Surgical Soft Tissue Management for Glenohumeral Deformity and Contractures in Brachial Plexus Birth Injury : A Systematic Review and Meta-analysis.

PURPOSE OF THE REVIEW: Consensus on the effects of soft tissue surgical intervention in the management of brachial plexus birth injury (BPBI) sequalae is lacking. The purpose of this review is to examine the available literature on the functional and structural outcomes following soft tissue surgical management of BPBI sequalae. RECENT FINDINGS: EMBASE, PubMed, and MEDLINE were searched for related literature from the point of database inception until April 2021. Relevant papers were screened by two reviewers independently and in duplicate. A meta-analysis was performed using a random effects model. A total of 25 studies (852 patients) were included in the review, with the number included in each meta-analysis varying based on outcome of interest. There were significant improvements from pre- to post-operative time points for the following measures: Mallet aggregate scores (5.0 points, p<0.0001), active external rotation in adduction (48.9°, p=0.003), passive external rotation in adduction (64.6°, p< 0.00001), active abduction (46.2°, p<0.00001), glenoid version (14.4°, p< 0.00001), and percentage of the humeral head anterior to the scapular line (17.53°, p< 0.00001). Furthermore, data revealed an overall complication rate of 9.3% (79/852 patients) and a major complication rate of 0.47% (4/852 patients). Patients with BPBI sequela experience statistically significant improvements in functional, structural, and range of motion outcomes of the GH joint following soft tissue surgical management. Understanding the ideal indications for each procedure and age of surgical management with future prospective studies will help to optimize surgical management of these patients.

Return to Sport After Surgical Management of Posterior Shoulder Instability: A Systematic Review and Meta-analysis.

BACKGROUND: Posterior shoulder instability accounts for a small proportion of all shoulder instability, although it can affect athletes of all types, from contact to overhead athletes. Surgical treatment is quite successful in these patients; however, the literature reports a wide range of rates of return to sport. PURPOSE/HYPOTHESIS: The purpose was to determine the return-to-sport rates after surgical stabilization for posterior shoulder instability. It was hypothesized that patients would experience a high rate of return to sport. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: Embase, PubMed, and MEDLINE were searched for relevant literature from database inception until April 2020, and studies were screened by 2 reviewers independently and in duplicate for studies reporting rates of return to sport after surgical management of posterior shoulder instability. Demographic data as well as data on return to sport and functional outcomes were recorded. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias was assessed for all included studies. RESULTS: Overall, 32 studies met inclusion criteria and comprised 1100 patients (1153 shoulders) with a mean age of 22.8 years (range, 11-65) and a mean follow-up of 43.2 months (range, 10-228). The pooled rate of return to any level of sport was 88% (95% CI, 84%-92%; I2 = 68.7%). In addition, the pooled rate of return to the preinjury level was 68% (95% CI, 60%-76%; I2 = 79%). Moreover, the pooled return-to-sport rate for contact athletes was 94% (95% CI, 90%-97%; I2 = 0%), while for throwing athletes it was 88% (95% CI, 83%-92%; I2 = 0%). CONCLUSION: Surgical management of posterior shoulder instability resulted in a high rate of return to sport, as well as significant pain reduction and functional improvement in most patients. However, only two-thirds of athletes can return to their preinjury levels of sport.

Glenohumeral Internal Rotation Deficit in the Adolescent Overhead Athlete: A Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this review was to investigate the average glenohumeral internal rotation deficit (GIRD) in the dominant arm of adolescent overhead athletes and to examine the association with shoulder and elbow injuries. DESIGN: Systematic review and meta-analysis. SETTING: MEDLINE, Embase, and PubMed were searched from inception to August 1, 2020. PARTICIPANTS: Adolescent overhead athletes with glenohumeral range of motion (ROM) measurements. INTERVENTIONS: Nonoperative treatments of GIRD. MAIN OUTCOME MEASURES: Glenohumeral ROM measurements comparing the dominant and nondominant extremities were pooled in a meta-analysis. RESULTS: Twenty-five studies were included in this review, which involved 2522 overhead athletes. Pooled internal rotation (IR) deficit of the dominant arm was 9.60° (95% confidence interval [CI] 7.87°-11.32°, P < 0.00001), with an external rotation (ER) gain of 6.78° (95% CI 4.97°-8.59°, P < 0.00001) and a total ROM (TROM) deficit of 1.78° (95% CI -0.70° to 4.26°, P = 0.16). The association between GIRD and shoulder or elbow injury was not clearly defined. Two studies reported treatment, and both used nonoperative treatment in the form of physiotherapy and sleeper stretches. CONCLUSIONS: The adolescent overhead athlete has roughly 10° of IR deficit in their dominant arm, accompanied by nearly 7° of ER gain, with similar ROM measurements for injured and uninjured athletes. Those with pathological GIRD have a greater degree of IR deficit, but without an accompanying compensatory increase in ER, leading to a TROM deficit of nearly 15°. Surgical treatment in the absence of other indications is rare, whereas physiotherapy and sleeper stretches remain the first-line treatment.

