The Functional Integrity of the Anterior Cruciate Ligament Can Be Objectively Assessed With the Use of Stress Radiographs: A Systematic Review.

Background: Stress radiography is a viable imaging modality that can also be used to assess the integrity of the anterior cruciate ligament (ACL) after primary or secondary injury. Because conventional radiography is relatively easy, affordable, and available worldwide, the diagnostic efficacy of ACL standing, lateral decubitus, and supine stress radiography should be evaluated. Purpose: To examine the existing literature regarding the application of stress radiography in evaluating the integrity of the ACL. Study Design: Systematic review; Level of evidence, 3. Methods: Using the PubMed and MEDLINE databases for relevant articles published between 1980 and the present, a systematic review was conducted to identify evidence related to the radiographic diagnosis or assessment of ACL tears. The literature search was conducted in September 2022. Results: Of 495 studies, 16 (1823 patients) were included. Four studies examined standing stress radiography, and 12 investigated lateral decubitus or supine stress radiography. Significant heterogeneity in imaging technique and recorded anterior tibial translation was identified. Anterior tibial translation for ACL-injured knees ranged from 1.2 to 10.6 mm for standing stress radiographs and 2.7 to 11.2 mm for supine stress radiographs, with high sensitivities and specificities for both. Conclusion: Stress radiography was a dependable diagnostic method for identifying ACL rupture. Further research is necessary to determine the ideal anatomic landmarks, optimal patient positioning, and appropriate applied stresses to establish a standardized protocol for both assessing ACL tears and evaluating the postoperative integrity of ACL reconstruction using stress radiography.

Editorial Commentary: Trends in Hip Arthroscopy Require Rapid Dissemination From Higher-Volume and Academic Surgeons to the Greater Orthopaedic Community.

Trends in hip arthroscopy show that labral repair and preservation, capsular repair and preservation, and treatment of femoroacetabular impingement during hip arthroscopy are associated with superior short-term and mid- to longer-term outcomes. Hip arthroscopy, and in particular arthroscopic femoroacetabular impingement correction, is in its infancy compared with many other orthopaedic procedures. As we assimilate knowledge, data, and evidence-based research, it is critical to evaluate surgical trends and how they affect our management of these patients and pathologies. However, it is important to recognize that there is great variability with regards to surgical volume and awareness of impending evidence-based research for relatively newer procedures such as hip arthroscopy. This can lead to delays for incorporating newer evidence-based techniques. The gap is closing, but the time required to close this disparity in management trends between higher-volume/academic surgeons and the orthopaedic community as a whole could be shorter. Whether this delay for adapting evidence-based trends is consistent across the spectrum of orthopaedic surgery or specific to smaller subspecialty areas such as hip arthroscopy is unclear. Regardless, it is essential that those who are performing the larger volume of cases and research must raise our voices, turn up our loudspeakers, and publish, present, and use social media platforms to spread the word of the latest evidence-based trends quickly! It is equally critical for the greater orthopaedic community to listen for the benefit of patients. If all parties collaborate, we can get up to speed in a timelier manner and achieve the best-possible outcomes together.

Radiographic and Dynamic Assessment for Resection of Cam Lesions in Patients With Femoroacetabular Impingement.

Cam-type femoroacetabular impingement is characterized by a pathologic asphericity of the femoral head-neck junction, and arthroscopic femoral osteoplasty is indicated to correct the bony abnormality and restore normal hip mechanics when symptomatic. Residual femoroacetabular impingement deformity after arthroscopy is a leading cause of failure, and it is therefore critical to perform a thorough fluoroscopic and dynamic assessment when addressing cam deformities arthroscopically. The fluoroscopic assessment uses 6 anteroposterior views, including 3 in hip extension (30° internal rotation, neutral rotation, and 30° external rotation) and 3 in 50° flexion (neutral rotation, 40° external rotation, 60° of external rotation), performed before, during, and after the femoral resection. The dynamic assessment includes evaluation of impingement-free range of motion and "end feel" (a subjective description of the tactile feedback during assessment of hip motion), and should be performed before and after the femoral resection in 3 specific positions (extension/abduction, flexion/abduction, and flexion/internal rotation). Although the anterior aspect of the head-neck junction is readily accessed through standard arthroscopic portals with the hip in 30 to 50° of flexion, the posterolateral, posteromedial, and posterior extent of the femoral head-neck junction are challenging to address. The natural external rotation of the proximal femur during flexion and internal rotation during extension can be used to gain posterior lateral and medial access. Antero/posteromedial femoral access can be obtained with >50° of hip flexion with the burr in the anteromedial portal. Posterolateral femoral access is achieved with hip extension with the burr in the anterolateral portal, and further posterolateral access can be achieved with the addition of traction, allowing resection of posterolateral deformities extending beyond the lateral retinacular vessels while remaining proximal to the vessels. This comprehensive intraoperative fluoroscopic and dynamic assessment and surgical technique can lead to a predictable correction of most cam-type deformities.

