Addition of Pericapsular Nerve Group and Transversus Abdominis Plane Blocks Significantly Reduces Opioid Use in Patients Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy.

INTRODUCTION: Previous studies have evaluated the effect of the pericapsular nerve group block for hip arthroscopy and the transverse abdominis plane block for periacetabular osteotomy and have shown decreased narcotic consumption in both groups. No published study has evaluated the effectiveness of combining the blocks when performing hip arthroscopy and periacetabular osteotomy under the same general anesthesia. It was hypothesized that patients treated for hip dysplasia with hip arthroscopy and concomitant periacetabular osteotomy using a pericapsular nerve group block, transverse abdominis plane block, and general anesthesia would have decreased postoperative pain and require less narcotic consumption than those undergoing the procedure with general anesthetic alone.  Methods: A single surgeon performed a retrospective analysis of consecutive patients undergoing concomitant hip arthroscopy and periacetabular osteotomy between 11/2020 and 6/2021. Fifteen consecutive patients undergoing the procedure with a general anesthetic alone (no-block group) were compared to 15 patients undergoing the same procedure with a combined pericapsular nerve group block, transverse abdominis plane block, and general anesthetic (block group). Hip arthroscopy was performed utilizing a post-free technique, and a rectus sparing approach was used for the periacetabular osteotomy. The nerve blocks were performed by multiple anesthesiologists using previously published methods. Operating room time, length of stay, visual analog scale pain scores, and total narcotic consumption in morphine milliequivalents were analyzed. Groups were compared using the chi-squared test for non-continuous demographic variables and a two-tailed t-test for continuous variables utilizing Microsoft Excel (Microsoft, Redmond, WA, USA), p-value set at 0.05 for significance.  Results: The no-block group consisted of 14 females and one male, while the block group was all females. No significant differences were observed between age, sex, BMI, surgery time, length of stay, or procedures performed, p>0.05. The maximal visual analog scale score in the post-anesthesia care unit was 8 ± 1.3 vs. 7 ± 1.9 in the no-block vs. block groups, respectively, p=0.15. The average hospital floor visual analog scale score was 5.7 ± 1.3 vs. 4.8 ± 1.3 in the no-block vs. block groups, respectively, p=0.07. Total pain medications required were 217.6 ± 54.6 vs. 154 ± 41.9 morphine milliequivalents in the no-block vs. block groups, respectively, p=0.001. No complications were reported in either group, and no patient in the block group demonstrated motor nerve palsy or postoperative fall. CONCLUSION:  This study demonstrated that patients undergoing combined hip arthroscopy and periacetabular osteotomy for symptomatic acetabular dysplasia who had pericapsular nerve group, transverse abdominal plane block, and general anesthesia required fewer narcotics in the first 24 hours after surgery compared to those who had general anesthesia alone.

Computer Navigation vs. Conventional Overlay Methods in Direct Anterior Total Hip Arthroplasty: A Single Surgeon Experience.

BACKGROUND:  The use of computer navigation (CN) is expanding in direct anterior (DA) total hip arthroplasty (THA). In this study, we investigated the use of a noninvasive, fluoroscopic-based, CN technology suite on operative outcomes in a single surgeon DA THA practice. HYPOTHESIS: Computer-navigated DA THA decreases leg length discrepancy (LLD) variation and fluoroscopic radiation dose without adding operative time compared to the traditional overlay (OL) technique. METHODS: A retrospective review was performed on a total of 109 primary DA THA patients, with 58 in the CN and 51 in the OL group. Outcome metrics were postoperative LLD, radiation dose per case, and operative time. Statistical analysis was completed with Mann-Whitney U tests for differences between the means for LLD, radiation dose, and operative time. RESULTS: No difference was observed in postoperative LLD between the CN (average: 1.8 mm) and OL (average: 1.9 mm) groups (p = 0.458). A significant reduction in average radiation dose (mGy) per case within the CN group (8.17 ± 6.09 mGy) compared to the OL group (13.17 ± 7.75 mGy) (p < 0.02) was observed. The average operative time in the CN group was 80 ± 18 minutes compared to 120 ± 32 minutes in the OL group (p < 0.01). CONCLUSION: There was no difference in LLD between the two groups. The addition of CN into a DA THA practice decreased both average radiation dose and operative time when compared to the standard OL technique.