Diagnosis and Management of Little League Shoulder: A Systematic Review.

BACKGROUND: Little League shoulder (LLS) is an overuse injury characterized by throwing-related pain that commonly presents in adolescent male athletes. Investigations into the optimal duration of rest from throwing and protocols for graduated return to sports (RTS) are lacking. PURPOSE: To summarize the current literature with respect to the diagnosis, management, RTS, and return to throwing for LLS. DESIGN: Systematic review; Level of evidence, 4. METHODS: The databases EMBASE, MEDLINE, and PubMed were searched between inception and April 22, 2020. References of retrieved records were reviewed for potentially eligible studies. English-language studies that reported the diagnosis and/or management of LLS in children or adolescents were included. Studies of animals or cadavers, review articles, and non-peer reviewed records were excluded. Data were summarized narratively using descriptive statistics. RESULTS: Overall, 23 studies (21 level 4 studies, 2 level 3 studies) met the criteria for a total of 266 participants with a weighted mean age of 12.8 years (range, 7.4-17 years). Treatment recommendations evolved from prolonged rest and complete cessation of throwing to shorter periods of rest and graduated RTS. Less than half (11/23) of studies reported specific criteria to RTS; 1 case report discussed a coaching strategy to resume throwing, and 1 case report discussed a regimented throwing program. The proportion of participants returning to any sport participation was 94.0% (n = 157/167). The proportion returning to their preinjury level of sport was 92.5% (n = 123/133). Upon RTS, 18.7% (n = 35/187) of participants experienced a recurrence of symptoms. Premature closure of the epiphysis was reported in 1 participant. CONCLUSION: Young athletes with LLS may return to play after a period of rest, and a high proportion return to their preinjury level of sport. Further prospective studies are warranted to develop evidence-based, graduated RTS protocols and to better capture any long-term sequelae of the condition.

A high rate of children and adolescents return to sport after surgical treatment of osteochondritis dissecans of the elbow: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review was to determine the return to sport rates following surgical management of ostechondritis dissecans of the elbow. METHODS: The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until August 2020 and studies were screened by two reviewers independently and in duplicate for studies reporting rates of return to sport following surgical management of posterior shoulder instability. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score. RESULTS: Overall, 31 studies met inclusion criteria and comprised of 548 patients (553 elbows) with a median age of 14 (range 10-18.5) and a median follow-up of 39 months (range 5-156). Of the 31 studies included, 14 studies (267 patients) had patients who underwent open stabilization, 11 studies (152 patients) had patients who underwent arthroscopic stabilization, and 6 studies (129 patients) had patients who underwent arthroscopic-assisted stabilization. The pooled rate of return to any level of sport was 97.6% (95% CI 94.8-99.5%, I2 = 32%). In addition, the pooled rate of return to the preinjury level was 79.1% (95% CI 70-87.1%, I2 = 78%). Moreover, the pooled rate of return to sport rate at the competitive level was 86.9% (95% CI 77.3-94.5%, I2 = 64.3%), and the return to sport for overhead athletes was 89.4% (95% CI 82.5-95.1%, I2 = 59%). The overall return to sport after an arthroscopic procedure was 96.4% (95% CI 91.3-99.6%, I2 = 1%) and for an open procedure was 97.8% (95% CI 93.7-99.9%, I2 = 46%). All functional outcome scores showed improvement postoperatively and the most common complication was revision surgery for loose body removal (19 patients). CONCLUSION: Surgical management of osteochondritis dissecans of the elbow resulted in a high rate of return to sport, including in competitive and overhead athletes. Similar rates of return to sport were noted across both open and arthroscopic procedures. LEVEL OF EVIDENCE: Level IV.

The Use of Elbow Arthroscopy for Management of the Pediatric Elbow: A Systematic Review of Indications and Outcomes.

