Editorial Commentary: Choose Wisely: Rotator Cuff All-Suture Anchors.

The defining feature of a surgeon's professional practice is clinical decision making coupled with surgical execution. Surgeons' decisions are continually being scrutinized, and clinicians are trained to consult and interpret the peer-reviewed literature in formulating a treatment plan. An important decision in the surgical episode of care is which implant(s) will be used, and surgeons should feel comfortable defending their implant choices. Understanding the finer details of a bench study is important in formulating a clinical opinion of a biomechanical investigation of surgical implants. The biomechanical properties of diverse brands of all-suture rotator cuff anchors are not significantly different. However, all-suture rotator cuff anchors require further comparison with traditional rotator cuff suture anchors in geriatric patients who potentially have osteoporosis.

Fascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial.

PURPOSE: To determine in a prospective, randomized fashion whether liposomal bupivacaine extends the effectiveness of decreased pain scores and reduces narcotic requirements following hip arthroscopy when used in addition to a fascia iliaca blockade with plain bupivacaine alone. METHODS: Double-blinded prospective randomized controlled trial of participants undergoing hip arthroscopy. Randomized to receive a fascia iliaca blockade with 40 mL 0.25% plain bupivacaine (100 mg; control group) or 20 mL 0.5% plain bupivacaine (100 mg) plus 20 mL liposomal bupivacaine (266 mg; study group). The primary outcome was Defense and Veterans Pain Rating Scale (DVPRS) scores in the postanesthesia care unit and on postoperative days (POD) 1, 2, 3, and 14. Secondary outcomes included postoperative opioid consumption and subjective loss of anterior thigh sensation. RESULTS: Seventy-four patients were enrolled, and 70 completed the study; 37 were randomized to the control group and 33 to the study group. There was no significant difference in postoperative DVPRS scores at any time point. There was no significant difference in total postoperative opioid use during any postoperative time points. While most patients reported anterior thigh numbness at discharge, significantly more patients in the study group reported anterior thigh numbness at POD2 (control, 19/37 numb vs study, 32/33 numb; P < .0001) and at POD3 (control, 8/37 numb vs study, 26/33 numb; P < .0001). CONCLUSIONS: In this prospective evaluation comparing plain bupivacaine versus the liposomal formulation administered via a fascia iliaca blockade there were no significant differences in postoperative pain scores and narcotic pill usage. Given the highly significant findings of prolonged anterior thigh numbness out to POD3 in patients who received liposomal bupivacaine, this formulation did exhibit prolonged effects; however, it did not provide improved pain control when used in this surgical population, likely due to the innervation of the hip capsule from differential nerve plexi. Given the 6-fold increased cost of using the liposomal formulation, we are unable to recommend its use via a fascia iliaca blockade for hip arthroscopy. LEVEL OF EVIDENCE: Level I, therapeutic study.

Editorial Commentary: Stronger and Faster Suture Configuration-But Is It Better? Challenges of Surgical Innovation in the Modern Era.

When evaluating the characteristics of a new surgical technique, it is important to consider practical effects of the technique on clinical practice, as it would be inappropriate to advocate for cost-prohibitive or excessively time-consuming methods, even if biomechanically superior. The Krackow stitch has long been considered the gold standard for suture-graft fixation; potential limitations with this technique include the risk of needle sticks to the surgical team and the time required to perform the stitch. A new proprietary method (SpeedTrap, DePuy-Mitek, Raynham, MA) offers a significantly faster solution with equivalent or better biomechanics; however, elongation of the suture-graft construct is still a concern, and the cost effectiveness remains unclear. Regardless, we are fortunate to be practicing in an era when we can have great appreciation for the problem-solving innovations of surgeons who practiced in prior decades as well as witness the continued effort to optimize clinical outcomes now and in the future.

Effectiveness of Thrombin-Collagen and Autologous Platelet-Rich Plasma in Total Hip Arthroplasty Hemostasis: A Prospective, Randomized, Controlled Trial.