Acetabular Rim Ossification Variants Are Found in Almost 20% of Patients Presenting With Hip Pain.

Purpose: To determine the prevalence of 4 different types of acetabular rim ossifications, including partial labral ossification or punctate calcification, true os acetabuli, acetabular rim stress fracture, and complete labral ossification, and to determine whether different types of periacetabular ossifications are linked to demographic or radiological factors. Methods: We retrospectively reviewed the medial records of patients presenting for hip-related complaints at 2 sports medicine practices from September 2007 to December 2009. An anteroposterior radiograph of both hips and a lateral radiograph of each hip was obtained for all patients and reviewed for findings of cam and pincer femoroacetabular impingement, degenerative changes (Tönnis grade), and periacetabular calcifications for both hips. These parameters were also evaluated with respect to symptoms, sex, and age. Results: Four hundred ninety-one consecutive patients (982 hips) presented to 2 orthopaedic surgeons at 2 centers for "hip"-related complaints. There were 223 males and 268 females (age 39 ± 14 years). The overall prevalence of periacetabular calcifications in hips was 17.6%, with 56.6% of calcifications in the symptomatic hip and 43.4% in the contralateral hip. Four basic patterns of calcification were identified: punctuate calcifications within the labrum (8.0% hips), large rounded calcifications (os acetabuli) (4.2% hip), large fragments with a vertical line of the superior-lateral acetabular rim, consistent with healed or non-healed stress fracture (2.0% hips), and complete ossification of the labrum (3.4% hips). Overall, male sex (P = .002), increased lateral center-edge angle (P = .046), and higher Tönnis grade (P < .001) statistically predicted the presence of periacetabular ossification. Punctate calcifications were more prevalent in males (P = .002). Higher Tönnis grade (P = .029) and increased alpha angle (P = .046) were more prevalent with os acetabuli. Younger age (P = .001), male sex (P = .048), increased alpha angle (P = .012), and increased lateral center-edge angle (P < .001) were more prevalent in acetabular rim fractures. No factors were statistically significant at predicting the presence of an ossified labrum. Conclusions: Periacetabular calcifications are not uncommon. Four particular patterns of calcification are identified: punctate labral calcifications (8%), larger rounded calcifications (i.e., os acetabuli) (4.2%), acetabular rim stress fractures (2%), and complete ossification of the labrum (3.4%) for a combined prevalence of 17.6% in patients presenting to an orthopaedic surgeon with "hip"-related complaints. Nearly half were in the asymptomatic hip. Male sex had a higher prevalence of periacetabular calcifications. An increased lateral center edge angle and higher Tönnis grade also had a higher prevalence of periacetabular calcifications. Younger male patients are more likely to have acetabular rim stress fractures. Patients with an increased alpha angle have a higher prevalence of os acetabuli and rim stress fractures. Clinical Relevance: This study aims to identify, quantify, and categorize periacetabular calcifications about the hip. Their clinical relationships and relevance have been discussed, but no study has distinctly categorized the various types and their prevalence. This study provides a framework for identification and categorization.

Clinic and Home-Based Exercise with Blood Flow Restriction Resolves Thigh Muscle Atrophy after Anterior Cruciate Ligament Reconstruction with the Bone-Patellar Tendon-Bone Autograft: A Case Report.