PURPOSE: The purpose of this review was to systematically examine the literature surrounding elbow arthroscopy for pediatric patients and to assess indications, functional outcomes, and complication rates. METHODS: This systematic review was carried out in accordance with PRISMA guidelines. EMBASE, PubMed, and MEDLINE were searched for relevant literature from inception until December 2019, and studies were screened by 2 reviewers independently and in duplicate for those investigating elbow arthroscopy in a pediatric population (<18 years). Editorials, review articles, and case reports were excluded. Demographic data and data on surgical indications, treatment outcomes, and complications were recorded. A methodological quality assessment was performed for all included studies using the Methodological Index for Non-Randomized Studies. RESULTS: Overall, 19 studies, all of level IV evidence, were identified with a total of 492 patients (513 elbows). The patient population was 22.3% female with a mean age of 14.0 years (range, 4.0-15.7) and a mean follow-up time of 33.0 months (range, 7.4-96 months). Twelve studies (263 patients) exclusively recruited patients with osteochondritis dissecans (OCD), although other indications for elbow arthroscopy included arthrofibrosis (50 patients), elbow fracture (37 patients), medial ulnar collateral ligament injury (31 patients), and posterior impingement (17 patients). All 13 reporting studies showed a significant improvement in the elbow flexion-extension arc, and 4 of 5 that reported a functional outcome score before and after surgery demonstrating a significant improvement. Last, the overall complication rates ranged from 0% to 23.8%, with a total of 8 instances of neurological injury (5 ulnar, 2 radial, 1 unspecified), all being transient and resolving within 3 to 6 months. CONCLUSION: Although elbow arthroscopy is primarily being performed for OCD in children and adolescents, there is evidence surrounding several other potential indications. Case series published to date have demonstrated significant improvements in functional outcomes and low rates of major complications. LEVEL OF EVIDENCE: Level IV, systematic review of level IV studies.

Arthroscopic management of greater trochanter pain syndrome and abductor tears has demonstrated promising results in terms of improvement in pain scores and functional outcomes: a scoping review.

PURPOSE: Greater trochanteric pain syndrome (GTPS) refers to the constellation of signs and symptoms related to pain in the trochanteric region and has recently replaced the previously ubiquitous term of 'greater trochanteric bursitis'. GTPS is common, particularly in women 50-79 years of age, and the understanding and management of GTPS have expanded considerably in recent years to include management with arthroscopic and endoscopic techniques in recalcitrant cases. The purpose of this scoping literature review was to summarize the current evidence on arthroscopic management of GTPS including sources of evidence, key concepts, and gaps in the literature. METHODS: A thorough electronic database search included studies published from 2009 to June 14, 2020. A total of 52 peer-reviewed articles were identified within the literature on arthroscopic or endoscopic management of GTPS. RESULTS: Of the 52 identified papers, 12 were technique descriptions, 10 papers were review articles, and 30 papers were original clinical papers. Of the 30 clinical papers, 24 (80%) were of level IV evidence, 5 (17%) were of level III evidence, and 1 (3%) was level II evidence. Among the 30 clinical studies, 988 patients were included with 761 (77%) female. Indications for surgical management included a failed trial of conservative management in all 30 studies, typically after a period of 3-6 months. Surgical management consisted of arthroscopic/endoscopic abductor tendon repair in 16 (53%) studies, arthroscopic/endoscopic bursectomy and iliotibial band release in 12 (40%) studies, and arthroscopic/endoscopic gluteal tendon contracture release in 2 (7%) studies. CONCLUSION: Overall, results following arthroscopic management of GTPS and abductor tears have been promising, including significantly improved pain scores and functional outcomes at final post-operative assessment. These studies support continued use and investigation of arthroscopic management strategies of GTPS and pave the way to conduct larger prospective studies to confirm these results in the future. LEVEL OF EVIDENCE: IV.

Iliopsoas Tenotomy During Hip Arthroscopy: A Systematic Review of Postoperative Outcomes.