Bovine derived thrombin-collagen combined with autologous platelet-rich plasma (PRP) has shown promise as a topical, surgical hemostatic agent. The purpose of this study was to determine the effect of thrombin-collagen-PRP on perioperative blood loss in total hip arthroplasty (THA). A prospective, single-blinded, randomized, controlled study comparing thrombin-collagen-PRP use to standard treatment was performed. All patients undergoing elective primary THA for osteoarthritis by a single physician at a single institution were included. Thirty-nine patients were enrolled. There was no significant difference in estimated total blood loss or blood transfusions received. There was no significant difference in operative blood loss, drain output, daily postoperative hematocrit, change in hematocrit, or length of stay. There is insufficient evidence to support the routine use of a topical thrombin-collagen-autologous PRP hemostatic agent in primary total hip arthroplasty. (Journal of Surgical Orthopaedic Advances 27(2):136-141, 2018).

Reaction Time and Brake Pedal Depression Following Arthroscopic Hip Surgery: A Prospective Case-Control Study.

PURPOSE: The purpose of this study was to determine whether patients diagnosed with femoroacetabular impingement (FAI) syndrome have prolonged braking times compared with age- and gender-matched controls and how long after surgery braking times return to preoperative baseline. METHODS: Fifty-nine patients undergoing arthroscopic hip surgery for FAI and 59 age- and gender-matched controls without FAI were enrolled in a prospective comparative study between September 2015 and October 2016. Total brake reaction time (BRT) and brake pedal depression (BPD) were measured for study patients preoperatively, and at 2, 4, and 6 weeks postoperatively. BRT and BPD were compared between study and control patients and between preoperative and postoperative time periods, using mixed effects models. RESULTS: Patients with FAI had significantly prolonged BRT (but not BPD) prior to surgery compared with controls (568 vs 520 msec, P = .002). For study patients undergoing left hip surgery, there was no difference in BRT or BPD between preoperative measurements and any postoperative time point, including the first postoperative appointment at 2 weeks (563 vs 566 msec, P = .89). Patients undergoing right hip surgery had significantly prolonged BRT at 2 weeks postoperatively compared with their preoperative baseline (688 vs 573 msec, P < .001). By 4 weeks postoperatively, study patients undergoing right hip surgery had returned to their preoperative baseline (573 vs 594 msec, P = .28). No significant effect was seen based on visual analog scale pain score, opiate usage, or patient-reported outcome scores. CONCLUSIONS: Patients undergoing arthroscopic surgery of the right hip show significantly prolonged BRT until 4 weeks after surgery, while patients undergoing surgery of the left hip show no postoperative impairment in either BRT or BPD. The clinical relevance of this measured difference (an increase in 10 feet of stopping distance at 60 miles per hour) remains an open question. LEVEL OF EVIDENCE: Level II, diagnostic, prospective.

Morphological Distribution of the Anterior Inferior Iliac Spine in Patients With and Without Hip Impingement: Reliability, Validity, and Relationship to the Intraoperative Assessment.

BACKGROUND: Subspinous impingement of the anterior inferior iliac spine (AIIS) on the femoral head-neck junction is increasingly recognized as a source of hip impingement. A classification system of AIIS morphology has previously been proposed that correlates with reduced hip motion and may predispose patients to subspinous hip impingement. PURPOSE: To examine the morphological distribution of AIIS types in patients with and without diagnosed hip impingement and correlate AIIS morphology to intraoperative findings at the time of surgery. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Three-dimensional reconstructed pelvic computed tomography scans were generated for a stratified sample of 449 hips in patients without a history of hip pain or hip impingement and 59 hips in patients with a diagnosis of hip impingement. Three blinded assessors classified the AIIS for each hip twice. The morphological distribution between symptomatic and asymptomatic patients was compared, controlling for age, sex, and affected side. Within the symptomatic cohort, AIIS morphology was compared with the intraoperative assessment of a low-lying AIIS using the Fisher exact test. RESULTS: The intraobserver reliability of the classification system in our cohort was substantial (κ = 0.68-0.77). The interobserver reliability was moderate (κ = 0.50). The morphological distribution between symptomatic and asymptomatic patients was similar, with 75% of patients in the asymptomatic group and 80% of the patients in the symptomatic group having a type 2 or type 3 AIIS. When matched for age, sex, and affected side, there was no significant difference in the assessed classification type between the groups ( P = .55). Within the symptomatic group, there was no significant correlation between the surgeon assessment of a low-lying AIIS and a type 2 or type 3 radiographic classification ( P = .10). The positive predictive value of a type 2 or type 3 AIIS classification for hip impingement symptoms was 10%, and the negative predictive value was 91%. CONCLUSION: These findings suggest that a high percentage of patients with AIIS morphology associated with subspinous impingement are, in fact, asymptomatic. The current radiographic classification scheme should not be used exclusively for clinical decision making.