Anterior cruciate ligament reconstruction (ACLR) results in thigh muscle atrophy. Of the various interventions proposed to mitigate thigh muscle atrophy, exercise with blood flow restriction (BFR) appears safe and effective. Some literature suggests daily exposure to exercise with BFR may be indicated during the early phase of ACLR rehabilitation; this case report outlines the methodology utilized to prescribe clinic- and home-based BFR within an outpatient rehabilitation program. A 15-year-old male soccer player suffered a left knee injury involving the anterior cruciate ligament and both menisci. He underwent ACLR and completed exercise with BFR as part of his clinic- and home-based rehabilitation program, which included practical blood flow restriction during home-based rehabilitation. After 16 weeks of rehabilitation, surgical limb thigh girth values were objectively larger than the non-surgical limb (surgical, 52.25 cm; non-surgical 50 cm), as well as the multi-frequency bioelectrical impedance analysis of his lower-extremity lean body mass (surgical limb, 10.37 kg; non-surgical limb, 10.02 kg). The findings of this case report suggest that the inclusion of clinic- and home-based BFR within an outpatient rehabilitation program may be indicated to resolve thigh muscle atrophy early after ACLR.

The Impact of Age on Clinical Outcomes of Acetabular Microfracture During FAI Surgery.

BACKGROUND: Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI). PURPOSE: To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort. STUDY DESIGN: Cohort Study; Level of evidence, 3. METHODS: Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed. RESULTS: Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score (P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up. CONCLUSION: Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.

Editorial Commentary: Minimizing Traction Force and Time as Well as Application of Specific Technical Pearls Might Trump the Importance of Choosing Between Post or Postless Hip Arthroscopy With Regards to Complications.

Recently, there has been a trend toward performing hip arthroscopy without a post (postless) in an effort to decrease perineal post-related complications. Previous studies have revealed a variable risk of pudendal nerve neuralgia and perineal soft-tissue injury when using a post. There is emerging evidence that arthroscopic hip procedures can be done without the use of a post, with less traction force on the perineal region, and with adequate exposure to safely accomplish a well-done femoroacetabular impingement corrective procedure. Prospective comparative studies with conclusive evidence of the superiority of either technique, however, are lacking. Complications with a post are likely associated with high traction forces, prolonged traction times, and potentially suboptimal technique and patient positioning. In addition, postless traction is in its infancy and new adverse events/outcomes are likely to emerge. There are likely specific situations and patient populations in which one technique might be superior to the other. We are the carpenters of medicine and rather than blaming our tools and throwing out a technique that has served us well for decades, we should better understand some important pearls and pitfalls that might allow either method to be safely performed.

Outcomes of Arthroscopic Decompression of the Anterior Inferior Iliac Spine: A Systematic Review and Meta-analysis.

BACKGROUND: Anterior inferior iliac spine (AIIS) impingement has been increasingly recognized as a source of extra-articular impingement and hip pain. However, no aggregate data analysis of patient outcomes after AIIS decompression has been performed. PURPOSE: To evaluate outcomes after arthroscopic AIIS decompression. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were queried for all English-language studies reporting outcomes of arthroscopic AIIS decompression performed in isolation or in conjunction with hip impingement correction surgery. After screening, 10 articles were included. The indications for AIIS decompression were recorded, and weighted mean improvements in patient-reported outcome (PRO) scores, complication rates, and revision rates were calculated. RESULTS: A total of 547 patients (311 women; 57%) were identified, with a total of 620 operative hips. The mean age was 28.42 ± 5.6 years, and the mean follow-up was 25.22 ± 11.1 months. A total of 529 hips (85%) underwent AIIS decompression, 530 hips (85%) underwent femoral osteochondroplasty, and 458 hips (74%) underwent labral repair. Of the patients, 13% underwent bilateral AIIS decompression. The mean modified Harris Hip Score improved from 61.3 ± 6.9 to 88.7 ± 4.7 postoperatively (change, 27.4 ± 5.7 points; P < .001), the Hip Outcome Score-Activities of Daily Living improved from 67.2 ± 10.6 to 91.1 ± 3.2 postoperatively (change, 24.0 ± 8.0 points; P = .001), and the Hip Outcome Score-Sports Specific Subscale improved from 36.8 ± 19.2 to 82.8 ± 3.8 postoperatively (change, 46.0 ± 18.2 points; P = .002). The pooled risk of postoperative complications was 1.1% (95% CI, 0.1%-2.1%), and the pooled risk of needing revision surgery was 1.0% (95% CI, 0.1%-2.0%). No complication was directly attributed to the AIIS decompression portion of the procedure. CONCLUSION: PROs improved significantly after hip arthroscopy with AIIS decompression, with a low risk of postoperative complications and subsequent revision surgeries. Failure to identify extra-articular sources of hip pain in outcomes of femoroacetabular impingement syndrome, including from the AIIS, could lead to poorer outcomes and future revision surgery.