Arthroscopic and Endoscopic Treatment of Proximal Rectus Femoris Avulsion.

Proximal rectus femoris avulsion (PRFA) is an uncommon injury that is poorly reported in the literature. Historically, these injuries have been treated nonoperatively or with open techniques. This is the first study showing endoscopic treatment of this injury. We present a systematic review of PRFA treatment and a case report of a patient whose injury was treated endoscopically. Sixty-four injuries were reported across several sports. Patients underwent nonoperative management, suture repair, suture anchor repair, or excision of the tendon stump. Surgical complications included lateral femoral cutaneous nerve injury and wound complications. The patient who underwent arthroscopic treatment had a good outcome. [Orthopedics. 2022;45(1):e1-e6.].

Post-Related Complications in Hip Arthroscopy Are Reported Significantly Greater in Prospective Versus Retrospective Literature: A Systematic Review.

PURPOSE: To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury. RESULTS: Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P < .001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively. CONCLUSIONS: The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries. LEVEL OF EVIDENCE: IV, systematic review of Level I-IV evidence.

A Novel Radiographic Finding of Intracapsular Heterotopic Ossification: A Report of Two Cases.

Symptomatic heterotopic ossification (HO) is a complication of hip arthroscopy that occurs in less than 1% of cases. To our knowledge, there are no reported cases of symptomatic intracapsular HO. We present 2 patients with a radiographic finding associated with intracapsular HO. Both patients underwent revision hip arthroscopy and required capsular reconstruction due to void of the iliofemoral ligament following excision of HO. We believe this radiographic finding may be useful to hip preservationists as it may be associated with capsular deficiency necessitating capsular reconstruction upon revision hip arthroscopy.

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.

Mandatory Nicotine Cessation for Elective Orthopedic Hip Procedures Results in Reduction in Postoperative Nicotine Use.

Purpose To determine the efficacy of mandatory preoperative nicotine cessation on postoperative nicotine use, and to identify independent predictors of nicotine use relapse in subjects undergoing hip preservation surgery or total hip arthroplasty by a single fellowship-trained orthopedic surgeon. Methods Consecutive subjects that underwent hip surgery from November 2014 to December 2017 were reviewed. Subjects who self-reported nicotine use, quit prior to surgery, and completed a minimum one-year follow-up were included. Multiple linear regression models were constructed to determine the effect of independent variables on nicotine use relapse following surgery. Results Sixty subjects were included in the study (mean follow-up 35.1 months (17-57 months), mean age 44.9 years (20-82 years), and 23 (38.3%) males). Twenty-eight subjects (46.7%) remained nicotine-free at final follow-up. The mean number of cigarettes per day decreased from 13.4 preoperatively to 8.4 postoperatively in the subjects who relapsed (P=0.002). The mean time to return to nicotine postoperatively was 2.4 months. The number of preoperative cigarettes per day was the only independent predictor of tobacco use relapse (P=0.005). Conclusion Mandatory preoperative nicotine cessation prior to elective hip surgery demonstrates a 46.7% nicotine-free survivorship at final follow-up with the number of preoperative cigarettes per day found to be the only independent predictor of nicotine use relapse. Level of evidence The level of evidence of this research study is Level III since it is a non-experimental study with a cohort of patients.

Achieving Post-Free Distraction in Hip Arthroscopy With a Pink Pad Patient Positioning Device Using Standard Hip Distraction Tables.

Iatrogenic pudendal nerve and groin complications have been reported to occur at rates up to 4.3%. While many of these complications are transient, the hip preservation community is in search of a safe postless distraction technique. Currently available postless distraction tables are expensive, require the surgeon to adopt a different technique, and have a high disposable fee. We present our technique for postless distraction using a standard table and a pink pad positioning device. Using our technique, we have demonstrated safe and cost-effective post-free distraction.