Outcomes of Hip Arthroscopy in the Older Adult: A Systematic Review of the Literature.

BACKGROUND: The indications for hip preservation surgery have expanded to include treatment of hip pathology in older adults. While several studies have examined the efficacy of hip arthroscopy in the setting of osteoarthritis, there has been no review of outcomes in older adults. PURPOSE: To review the outcomes of hip arthroscopy in older adults and identify factors associated with treatment failures. STUDY DESIGN: Systematic review. METHODS: PubMed, EMBASE, and the Cochrane Library were searched through March 2016 for studies reporting outcomes of primary hip arthroscopy in patients older than 40 years. Inclusion in the review was based on age, patient-reported outcome (PRO) measures, and duration of follow-up. Two authors screened the results and extracted data for use in this review. Standardized mean difference was calculated to estimate effect size for PRO scores within studies. RESULTS: Eight studies with 401 total patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) or labral tears were included in this review. Seven of the 8 studies reported favorable PRO scores and significant postoperative improvement with moderate to large effect size. The included studies demonstrated a trend toward higher effect sizes with an increasing percentage of labral repair compared to isolated labral debridement. The complication rate was comparable to that of previous reports involving younger patients; however, the overall reoperation rate was 20.8%. Conversion to hip arthroplasty ranged from 0% to 30%, with an overall conversion rate of 18.5% at a mean time of 17.5 months following arthroscopy. The most common risk factors for conversion to arthroplasty were low preoperative PRO scores and advanced arthritis. CONCLUSION: Hip arthroscopy appears to be a safe and efficacious treatment for labral tears and FAI in older patients who do not have significant underlying degenerative changes. However, in this population, there is a significant proportion of patients who eventually require hip arthroplasty. Outcomes may be affected by type of treatment (ie, labral debridement vs repair). Additional high-quality studies are needed to understand how these factors affect outcomes.

Hip Arthroscopy in Patients With Lower-Extremity Amputations: Patient Positioning and Traction Technique.

Improved battlefield survival rates have resulted in a significant number of young active patients with lower-extremity amputations. Because of the increased demands placed on their hips, patients with amputations may be more susceptible to the sequelae of hip pathology and femoroacetabular impingement. Arthroscopic management of hip pathology may be successfully performed in patients with ipsilateral, contralateral, or bilateral lower-extremity amputations. We describe our experience in this unique patient population. A technique for secure patient positioning that provides sufficient countertraction in the case of contralateral amputation is described, as is the use of skeletal traction with a temporary external fixator for joint distraction in patients with ipsilateral amputations. Considerations specific to patients with high transfemoral amputations are discussed as well.

Primary versus revision arthroscopic reconstruction with remplissage for shoulder instability with moderate bone loss.