Editorial Commentary: Restoration of Hip Capsular Tension Is More Important Than Repair Construct Configuration.

The debate regarding optimal capsular management during hip arthroscopy has been evolving for over 20 years. Femoroacetabular impingement emerged in the arthroscopic world in the early 2000s. However, the ability to address osseous deformities and decompress and/or reshape them was limited by the hip capsular structures and small capsulotomies. Some surgeons attempted to arthroscopically manage these deformities with limited capsulotomies, with not surprisingly limited success. Others made larger capsular windows (capsulectomies) to more accurately manage these deformities but potentially left some patients with varying degrees of iatrogenic microinstability or macroinstability. Over time, an increasing awareness of post-arthroscopy instability in the form of case reports, case series, and backroom chatter among the hip arthroscopy thought leaders brought the idea of routine capsular closure to the forefront. Biomechanical studies defined the role of the hip capsular ligaments, the deficits created with various capsulotomies during surgery, and the ability to restore stability after capsular repair. Clinical studies revealed better outcomes and lower revision rates after capsular repair for subtle osseous and soft-tissue instability, revision cases, and athletes compared with unrepaired capsulotomies. Various capsular repair constructs (side-to-side repairs, capsular shifts, and various suture configurations and suture materials) have been proposed, without evidence to support a superior technique or suture material. In the end, capsular management is an evolving art that takes into account various patient-specific factors (i.e., individual activity requirements, soft-tissue and osseous parameters, and intraoperative impressions) with the end goal of achieving a stable, impingement-free joint. There might be various capsular management roads to travel, but the destination remains the same.

Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers.

Making an accurate preoperative diagnosis is critical to optimizing outcomes after hip arthroscopy. A detailed history, thorough physical examination, imaging studies, and diagnostic injections must all be considered in the decision-making process. In today's health care climate, it is imperative to obtain essential and indicated preoperative information while being mindful of health care dollars. Magnetic resonance imaging (MRI) of the hip has been shown to be a highly sensitive modality for hip and pelvis disorders. However, it is critical to recognize that acetabular labral tears and other hip pathology are highly prevalent in an asymptomatic young adult population. There are certainly situations when an MRI should be obtained (suspected arthritic symptoms, avascular necrosis, synovial disorders, uncommon osseous tumors); however, these patients generally present with atypical symptoms. In addition, obtaining an MRI can delay surgical intervention, which has been shown to lead to inferior outcomes in prior studies. MRI is not imperative when patients present with typical intermittent, deep anterior, lateral, groin pain with prolonged sitting, twisting and pivoting, and transitioning from sitting to standing. The typical physical examination includes positive hip impingement testing (FADIR / anterior impingement test) that recreates the patients presenting complaints. Appropriate imaging includes plain radiographs revealing adequate acetabular coverage (not significantly dysplastic) or acetabular overcoverage (pincer-type femoracetabular impingement), cam-type femoracetabular impingement, and well-maintained joint space on all views, including a false profile radiograph to further evaluate the anterior joint space. Finally, a diagnostic injection can be invaluable to further confirm the hip joint proper as the source of pain. If all of the above criteria are met, I strongly believe an MRI is unlikely to alter the surgical decision-making process. In the end, the treating clinician should determine when an MRI is necessary based on the presenting symptoms and examination, rather than insurers applying a blanket requirement for preauthorization. This physician autonomy would ultimately lead to more efficient and cost-effective patient care. Medicine is an art, and unjustified handcuffing of the artist without evidence could result in inferior results.

Male Gender and Competitive Athlete Status Are Associated With Better Outcomes Following Hip Arthroscopy In Patients With Global Acetabular Retroversion.