BACKGROUND: Arthroscopic iliopsoas tendon release is a surgical treatment option for painful snapping hips, although it has been associated with controversy surrounding potential complications including decreased hip flexion strength, iatrogenic hip instability, and iliopsoas atrophy. PURPOSE: To systematically assess the efficacy and safety of arthroscopic iliopsoas tenotomy during hip arthroscopic surgery as an intervention for painful snapping hips. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A total of 3 online databases (Embase, PubMed, and MEDLINE) were searched from database inception until September 2019 for studies investigating iliopsoas tenotomy during hip arthroscopic surgery. Studies were screened by 2 reviewers independently and in duplicate, and studies investigating arthroscopic iliopsoas tendon release were included. Demographic data as well as data on treatment success, functional outcome scores, and radiological outcomes were recorded. A risk of bias assessment was performed for all included studies. RESULTS: Overall, 21 studies were identified with a total of 824 patients (875 hips). These patients were 82.5% female (680/824), with a mean age of 28.1 years (range, 12-62 years) and mean follow-up of 32.1 months (range, 3-73 months). Arthroscopic iliopsoas tenotomy was performed at the level of the labrum in 811 hips (92.7%) or the lesser trochanter in 64 hips (7.3%). The overall reported success rate of the procedure in resolving snapping hips was 93.0% (266/286), and all studies reported an improvement in functional outcome scores. Only 6 studies (93 hips) discussed postoperative hip flexion strength, with complete recovery of strength reported in 4 studies (47 hips) and mild decreases reported in the other 2 studies (46 hips). Iliopsoas atrophy was evaluated radiologically (3 studies; 66 hips) and was found postoperatively in 92.4% (61/66) of hips. No major complications were reported. CONCLUSION: Arthroscopic release of the iliopsoas tendon was effective in alleviating pain and persistent clicking associated with a snapping hip. Although patients demonstrated some early postoperative weakness and iliopsoas atrophy on radiological imaging, the results from studies to date showed satisfactory clinical function and return to sports/activities. High-quality comparative studies are needed to further assess arthroscopic iliopsoas tendon release to determine the optimal technique and location of tendon release.

What can we learn from surveys? A systematic review of survey studies addressing femoroacetabular impingement syndrome.

The purpose of this study was to systematically review the methodology, response rate and quality of survey studies related to femoroacetabular impingement (FAI) syndrome. A search was conducted on three databases (PubMed, EMBASE, MEDLINE) for relevant studies from database inception to 27 January 2020. Data extracted included study and survey characteristics, as well as response rates. The quality of the included studies was also assessed using a previously published quality assessment tool. Data were analysed with means, ranges, standard deviations, 95% confidence intervals and bivariate analysis. Eleven studies (13 surveys) were included in this review out of a total of 1608 initial titles found. Surveys were most often administered via the Internet (72%) to orthopaedic surgeons (54%). The mean response rate was 70.4%. The mean quality score was moderate 13.3/24 (SD ±4.3). The criterion that most often scored high was 'clearly defined purpose and objectives' (11/11). The most common survey topic investigated surgeons' knowledge regarding FAI diagnosis and management (n = 7). In addition, bivariate analysis between quality score and response rate showed no significant correlation (Spearman's rho = -0.090, P = 0.85). Overall, survey studies related to FAI syndrome most often use Internet-based methods to administer surveys. The most common target audience is orthopaedic surgeons. The topics of the surveys most often revolve around orthopaedic surgeons' knowledge and opinions relating to the diagnosis and management of FAI syndrome. The response rate is high in patient surveys and lower in larger surgeon surveys. Overall, the studies are of moderate quality.

Clinical and radiographic predictors of failed hip arthroscopy in the management of dysplasia: a systematic review and proposal for classification.

PURPOSE: As indications for hip arthroscopy continue to expand, its efficacy in patients with more complex deformities of the hip, such as those with acetabular dysplasia, remains controversial. The purpose of this systematic review is to identify the predictors of failed hip arthroscopy in dysplastic hips and to propose a standardize prognostic sub-classification of dysplasia. METHODS: This systematic review was performed in accordance with the (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA guidelines. Three databases [EMBASE, PubMed, and Ovid (MEDLINE)] were searched using terms including "hip arthroscopy" and "dysplasia". Studies were screened and data extracted in duplicate. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Due to the non-uniform nature of study data, findings were presented in descriptive summary form. RESULTS: Thirteen studies were included in this systematic review, comprising 712 dysplastic patients (773 hips) with mean age 34.2 years and 74.1% females. Most studies defined hip dysplasia by a lateral centre-edge angle (LCEA) of 20°-25° (borderline) or 15°-20° (moderate). Failure was defined as progression to revision arthroscopy, peri-acetabular osteotomy, or total hip arthroplasty. Overall, failure rate was 192/743 (25.8%) at an average of 28.1 months following index arthroscopy. Smaller LCEA, larger Tönnis angle, broken Shenton line, and decreased joint space (≤ 2 mm) were radiographic predictors of failure. Severe cartilage lesions to the femoral head or acetabulum were associated with failure in five studies. Labral debridement led to more failures than labral repair. CONCLUSION: Overall, hip arthroscopy yielded good outcomes in mildly dysplastic hips without severe chondral damage. Hip arthroscopy is expected to result in a failed outcome in individuals with moderate-to-severe hip dysplasia (LCEA < 15°), severe cartilage lesions, larger Tönnis angle (> 20°), broken Shenton line, and decreased joint space (≤ 2 mm). Arthroscopic surgery may be more effective in individuals with borderline-to-mild (LCEA 15°-25°) acetabular dysplasia in the absence of severe cartilaginous lesions (7-year survival: 89.6%). A standardized prognostic classification of hip dysplasia based on the LCEA and Tönnis angle is proposed. LEVEL OF EVIDENCE: Systematic review of non-randomized studies, Level IV.