PURPOSE: This study aims to evaluate our outcomes of arthroscopic remplissage in this setting. METHODS: A retrospective review was performed to identify patients who underwent arthroscopic remplissage of an engaging Hill-Sachs lesion along with anterior capsulolabral reconstruction for anterior glenohumeral instability with moderate glenohumeral bone loss at our institution. Thirty-five patients, with a minimum of 2 years' follow-up, were identified. We assessed the American Shoulder and Elbow Surgeons score, incidence of recurrent instability, and postoperative Rowe instability score. RESULTS: Follow-up was available for 30 patients (31 shoulders). The mean age was 24.6 years, with a mean follow-up period of 41 months. Prior instability surgery had failed in 11 patients, and they underwent capsulolabral reconstruction and remplissage ("revision surgery"). The failure rate in revision cases (36%) was significantly higher than the failure rate in primary surgery cases (0%) (P = .01). Failure resulted from trauma in all 4 patients, and none required further surgery. The mean American Shoulder and Elbow Surgeons score for all patients improved from 50 preoperatively to 91 postoperatively (P < .001), with no significant postoperative difference between primary and revision patients (P = .13). The patients with clinical failure showed nonsignificant improvement from 41 preoperatively to 72 postoperatively (P = .08). The mean postoperative Rowe score for the entire cohort was 90. The Rowe score was significantly lower in the 4 cases of failure than in the 27 non-failure cases (51 v 96, P < .001). CONCLUSIONS: In our experience, aggressive capsulolabral reconstruction with remplissage in traumatic instability patients with moderate bone loss and engaging humeral Hill-Sachs lesions yields acceptable outcomes for primary instability surgery. However, a significantly higher failure rate occurred when arthroscopic reconstruction with remplissage was performed in the revision setting. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Current concept review: vitamin D and stress fractures.

Critical review of the available evidence indicates that a relationship exists between sufficient vitamin D status and stress fractures, although genetic and environmental factors are involved as well. Patients at high risk for stress fracture should be educated on protective training techniques and the potential benefits of supplementation with combined calcium and vitamin D, particularly if increased exercise is planned during winter or spring months, when vitamin D stores are at their lowest. The amount of vitamin D intake required is highly variable depending on many factors including sun exposure, and therefore many recommendations have been made for daily vitamin D intake requirements. While the Institute of Medicine guidelines suggest that 600 to 800 IU of vitamin D are required for adequate bone health in most adults, we recommend that most patients receive 800 to 1,000 IU and perhaps as high as 2,000 IU of vitamin D3 as outlined by the previously mentioned review article since vitamin D is a safe treatment with a high therapeutic index. Also, at least 1,000 mg of calcium per day is required for optimal bone health and 1,200 mg may be needed in certain populations. Orthopaedists should consider prescribing vitamin D and calcium prophylactically in high-risk patients. In patients in whom deficiency is a concern, serum 25(OH)D level is the appropriate screening test, with therapeutic goals for bone health being at least 50 nmol/L (20 ng/mL) and may be as high as 90 to 100 nmol/L (36 to 40 ng/mL).

Simple elbow dislocations: evaluation, management, and outcomes.

Elbow dislocations are common athletic injuries and occur during a fall onto an outstretched hand as a combination of axial-compressive and rotational-shear forces are conducted across the elbow joint. Simple dislocations are those that involve purely ligamentous injury, while complex dislocations include periarticular fractures. The initial assessment, radiographic evaluation, and on-field treatment of these injuries is discussed. Multiple reduction techniques are described with the patient positioned both supine and prone. Definitive management involves primarily nonoperative treatment with limited immobilization and early active range of motion to minimize joint contracture and hasten return to pre-injury activities. For unstable elbows, surgical treatment is usually appropriate. Operative management may involve exploration, lateral ligament repair or reconstruction, and assessment of the need for medial ligament repair or reconstruction. The role of arthroscopic and arthroscopically assisted surgery for elbow dislocation is evolving. Clinical series have shown that extended periods of immobilization (> 3 weeks) are associated with poor outcomes. Early active range of motion should be initiated as early as possible because late or recurrent instability is uncommon. Contracture is the most common adverse sequela of elbow dislocation. The literature indicates an average of 3° to 8° of extension loss with standard management of simple elbow dislocations.