Purpose: To evaluate outcomes of hip arthroscopy in patients with global acetabular retroversion and to identify correlations between sex, radiographic measurements, athlete status, and return to play with patient-reported outcomes (PROs). Methods: Retrospective study of patients with global acetabular retroversion who underwent arthroscopic femoroacetabular impingement (FAI) surgery was performed. Global acetabular retroversion was defined by 3 criteria: the crossover sign, ischial spine sign, and posterior wall sign on an anteroposterior (AP) pelvic radiograph. Radiographs were used to measure lateral center edge angle, alpha angle, and anterior and posterior wall indices. Femoral version was measured with 3-dimensional computed tomography. Demographics included age, gender, athlete status, return to play, and reoperation. PROs included modified Harris Hip Score, Hip Outcome Score (HOS), Hip Disability and Osteoarthritis Outcome Score, visual analog scale (VAS), and Veterans RAND-12. Spearman correlation determined correlation with perioperative PROs. Generalized estimating equation determined independent predictors. Significance was set at P = .05. Results: From 2013 to 2019, 149 patients (65.0% female) with 160 hips with FAI and global acetabular retroversion underwent hip arthroscopy. Follow-up averaged 29.6 months. All PROs demonstrated significant improvement with the exception of the Veterans RAND-12 Mental. Female patients scored significantly lower on most postoperative PROs and had greater VAS scores (P = .0002-0.0402). A greater proportion of male subjects met the minimum clinically important difference for the modified Harris Hip Score (88.00% vs 78.79%) Low femoral version correlated with greater HOS ADL, HOS Sport, and Hip Disability and Osteoarthritis Outcome Score Sport scores (P = .0077-0.0177). Athletes reported lower preoperative VAS scores, and higher perioperative scores in multiple PROs (P = .0004-0.0486). Nine hips (5.63%) underwent reoperation. Conclusions: Patients with global acetabular retroversion and FAI undergoing hip arthroscopy report good outcomes at short-term follow-up. Male subjects and athletes had superior outcomes compared to female subjects and nonathletes. Radiographic measurements did not correlate with outcomes with exception of low femoral version. Athletes reported lower preoperative pain scores and greater postoperative PROs than nonathletes. Level of Evidence: Level IV, therapeutic case series.

Quadriceps Strength following Anterior Cruciate Ligament Reconstruction: Normative Values based on Sex, Graft Type and Meniscal Status at 3, 6 & 9 Months.

Background: Higher postoperative quadriceps function has been positively associated with surgical outcomes after anterior cruciate ligament reconstruction (ACLR). However, the impact of autograft harvest and/or a concomitant meniscal procedure on the recovery of quadriceps strength is not well defined. Purpose: To describe postoperative recovery of quadriceps strength following ACLR related to autograft selection, meniscal status, and sex. Study Design: Retrospective Cohort. Methods: One hundred and twenty-five participants who underwent ACLR with either a hamstring tendon (HT), bone-patellar tendon-bone (BPTB) or quadriceps tendon (QT) autograft were included. At postoperative months 3, 6 and 9, each participant completed an isometric quadriceps strength testing protocol at 90-degrees of knee flexion. Participants' quadriceps average peak torque (Q-AvgPKT), average peak torque relative to body weight (Q-RPKT), and calculated limb symmetry index (Q-LSI) were collected and used for data analysis. Patients were placed in groups based on sex, graft type, and whether they had a concomitant meniscal procedure at the time of ACLR. At each time point, One-way ANOVAs, independent samples t-test and chi-square analyses were used to test for any between-group differences in strength outcomes. Results: At three months after ACLR, Q-RPKT was significantly higher in those with the HT compared to the QT. At all time points, males had significantly greater Q-RPKT than females and HT Q-LSI was significantly higher than BPTB and QT. A concomitant meniscal procedure at the time of ACLR did not significantly affect Q-LSI or Q-RPKT at any testing point. Conclusion: This study provides outcomes that are procedure specific as well as highlights the objective progression of quadriceps strength after ACLR. This information may help better-define the normal recovery of function, as well as guide rehabilitation strategies after ACLR. Level of Evidence: 3.

Arthroscopic Debridement Versus Refixation of the Acetabular Labrum Associated With Femoroacetabular Impingement: Updated Mean 7-Year Follow-up.