Return to Sport After Surgical Management of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the rates and timing of return to sport for the surgical management of proximal hamstring avulsions (PHAs). METHODS: Three databases, PubMed, MEDLINE, and EMBASE, were searched from database inception until October 7, 2017, by 2 reviewers independently and in duplicate. The inclusion criteria were studies reporting return to sport outcomes for surgical management of acute, chronic, complete, and partial PHA. The rate of return to sports was combined in a meta-analysis of proportions using a random-effects model. RESULTS: Overall, 21 studies with a total of 846 patients met the inclusion criteria, with a mean age of 41.4 years (range, 14-71 years) and a mean follow-up of 37.8 months (range, 6-76 months). Two studies were of prospective comparative design (level II), 2 were retrospective comparative (level III), 8 were prospective case series (level IV), and 9 were retrospective case series (level IV). The overall mean time to return to sport was 5.8 months (range, 1-36 months). The pooled rate of return to any sport participation was 87% [95% confidence interval (CI), 77%-95%]. The pooled rate of return to preinjury level of sport was 77% (95% CI, 66%-86%). CONCLUSIONS: Pooled results suggest a high rate of return to sport after surgical management of PHA; however, this was associated with a lower preinjury level of sport. No major differences in return to sport were found between partial versus complete and acute versus chronic PHA.

Correction to: Clinical and radiographic predictors of failed hip arthroscopy in the management of dysplasia: a systematic review and proposal for classification.

Unfortunately, the author name was incorrectly published in the original publication as Sochi Uchida insted of Soshi Uchida. The author name is corrected here by this Erratum. The â€‹original â€‹article â€‹has â€‹been â€‹corrected.

The dimensions of the hip capsule can be measured using magnetic resonance imaging and may have a role in arthroscopic planning.

PURPOSE: The purpose of this study was to systematically evaluate the dimensions and thickness of the hip joint capsule. Secondarily, the study assessed whether there were any described correlations between capsule thickness and stability of the hip joint. METHODS: Four databases (PubMed, Ovid [MEDLINE], Cochrane Database, and EMBASE) were searched from database inception to May 2018, and two reviewers independently and in duplicate screened the resulting literature. Methodological quality of all included papers was assessed using the Methodological index for non-randomized studies (MINORS) criteria. Mean differences were combined in a meta-analysis using a random effects model when possible. RESULTS: A total of 14 studies (1 level I, 1 level II, 4 level III, 5 level IV) were identified including 796 patients (1013 hips) with a mean age of 39.5 years (range 2-95). Of the included patients, 55.2% were female and they were followed up for a mean of 7.6 months (range 1-12.5 months). The thickness of the capsule was measured in cadaveric specimens, ultrasound, and magnetic resonance imaging (MRI), with MRI measurements reported most consistently and with the least variation. Mean thickness of the anterior capsule in patients without hip disease on MRI ranged from 4.4 and 4.7 mm. Mean thickness of the anterior capsule in patients with FAI ranged between 4.9 and 5.0 mm. Males had significantly thicker capsules than females (mean difference = 1.92 mm, 0.35-3.49, P = 0.02). Clinical laxity of the hip joint, as well as female gender was correlated with thinner anterior joint capsules. CONCLUSION: The thickness of the anterior hip capsule can be measured consistently using MRI. A thinner anterior capsule may be associated with clinical laxity of the hip joint. The relevance of capsular thickness on postoperative instability following hip arthroscopy is poorly understood and warrants further investigation. The thickness of the anterior hip capsule, as measured on MRI, has the potential to be used as part of the clinical decision-making in capsular management strategies. LEVEL OF EVIDENCE: IV.

