-year follow-up. Achievement of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) was determined using previously established values. Labral width magnetic resonance imaging measurements were performed by 2 independent readers at standardized "clockface" locations. Patients were stratified into 3 groups at each position: lower-width (<½ SD below mean), middle-width (within ½ SD of mean), and upper-width (>½ SD above mean). Multivariable regression was used to evaluate associations of labral width with patient-reported outcomes and reoperation rate. RESULTS: Seventy-three patients (age: 41.0 ± 12.0 years; 68.5% female) were included. Inter-rater reliability for labral width measurements was high at all positions (intraclass correlation coefficient 0.94-0.96). There were no significant intergroup differences in mHHS/NAHS improvement (P > .05) or in achievement rates of MCID/SCB/PASS at each clockface position (P > .05). Eleven patients (15.1%) underwent arthroscopic revision and 4 patients (5.5%) converted to total hip arthroplasty. Multivariable analysis found lower-width groups at 11:30 (odds ratio 1.75, P = .02) and 3:00 (odds ratio 1.59, P = .04) positions to have increased odds of revision within 5 years; however, labral width was not associated with 5-year improvement in mHHS/NAHS, achievement of MCID/PASS/SCB, or conversion to total hip arthroplasty (P > .05). CONCLUSIONS: Hip labral width <½ SD below the mean measured on preoperative magnetic resonance imaging at 11:30- and 3:00-clockface positions was associated with increased odds of reoperation after arthroscopic labral repair and treatment of FAIS. Labral width was not associated with 5-year improvement of mHHS, NAHS, achievement of clinical thresholds, or conversion to arthroplasty. LEVEL OF EVIDENCE: Level IV, case series.

Concomitant open distal clavicle excision is associated with greater improvement in range of motion without increased risk of acromial stress fracture after reverse total shoulder arthroplasty: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the effect of concomitant open distal clavicle excision (DCE) on postoperative clinical outcomes and incidence of acromial and scapular stress fractures (ASFs) in patients with symptomatic acromioclavicular joint osteoarthritis (ACJ OA) undergoing reverse total shoulder arthroplasty (RTSA). METHODS: A single-surgeon retrospective cohort study was conducted including patients who underwent primary elective RTSA with or without DCE from 2015 to 2019 with a minimum 6-month follow-up period. Shoulder active range of motion (AROM) and visual analog scale (VAS) pain were recorded preoperatively and postoperatively. ASFs and other adverse events were identified using postoperative notes and/or radiographs. Characteristics and outcomes were compared between the RTSA and RTSA-DCE groups. RESULTS: Forty-six RTSA patients (mean age, 67.9±8.7 years; 60.9% male; mean follow-up, 24.9±16.6 months) and 70 RTSA-DCE patients (mean age, 70.2±8.9 years; 20.0% male; mean follow-up, 22.7±12.9 months) were included. There were no significant intergroup differences in rates of ASF (RTSA, 0.0% vs. RTSA-DCE, 1.4%; P=1.00), stress reactions (RTSA, 8.7% vs. RTSA-DCE, 11.4%; P=0.76), reoperation, revision, or infection (all P>0.05), or in pre-to-postoperative reduction in VAS pain (P=0.17) at latest follow-up. However, the RTSA-DCE group had greater pre-to-postoperative improvement in flexion AROM (RTSA, 43.7°±38.5° vs. RTSA-DCE, 59.5°±33.4°; P=0.03) and internal rotation (IR) AROM (P=0.02) at latest follow-up. CONCLUSIONS: Concomitant DCE in RTSA improves shoulder flexion and IR AROM, alleviates shoulder pain, and does not increase the risk of ASFs. Level of evidence: III.

Clinical Presentation and Outcomes of Sacral Stress Fractures in Athletes: A Case Series of 13 Patients.

BACKGROUND: Sacral stress fractures are a rare cause of low back pain in athletes. Given the low incidence of these fractures, there is a scarcity of data on symptomatology, risk factors, and clinical outcomes. HYPOTHESIS: Patients diagnosed with sacral stress fractures would be athletes presenting with low back pain. STUDY DESIGN: Case series of 13 patients with sacral stress fractures. LEVEL OF EVIDENCE: Level 4. METHODS: We conducted a retrospective review of medical records to identify patients diagnosed with sacral stress fractures at a single academic institution. Fractures were diagnosed on noncontrast T2-weighted magnetic resonance imaging scans and categorized using the Bakker classification system. Subjects were administered an electronic survey that asked about (1) the onset, time course, and location of pain and other symptoms; (2) time to treatment and treatment modalities pursued; (3) sports performance and time to return to sport; and (4) risk factors for stress fractures. RESULTS: Of 18 eligible patients, 13 (72.2%) completed the survey with mean follow-up of 49.6 months (range, 1-144 months). Mean age was 28.0 years (range, 18-52 years); 9 patients (69.2%) were female, of whom 7 (77.8%) were premenopausal. The most common fracture type was Bakker type B (8 patients; 61.5%). Most patients presented with acute lumbosacral back pain in the setting of running/jogging activities. All patients underwent nonoperative treatment for an average of 3.8 months (range, 0-8 months) and three-quarters reported pain resolution at last follow-up. Rate of return to sport was 83.3%, but most patients reported ongoing deficits in running performance. CONCLUSION: Sacral stress fractures commonly present as acute lumbosacral back pain provoked by running sports. While the pain associated with these fractures prevents most athletes from participating in sports, nonoperative management appears to be an effective treatment modality with a high rate of return to sport.