BACKGROUND: Short- and midterm follow-up studies suggest that arthroscopic labral refixation/preservation leads to superior outcomes compared with labral excision/debridement. PURPOSE: To update the previous early (16 months) and midterm (mean, 42 months) follow-up of this cohort, which reported better patient-reported outcome measures and lower failure rates in the repair/refixation group. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors identified patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. A consecutive group of patients within the labral debridement group thought to be repairable with the authors' current arthroscopic techniques were compared with a group of consecutive patients who underwent labral repair/refixation. In 46 hips, the labrum was focally excised/debrided consistent with pincer- or combined pincer- and cam-type impingement; in 54 hips, the labrum was repaired/refixed. Subjective outcomes were measured with the modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) for pain preoperatively and postoperatively. RESULTS: The mean age was 34.0 years in the debridement group and 28.3 years in the repair/refixation group, with a mean follow-up of 7.3 years (range, 2-13.6 years). At the mean follow-up of 7.3 years, subjective outcomes were significantly improved (P < .01) for both groups compared with preoperative scores. The mHHS (P = .008), SF-12 score (P = .012), and VAS pain score (P = .002) were all significantly better for the repair/refixation group compared with the debridement group. Although most recent outcomes for both groups fell slightly at the mean follow-up of 7.3 years in comparison with the 16-month and 3.5-year follow-ups, these differences were not significant. However, the failure rate in the debridement group did get significantly worse (P = .014). Good to excellent results were 47.7% in the debridement group and 86.3% in the refixation group (P < .001), and failure rates were 30.4% (debridement) and 13% (refixation) (P = .033). There were 4 revisions in the debridement group and 3 revisions in the refixation group. CONCLUSION: Longer term, >7-year follow-up comparing focal labral excision/debridement with repair/refixation revealed better patient-reported outcomes and lower failure rates in the labral repair/refixation cohort. Additionally, despite an absolute decrease in patient-related outcome scoring and number of good/excellent results in both groups compared with the 3.5-year report, there was a significantly greater increase in failure rates over time for the excision/debridement group with better maintenance of good to excellent results in the repair/refixation group.

Editorial Commentary: Psoas Tenotomy in the Setting of a Borderline Dysplastic Hip Risks Iatrogenic Instability: Be Extremely Cautious and Particularly in Athletes.

Successful outcomes after psoas tenotomies have been reported and proposed in the setting of recalcitrant internal snapping and psoas impingement. However, case reports citing hip flexion weakness and iatrogenic instability created concern regarding the role for psoas tenotomies. Despite these concerns, some recent studies reporting improved outcomes after endoscopic psoas tenotomies breathe further life into this controversial topic. Psoas tenotomy in the setting of a borderline dysplastic hip likely carries an even greater risk for iatrogenic instability. It might be critical to evaluate for clinical signs and symptoms of instability in addition to radiographic parameters to avoid this potentially devastating complication. In addition, the traditional definition of borderline dysplasia is based on lateral acetabular coverage that might be less important than anterior acetabular coverage and femoral version when contemplating psoas tenotomies on the basis of the dynamic anterior stabilizing effect of the iliopsoas myotendinous unit. Surgeons should also be extremely cautious when considering psoas tenotomy in an athletic population with the potential for persistent weakness and limited data hinting at inferior sports specific outcomes. In the end, it is not clear whether the psoas tenotomy "drives" the improvements seen in some studies, or whether many of these patients ultimately battle their way into a minimally clinically important difference "despite" the psoas tenotomy.

High incidence of acute self-reported sleep disturbances in patients following arthroscopic-assisted knee surgery.

OBJECTIVES: To evaluate the self-reported incidence of sleep disturbances, defined as ≤7 hours of sleep per 24-hour period, in patients undergoing arthroscopic-assisted knee surgery. METHODS: Patients who underwent arthroscopic knee surgery over the course of a 4-month period were prospectively included. Patients were excluded if a history of insomnia or other sleep altering medical history was reported. Self-reported sleep metrics included average number of hours of sleep per night, average number of awakenings during sleep per night, perceived quality of sleep, average pain level during sleep and number of hours of physical activity/therapy per week. Data were collected at weeks 1, 3, and 6 postoperatively. Joint circumference was measured on postoperative day 1 and served as an indicator of a knee effusion. Paired t-tests were used to compare preoperative to postoperative hours of sleep. Simple and multiple linear regression were used to evaluate relationships between surgical variables and postoperative sleep metrics. RESULTS: There were 123 patients who underwent arthroscopic knee surgery during the prospective enrolment period; 83 patients were included in the final analysis. The overall incidence of preoperative sleep disturbances was 20% (n=17). The overall incidence of self-reported postoperative sleep disturbances was 99%, 96% and 90% at weeks 1, 3 and 6, respectively. The average number of hours slept was significantly reduced at 1, 3 and 6 weeks postoperatively compared with the preinjury state (p<0.001). Knee joint circumference had a significantly negative correlation with average number of hours of sleep in the first 6 weeks postoperatively (R=-0.704; p=0.001). Surgical variables including severity of surgery, weekly postoperative pain level and weekly hours of postoperative physical therapy were not significant independent predictors of acute postoperative sleep disturbances (p>0.05). CONCLUSION: Sleep disturbances were commonly reported in patients following arthroscopic knee surgery without correction of sleep metrics by 6 weeks postoperatively. The majority of sleep disturbances in this cohort correlated with an increased knee effusion. A multidisciplinary team approach is recommended to counsel patients regarding the potential for and problems with acute sleep disturbances following arthroscopic knee surgery. Level of evidence: 3.