Predictors of Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Systematic Review.

BACKGROUND: The benefits of hip arthroscopic surgery in the setting of femoroacetabular impingement (FAI) have been well established; however, some patients may experience a greater degree of improvement than others. Identifying positive and negative predictors of outcomes would assist the orthopaedic surgeon's management algorithm for patients with FAI. PURPOSE/HYPOTHESIS: The objective of this systematic review was to identify demographic, radiographic, and other operative predictors of positive and negative outcomes after hip arthroscopic surgery for patients with FAI. It was hypothesized that factors including FAI morphology, age, body mass index (BMI), sex, dysplasia, articular cartilage damage, radiographic joint space, and labral treatment would predict outcomes after hip arthroscopic surgery. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: This systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three databases (Embase, PubMed, and Ovid [MEDLINE]) were searched on May 19, 2018, using terms including "hip," "arthroscopy," and "FAI." Studies were screened and data extracted in duplicate. RESULTS: A total of 39 studies were included in this systematic review, comprising 9272 hips with a mean age of 36.5 years (47.2% female). Younger age, male sex, lower BMI (<24.5 kg/m2), Tönnis grade 0, and preoperative pain relief from diagnostic intra-articular hip injections predicted positive outcomes. Female sex, older age (>45 years), longer duration of preoperative symptoms (>8 months), elevated BMI, increased Tönnis grade (≥1), chondral defects, decreased joint space (≤2 mm), increased Kellgren-Lawrence grade (>3), increased lateral center-edge angle (LCEA), and undergoing labral debridement alone were predictors of negative outcomes. CONCLUSION: In patients with FAI, younger age, male sex, lower BMI (<24.5 kg/m2), Tönnis grade 0, and pain relief from preoperative intra-articular hip injections are significantly more likely to achieve positive outcomes after hip arthroscopic surgery. On the other hand, older age (>45 years), female sex, elevated BMI, osteoarthritic changes, decreased joint space (≤2 mm), chondral defects, increased LCEA, and undergoing labral debridement compared with labral repair are associated with negative outcomes.

Preoperative Patient Factors Affecting Length of Stay following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Total knee arthroplasty (TKA) yields substantial improvements in quality of life for patients with severe osteoarthritis. Previous research has shown that TKA outcomes are inferior in patients with certain demographic and clinical factors. Length of stay (LOS) following TKA is a major component of costs incurred by healthcare providers. It is hypothesized that patient-related factors may influence LOS following TKA. The purpose of this systematic review and meta-analysis is to investigate these factors. METHODS: Three databases (PubMed, Embase, and OVID Medline) were searched using variants of the terms "total knee arthroplasty" and "length of stay". Studies were screened and data abstracted in duplicate. The primary outcome was the effect of prognostic variables on LOS following TKA. Meta-analysis was performed using the Review Manager (RevMan) software (version 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014). RESULTS: A total of 68 studies met all inclusion criteria for this review. These studies comprised 21,494,459 patients undergoing TKA with mean age 66.82 years (range, 15-95 years) and 63.8% (12,165,160 of 19,060,572 reported) females. The mean MINORS score was 7, suggesting that studies had a low quality of evidence. Mean LOS following TKA has steadily decreased over the past 4 decades, partially because of the implementation of fast-track programs. Demographic factors associated with increased LOS were age >70 years (mean difference [MD] = 0.81; 95% confidence interval [CI] = 0.38-1.24), female gender (MD = 0.32; 95% CI = 0.29-0.48), body mass index >30 (MD = 0.09; 95% CI = 0.01-0.16), and non-White race (MD = 0.20; 95% CI = 0.10-0.29). Clinical factors associated with increased LOS were American Society of Anesthesiologists score 3-4 vs 1-2 (MD = 1.12; 95% CI = 0.58 to 1.66), Charlson Comorbidity Index > 0 vs 0 (MD = 0.77; 95% CI = 0.32 to 1.22), and preoperative hemoglobin < 130 g/L (MD = 0.66; 95% CI = 0.34 to 0.98). CONCLUSION: This systematic review and meta-analysis showed that increased age, female gender, body mass index ≥ 30, non-White race, American Society of Anesthesiologists > 2, Charlson Comorbidity Index > 0, and preoperative hemoglobin < 130 g/L were predictors of increased LOS. Mean LOS has steadily decreased over the past decades with the implementation of perioperative "fast-track" programs. Future research should investigate the benefits of preoperative risk factor modification on LOS, in addition to novel surgical approaches, anesthetic adjuvants, and physiotherapy modifications. LEVEL OF EVIDENCE: IV, systematic review, and meta-analysis of level III and IV evidence.