Relationship Between PROMIS Computer Adaptive Tests and Legacy Hip Measures Among Patients Presenting to a Tertiary Care Hip Preservation Center.

BACKGROUND: Legacy hip outcome measures may be burdensome to patients and sometimes yield floor or ceiling effects. Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) allow for low-burden data capture and limited ceiling and floor effects. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether the PROMIS CAT domains demonstrate correlation against commonly used legacy patient-reported outcome measures in a population of patients presenting to a tertiary care hip preservation center. The authors hypothesized the following: (1) PROMIS CAT scores based on physical function (PF), pain interference (PIF), pain behavior, and pain intensity would show strong correlation with the following legacy scores: modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), Hip Outcome Score (HOS) Sports and Activities of Daily Living subscales, and Veterans RAND-6D (VR-6D) utility measure. (2) The mental and physical health portions of the VR-6D legacy measure would show weak correlation with mental- and psychosocial-specific PROMIS elements-depression, anxiety, fatigue, sleep, and ability to participate in social roles and activities. (3) All PROMIS measures would exhibit fewer floor and ceiling effects than legacy scores. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Prospective data were collected on 125 patients in the hip preservation clinics. Enrollees completed legacy scores (visual analog scale for pain, mHHS, iHOT-12, HOS, and VR-6D) and PROMIS CAT questionnaires (PF, PIF, pain behavior, anxiety, depression, sleep, social roles and activities, pain intensity, fatigue). Spearman rank correlations were calculated, with rs values of 0 to 0.3 indicating negligible correlation; 0.3 to 0.5, weak correlation; 0.5 to 0.7, moderately strong correlation; and >0.7, strong correlation. Floor and ceiling effects were evaluated. RESULTS: As anticipated, the PF-CAT yielded strong correlations with the iHOT-12, mHHS, HOS-Sports, HOS-Activities of Daily Living, and VR-6D, with rs values of 0.76, 0.71, 0.81, 0.87, and 0.71, respectively. The PIF-CAT was the only pain score to show moderately strong to strong correlation with all 14 patient-reported outcome measures. A strong correlation was observed between the VR-6D and the social roles and activities CAT ( rs = 0.73). The depression CAT had a significant floor effect at 19%. No additional floor or ceiling effect was present for any other legacy or PROMIS measure. CONCLUSION: The PF-CAT shows strong correlation with legacy patient-reported outcome scores among patients presenting to a tertiary care hip preservation center. The PIF-CAT also correlates strongly with legacy and PROMIS measures evaluating physical and mental well-being. PROMIS measures are less burdensome and demonstrate no floor or ceiling effects, making them a potential alternative to legacy patient-reported outcome measures for the hip.

A Novel All-Inside Arthroscopic Technique for Radial-Sided Triangular Fibrocartilage Complex Tears: A Case Report and Review of Literature.

BACKGROUND: Triangular fibrocartilage complex (TFCC) injuries are a known cause of ulnar-sided wrist pain. Wrist arthroscopy is the gold standard for diagnosis of these lesions and is becoming a more frequent method of treatment. Isolated radial-sided tears are uncommon and treatment of these lesions is controversial. There are few reports on repair techniques. Here we report on a novel arthroscopic, all-inside technique for traumatic radial-sided TFCC tears that resulted in full range of motion, significant improvement in pain, and ultimately return to sport. METHODS: This is a single case report describing an all-inside, arthroscopic repair of a radial-sided TFCC tear. The techniques and postoperative protocol are discussed. Clinical outcomes were reported at final follow-up of 3.5 months. RESULTS: At final follow-up, our patient had full wrist range of motion, 95% strength, occasional 1/10 pain, and returned to sport at her previous level of play. There were no complications. CONCLUSION: Although just a single case report, our patient had an excellent result based on modified Mayo wrist score. When comparing our result and the previous literature, this technique seems to be a valid method for addressing radial-sided TFCC tears.