Posterior Tibial Slope: Understand Bony Morphology to Protect Knee Cruciate Ligament Grafts.

Improved understanding of the biomechanical significance and clinical repercussions of tibial slope on cruciate ligament function has sparked a newfound clinical interest in this morphological feature. Using either magnetic resonance imaging or lateral tibia radiographs, the anterior-posterior angulation of the tibial plateau relative to the tibial shaft can be measured. Clinical and biomechanical studies have reported that increased posterior tibial slope (PTS) places significantly increased tension on the native and reconstructed anterior cruciate ligament (ACL), leading to an increased risk of failure. It has also been suggested that increased PTS of the lateral tibial plateau has a greater impact on ACL forces and anterior tibial translation than PTS of the medial tibial plateau. Conversely, a decreased PTS has been shown to be a risk factor for recurvatum deformity, posterior cruciate ligament (PCL) injury, and posterior tibial translation and has been linked to single bundle PCL reconstruction failure. In the setting of ACL insufficiency with a PTS greater than 12°, anterior closing wedge osteotomy has been shown to be protective for ACL reconstructions. Alternatively, some surgeons have advocated for the addition of lateral extraarticular stabilization procedures in the setting of increased PTS. Further, in the setting of PCL insufficiency with an anteriorly directed, or flat, PTS, anterior opening wedge osteotomy has shown encouraging results. In addition, double bundle PCL reconstructions should be strongly considered in the setting of anteriorly directed, or flat, tibial slope.

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.

PURPOSE: To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported. RESULTS: Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication. CONCLUSIONS: A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location. LEVEL OF EVIDENCE: Level V, systematic review of Level I to V studies.

Capsule-Preserving Approach to Arthroscopic Decompression of the Anterior Inferior Iliac Spine.

Hip arthroscopy techniques have evolved to treat a wide range of extra-articular pathologies. Subspine impingement commonly occurs in femoroacetabular impingement, particularly in athletes with a high range of motion, patients with low degrees of femoral version, and those with large subspine deformities. A reliable technique that preserves the hip capsule would be helpful for hip arthroscopy surgeons. This note details our technique using pericapsular windows proximal to the interportal capsulotomy to access and decompress a subspine deformity in the setting of hip femoroacetabular impingement.

Editorial Commentary: Ultrasound-Guided Injection With Dynamic Assessment Could Improve Outcomes in Atypical and Revision Hip Arthroscopy Patients: But Today, Few Are Trained to Hear at Such High Frequencies.

Imaging modalities for hip disorders all have their strengths and weaknesses. Magnetic resonance imaging is superior for evaluating soft tissue pathology, computerized tomography best characterizes osseous morphology, and plain radiographs can accurately depict 2-dimensional anatomy and are familiar to most clinicians. Ultrasound-guided injections have become commonplace in the musculoskeletal arena. Ultrasound evaluation of musculoskeletal anatomy has received increased attention, has the ability to image soft tissue and osseous structures, and more importantly, has the ability to dynamically evaluate these structures in real time. A noninvasive dynamic assessment of the hip region could be an absolute game changer for the hip preservation/sports medicine community in the diagnosis of atypical hip pain, femoroacetabular impingement, and labral tears. Widespread ability and expertise to perform these dynamic ultrasound assessments, however, is not in place at this time. We need more training and studies to best harness the potential benefits of these sound waves.