Health-Related Quality of Life After Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review and Meta-analysis.

CONTEXT: Hip pain from femoroacetabular impingement (FAI) can impair health-related quality of life (HRQL) but can be treated via hip arthroscopy techniques. OBJECTIVE: To systematically assess the HRQL outcomes after arthroscopic management of FAI. DATE SOURCES: Three online databases (EMBASE, PubMed, and Ovid [MEDLINE]) were searched for relevant literature from database inception until June 2018 and screened by 2 reviewers independently and in duplicate. STUDY SELECTION: Level I to IV English studies that investigated HRQL outcomes after hip arthroscopy were included. Data for generic and hip-specific HRQL outcomes were collected. Mean differences were plotted in a forest plot when possible. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. RESULTS: A total of 29 studies were included for assessment. Of the 6476 patients (6959 hips), the mean age was 32 years (range 9-79 years) and 50.7% were female. Significant improvements were reported in all studies assessing generic HRQL outcomes, including the 12-Item Short Form Health Survey (range of mean postoperative scores, 82.2-89.8), and EuroQOL-5D scores (range of mean postoperative scores, 0.74-0.87) between 12 and 24 months postoperatively. Significant improvements were similarly identified in the hip-specific HRQL outcomes scores, with the majority of studies also reporting improvement between 12 and 24 months postoperatively. Mean improvement in International Hip Outcome Tool-33 scores from preoperative values to postoperative values ranged from 22.7 to 43.2 ( I2 = 44%), for studies with follow-up between 12 and 24 months. CONCLUSION: Hip arthroscopy can lead to significant improvement in generic and hip-specific HRQL outcomes at 12 to 24 months postoperatively in patients with FAI who do not have advanced hip osteoarthritis. Confirmatory, high-quality, prospective studies are warranted to compare this observed improvement with other treatment modalities for FAI and to determine long-term outcomes.

Sources, Quality, and Reported Outcomes of Superior Capsular Reconstruction: a Systematic Review.

PURPOSE: Superior capsular reconstruction (SCR) has gained attention as a potential treatment option for those with massive irreparable rotator cuff tears without significant arthritis. The aim of this systematic review is to review and evaluate the current sources and quality of SCR literature as well as reported outcomes. METHODS: Three databases (PubMed, Ovid [MEDLINE], and EMBASE) were searched independently and in duplicate to systematically screen the literature. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist guided the reporting and data abstraction. The results are presented in a narrative summary fashion using descriptive statistics. RESULTS: Overall, 58 studies were identified, including 304 different patients. There was a rapid increase in the number of publications observed over the past 3 years, with the most dramatic single-year increase noted from 2017 to 2018 (175% increase). There are no level 1 studies, and 95% of the included studies were level 4 and 5 evidence. Comparing pre-operative to post-operative pooled-weighted mean outcome scores, the American Shoulder and Elbow Surgeons score improved from 44.2 to 84.8, the Visual Analogue Scale from 5.0 to 1.5, and acromiohumeral distance from 6.5 to 8.4 mm, respectively. Range of motion in forward elevation also improved from 111° to 152°. Among studies reporting, the complication rate was 13.4% with a revision surgery rate of 4.3%. CONCLUSION: Over the past 3 years there has been considerable growth in the number of publications of publications related to SCR. Despite a lack of high-quality clinical evidence, preliminary available evidence does suggest promising results both functionally and radiographically. There is a need for future higher-quality research such as large randomized controlled trials to improve our current understanding of the benefits of SCR.

What Makes Suture Anchor Use Safe in Hip Arthroscopy? A Systematic Review of Techniques and Safety Profile.