Reprint of: Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but Not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories. METHODS: We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model. RESULTS: 285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P = .006) and at 2-year follow-up (P = .008). There were no significant intergroup differences in time to achievement for MCID (P = .92) or SCB (P = .69), but obese patients had longer time to PASS than normal BMI patients (P = .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR = .55; P = .007) but not MCID (HR = 0.91; P = .68) or SCB (HR = 1.06; P = .30). CONCLUSIONS: Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Cannabis Use Disorder Not Associated With Opioid Analgesic Use or Patient-Reported Outcomes After ACL Reconstruction: A Retrospective Matched-Cohort Analysis.

BACKGROUND: The purpose of this study was to compare opioid analgesic use and patient-reported outcomes (PROs) after anterior cruciate ligament reconstruction (ACLR) between patients with and without cannabis use disorder (CUD). HYPOTHESIS: We hypothesized that patients with CUD would have greater postoperative opioid usage with comparable improvement in PROs. STUDY DESIGN: Retrospective matched-cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: We identified patients with CUD who underwent primary ACLR at a single center and had minimum 3-month follow-up. Patients with CUD were propensity score matched 1:1 to non-CUD controls with respect to age, sex, and follow-up time. Total refills, days supply, and morphine milligram equivalents (MMEs) of opioid analgesics prescribed were calculated for up to 1 year postoperatively. Patient-Reported Outcome Information System (PROMIS) instruments were used to assess PROs. Opioid use and outcomes were compared between CUD and control groups using Mann-Whitney U test and Fisher's exact test. P values <0.05 were considered significant. RESULTS: A total of 104 patients with CUD were matched to 104 controls. Both groups were majority male (65.4% male, 34.6% female). The CUD group had a mean age of 29.9 years and mean follow-up time of 16.1 months. There was no significant intergroup difference in opioid prescription rates (CUD 82.7% vs control 83.7%, P ≥ 0.99). Among patients prescribed opioids, there were no significant intergroup differences in total days supply (P = 0.67), total MMEs (P = 0.71), or MMEs per day (P = 0.65). There were no significant differences in pre- to postoperative improvement in PROMIS Pain Intensity (P = 0.51), Pain Interference (P = 0.81), Mobility (P = 0.90), Mental Health (P = 0.74), or Physical Health (P = 0.94). CONCLUSION: There were no significant differences detected in opioid usage or PRO improvement after ACLR between patients with CUD and those without. However, because a sample size was not determined a priori, a larger sample may show a difference. CLINICAL RELEVANCE: CUD does not appear to correlate with inferior outcomes after ACLR.

Force plate jump testing metrics are predictive of performance on a multimodal return to sport testing protocol among anterior cruciate ligament reconstruction patients at minimum six-month follow-up.

BACKGROUND: Force plate-based jump testing may serve as a potential alternative to traditional return to sport (RTS) testing batteries. The purpose of our study was to identify force plate jump metrics that were predictive of RTS test findings in patients who were at least six months postoperative following anterior cruciate ligament reconstruction (ACLR). METHODS: We conducted a cross-sectional study of patients who underwent ACLR at our center and were at least six months postoperative. Subjects completed a multimodal Institutional RTS (IRTS) testing battery which included range of motion (ROM) testing and isokinetic quadriceps strength testing. Subjects also completed a countermovement jump testing protocol on a commercially-available force plate. Jump metrics predictive of IRTS test findings were identified using multivariable linear and logistic regression with stepwise selection. Model significance was assessed at α=0.002. RESULTS: Sixteen patients (7M, 9F) were enrolled in our study with median age of 29 years (range 20-47). Relative concentric impulse was positively predictive of knee flexion active ROM (ß=7.07, P=0.01) and passive ROM (ß=9.79, P=0.003). Maximum power was positively predictive of quadriceps strength at 60 deg/s (ß=3.27, P<0.001) and 180 deg/s (ß=2.46, P<0.001). Center-of-pressure (COP) shift acceleration along the force plate X-axis was negatively predictive of Bunkie lateral test score (ß=-945, P<0.001) and medial test score (ß=-839, P=0.03). CONCLUSIONS: Force plate-derived vertical jump testing metrics are predictive of certain components of a multimodal RTS physical assessment for ACLR patients, including knee flexion ROM, quadriceps strength on isokinetic testing, and Bunkie Test performance.