PURPOSE: To perform a systematic review that assesses the current literature on suture anchor placement for the purpose of identifying factors that lead to suture anchor perforation and techniques that reduce the likelihood of complications. It was hypothesized that suture anchor placement in hip arthroscopy would generally be safe, with the exception of the complications of articular cartilage violation and psoas tunnel perforation. Perioperative factors, related to patient, surgeon, and technical variables, may influence the safety of suture anchor insertion. METHODS: Three databases (PubMed, Ovid MEDLINE, and Embase) were searched, and 2 reviewers independently screened the resulting literature. The inclusion criteria were clinical and biomechanical studies examining the use of suture anchors in hip arthroscopy. The methodologic quality of all included articles was assessed using the Methodological Index for Non-Randomized Studies criteria and the Cochrane risk-of-bias assessment tool. Results are presented according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using descriptive statistics. RESULTS: We included 14 studies in this review, comprising 4 case series (491 patients; 56.6% female patients; mean age, 33.9 years), 9 controlled cadaveric or laboratory studies (111 cadaveric hips and 12 synthetic acetabular bone blocks; 42.2% female hips; mean age, 60.0 years) with a mean Quality Appraisal for Cadaveric Studies score of 11, and 1 randomized controlled trial (37 hips; 55.6% female hips; mean age, 34.2 years). Anterior cortical perforation into the psoas tunnel by suture anchors led to pain and impingement of pelvic neurovascular structures. The anterior acetabular positions (3- to 4-o'clock position) had the thinnest bone, smallest rim angles, and highest incidence of articular perforation. Drilling angles from 10° to 20° measured off the coronal plane were acceptable. The midanterior and distal anterolateral portals were used successfully, with 1 study reporting difficulty placing anchors at anterior locations through the distal anterolateral portal. One study showed that curved suture anchor drill guides allow for a better trajectory away from the articular cartilage. Small-diameter (≤1.8-mm) all-suture anchors had a lower in vivo incidence of articular perforation with similar stability and pullout strength to other anchor types in biomechanical studies. CONCLUSIONS: Suture anchors at anterior acetabular rim positions (3- to 4-o'clock position) should be inserted with caution. Large-diameter (≥2.3-mm) suture anchors increase the likelihood of articular perforation without increasing labral stability. Inserting small-diameter (≤1.8-mm) all-suture anchors from 10° to 20° drilling angles may increase safe insertion angles from all cutaneous portals. Direct arthroscopic visualization, the use of fluoroscopy, distal-proximal insertion, and the use of nitinol wire can help prevent articular violation. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Athletes experience a high rate of return to sport following hip arthroscopy.

PURPOSE: The purpose of this systematic review was to evaluate the rate at which patients return to sport following arthroscopic hip surgery. METHODS: The databases MEDLINE, EMBASE, and PubMed were searched by two reviewers, and titles, abstracts, and full-text articles screened in duplicate. English language studies investigating hip arthroscopy with reported return to sport outcomes were included. A meta-analysis of proportions was used to combine the rate of return to sports using a random effects model. RESULTS: Overall, 38 studies with 1773 patients (72% male), with a mean age of 27.6 years (range 11-65) and mean follow-up of 28.1 months (range 3-144) were included in this review. The pooled rate of return to sport was: 93% [95% confidence interval (CI) = 87-97%] at any level of participation; 82% (95% CI = 74-88%) at preoperative level of sporting activity; 89% (95% CI = 84-93%) for competitive athletes; 95% (95% CI = 89-98%) in pediatric patients; and 94% (95% CI 89.2-98.0%) in professional athletes. There was significant correlation between a shorter duration of preoperative symptoms and a higher rate of return to sports (Pearson correlation coefficient = - 0.711, p = 0.021). CONCLUSION: Hip arthroscopy yields a high rate of return to sport, in addition to marked improvement in pain and function in the majority of patients. The highest rates of return to sport were noted in pediatric patients, professional athletes, and those with a shorter duration of preoperative symptoms. This study provides clinicians with evidence-based data on athletes' abilities to return to sport after arthroscopic hip surgery and identifies sub-populations with the highest rates of return to sport. LEVEL OF EVIDENCE: IV, systematic review of Level II-IV studies.

Anterior Capsule Reconstruction of the Native Hip: A Technique Guide.

This is a technique guide for open anterior capsule reconstruction in unstable native hips due to Ehlers-Danlos syndrome. Ehlers-Danlos syndrome is a connective tissue disease that predisposes an individual to hypermobility of their soft tissues and recurrent subluxations and dislocations of their joints. This may lead to constant instability, guarding of the hip, and subsequent arthritic changes and poor quality of life. We demonstrate anterior capsule reconstruction of the hip using an Achilles tendon allograft performed through a direct anterior approach to the hip (Heuter's approach). This technique guide outlines in detail the surgical steps required to accomplish this reconstructive procedure. Furthermore, a narrated surgical video is provided that clearly depicts the anticipated result of the increased constrained provided to the hip from the anterior capsule reconstruction using an Achilles tendon allograft.