Home ownership, full-time employment, and other markers of higher socioeconomic status are predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction.

BACKGROUND: The purpose of this study was to identify socioeconomic predictors of time to initial evaluation, time to surgery, and postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction (MPFLR). METHODS: We conducted a retrospective review of patients at our institution who underwent primary MPFLR with allograft from 2011 to 2019 and had minimum 12-month follow-up. Patients were administered an email survey in January 2022 to assess symptom history, socioeconomic status, and postoperative outcomes including VAS satisfaction and Kujala score. Predictors of time to initial evaluation, time to surgery, and postoperative outcomes were identified using multivariable linear and logistic regression with stepwise selection. RESULTS: Seventy patients were included in the cohort (mean age 24.8 years, 72.9% female, mean follow-up time 45.7 months). Mean time to evaluation was 6.4 months (range 0-221) and mean time to surgery was 73.6 months (range 0-444). Having a general health check-up in the year prior to surgery was predictive of shorter time to initial evaluation (ß = - 100.5 [- 174.5, - 26.5], p = 0.008). Home ownership was predictive of shorter time to surgery (ß = - 56.5 [- 104.7, 8.3], p = 0.02). Full-time employment was predictive of higher VAS satisfaction (ß = 14.1 [4.3, 23.9], p = 0.006) and higher Kujala score (ß = 8.7 [0.9, 16.5], p = 0.03). CONCLUSION: Markers of higher socioeconomic status including having a general check-up in the year prior to surgery, home ownership, and full-time employment were predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes. LEVEL OF EVIDENCE:  IV, retrospective case series.

Arthroscopic Meniscus Repair Using an All-Inside, All-Suture, Knotless Device.

With an increased appreciation of the importance an intact meniscus has on normal knee kinematics and function, more meniscal tears are being treated with a repair rather than partial meniscectomy. There are several techniques for repairing torn meniscal tissue, including the outside-in, inside-out, and all-inside repairs. Each technique comes with its advantages and drawbacks. The inside-out and outside-in techniques allow for greater control of the repair using knots outside the joint capsule; however, they pose a risk for neurovascular injury and require additional incisions. Arthroscopic all-inside repairs have seen increasing popularity, but with current techniques, fixation is achieved either with intra-articular knots or extra-articular implants, leading to variable outcomes and the potential for postoperative complications. This technical note describes the use of SuperBall, an all-inside meniscus repair device that provides an all-arthroscopic approach, no intraarticular knots or implants, and surgeon-guided tensioning of the meniscus repair.

Patients aged 50-75 years take longer to achieve the patient acceptable symptom state than patients aged 20-34 years following primary hip arthroscopy for femoroacetabular impingement syndrome.

PURPOSE: Though an increasing number of adults older than 50 years are undergoing hip arthroscopy for treatment of Femoroacetabular Impingement Syndrome (FAIS), it is unclear how their timeline for functional outcome improvement compares to that of younger patients. The purpose of this study was to assess the impact of age on time to achieving the Minimum Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) following primary hip arthroscopy for FAIS. METHODS: A retrospective comparative single-surgeon cohort study of primary hip arthroscopy patients with minimum 2-year follow-up was conducted. Age categories were 20-34 years, 35-49 years, and 50-75 years. All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6-month, 1-year, and 2-year follow-up. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥ 8.2 and ≥ 19.8, respectively. PASS cutoff was set at postoperative mHHS ≥ 74. Time to achievement of each milestone was compared using interval-censored survival analysis. The effect of age was adjusted for Body Mass Index (BMI), sex, and labral repair technique using an interval-censored proportional hazards model. RESULTS: Two hundred eighty-five patients were included in the analysis with 115 (40.4%) aged 20-34 years, 92 (32.3%) aged 35-49 years, and 78 (27.4%) aged 50-75 years. There were no significant differences between groups in time to achievement for the MCID (n.s.) or SCB (n.s.). However, patients in the oldest group had significantly longer time to PASS than those in the youngest group, both in the unadjusted analysis (p = 0.02) and after adjusting for BMI, sex, and labral repair technique (HR 0.68, 95% CI 0.48-0.96, p = 0.03). CONCLUSION: Achievement of the PASS, but not the MCID or SCB, is delayed among FAIS patients aged 50-75 years who undergo primary hip arthroscopy compared to those aged 20-34 years. Older FAIS patients should be counseled appropriately about their longer timeline to achieving hip function comparable to their younger counterparts. LEVEL OF EVIDENCE: III.