Inclusive Mentorship and Sponsorship.

Mentorship and sponsorship are part of academia because they are vital for professional and personal development. Inclusive mentorship is defined as mentoring across differences. It highlights the need of all mentors to be well-versed culturally and to recognize and circumvent bias and microaggressions. Inclusive mentorship can also elevate underrepresented populations in medicine and create intercultural relationships that also benefit the relationships we have with our diversifying patient populations. There are still several barriers prohibiting inclusive mentorship from being widely understood and employed. This article discusses the importance of and techniques for improving inclusive mentorship.

Testosterone Levels Before and After Anterior Cruciate Ligament Reconstruction A Prospective Observational Study.

PURPOSE: Over 200,000 anterior cruciate ligament (ACL) reconstructions are performed in the US each year. The recovery process following surgery can be slow and difficult with patients suffering persistent strength and endurance deficits. Testosterone is an important anabolic hormone responsible for maintenance and development of muscle mass. While the response of the hypothalamic-pituitary axis (HPA) to surgery has been investigated, no studies exist tracking the HPA response, specifically that involved in testosterone homeostasis, to ACL reconstructions. The purpose of this study was to explore the response of endogenous testosterone production after ACL reconstruction and determine a possible correlation between perioperative testosterone levels in males and postoperative strength and clinical outcomes. METHODS: This was a single-center, prospective observational study measuring preoperative and postoperative testosterone levels. Plasma testosterone, follicle stimulating hormone (FSH), and lutenizing hormone (LH) were measured before 10:30 am on the day of surgery. These were then checked at the same time of day at 1 week, 6 weeks, and 12 weeks postoperatively. Patients were also evaluated with the visual analog scale for pain (VAS), Tegner, and Lysholm scales preoperatively and at postoperative visits. Statistical analysis was performed using ANOVA and were considered significant at p < 0.05. RESULTS: Twenty male patients with a mean age of 34.0 ± 9.2 years undergoing ACL reconstruction were enrolled between October 2017 and April 2018. Results showed a decrease in testosterone (3.7 ng/mL vs. 2.9 ng/mL, p = 0.05), free testosterone (8.2 pg/mL vs. 6.8 pg/mL, p = 0.05), and follicle stimulated hormone (1.8 mIU/mL vs. 1.7 mIU/ mL, p = 0.83) between the preoperative plasma draw and 1-week postoperative follow-up visit. Luteinizing hormone (1.1 mIU/mL vs. 1.5 mIU/mL, p = 0.11) increased postoperatively. By week 6, testosterone returned to baseline (3.7 ng/mL vs. 3.9 ng/mL), while free testosterone continued to increase through week 12. Lutenizing hormone peaked at the 1-week postoperative visit and trended downward until week 6 (1.5 mIU/mL vs. 1.4 mIU/mL, p = 0.79). Follicle stimulating hormone continued to increase after the week-1 visit through week 12. Patient reported outcomes exhibited a trend similar to hormone levels, with the lowest patient reported outcome (PRO) scores reported at week 1 and a constant trend upward. Although there were similar trends, there were no significant correlations between change in hormone levels and change in PRO scores. CONCLUSION: Our study emphasizes the crucial period of hormonal decrease and their return to baseline. This knowledge will contribute to the understanding and timing of hormone therapy supplementation. Short-term testosterone replacement may be beneficial to return patients to work and physical activity at a faster rate.

Lower extremity injuries in U.S. national fencing team members and U.S. fencing Olympians.

INTRODUCTION: Fencing is growing rapidly in popularity and competitiveness with fencers beginning at a younger age and competing in more tournaments. Even though fencing has a low risk of time-loss injury, fencers are inevitably going to experience injuries if proper athletic training and prevention does not occur. We aim to describe and compare the lower extremity injuries experienced by fencers that have trained at the highest level in the sport. We hypothesized that athletes who fenced longer would suffer more knee and hip injuries and report lower IKDC and HOS scores. METHODS: This is an epidemiology study distributed to members of the U.S. national team and Olympic team from 1980 to 2018. The electronic survey included questions regarding age, weapon, number of years fencing, number of national and Olympic teams, injuries on the dominant and nondominant hip and knee, time missed due to injury, and methods for treatment. The survey also included the International Knee Demographic Committee (IKDC) and Hip Outcome Score (HOS). RESULTS: There were 153 national team members between July 1980 and July 2018, 110 with contact information. A total of 77 athletes submitted the survey, consisting of 30 females and 47 males. Female fencers had more hip injuries and lower IKDC and HOS scores than their male counterparts. In total, there were 71 injuries to the dominant (front) knee and 28 injuries to the nondominant (back) knee. There were 32 dominant hip injuries and 5 nondominant hip injuries. Saber fencers reported the most dominant and nondominant hip and knee injuries. CONCLUSION: The intense, repetitive and asymmetrical movements involved in fencing affect the weight bearing leg and the nondominant leg in all weapons. Special attention should be paid to female fencers as they experience more hip and knee injuries resulting in impaired joint function.

Opioid Use Is Reduced in Patients Treated with NSAIDs After Arthroscopic Bankart Repair: A Randomized Controlled Study.

PURPOSE: To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids after arthroscopic shoulder capsulolabral (Bankart) repair for recurrent anterior shoulder instability. METHODS: This was a single-center, prospective, randomized controlled study. Patients aged 18 to 65 years indicated for arthroscopic shoulder capsulolabral repair for recurrent anterior shoulder instability were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) 30 ibuprofen (600 mg every 6 to 8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg every 6 hours as needed for breakthrough pain) or (2) 30 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 24, 48, and 96 hours and 1 week after surgery, which included questions about analgesic medication usage, visual analog scale (VAS) pain score, incidence of adverse events, and patient satisfaction. RESULTS: Between December 2017 and May 2019, 80 patients (mean age 31.3 ± 10.4 years) were enrolled. Overall there were no significant differences in VAS pain score or patient satisfaction between the 2 groups. Patients in the opioid-only group had a significantly higher mean opioid consumption on postoperative days (PODs) 2 to 4 (5.5 versus 2.9, P = .05) and after 1 week (11.7 versus 7.9 tablets, P = .05) compared with patients in the NSAID group. Of patients in the NSAID group, 17.5% experienced adverse effects, compared with 35% in the opioid-only group. CONCLUSIONS: Use of oral NSAIDs with limited breakthrough opioids results in significantly less opioid use after arthroscopic Bankart repair in the first postoperative week compared with opioids only. Both groups used limited amounts of opioids to control postoperative pain. There were no differences in pain levels at any time point postoperatively or satisfaction between patient groups. LEVEL OF EVIDENCE: II, nonblinded randomized control trial.

Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis.

PURPOSE: To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes. METHODS: A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable. RESULTS: Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. CONCLUSIONS: Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use. LEVEL OF EVIDENCE: Level II, systematic review and meta-analysis of RCTs.

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis.

BACKGROUND: Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year. PURPOSE: To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate. RESULTS: Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores (P < .05). No benefit was found in any of the studies evaluating subacromial infusions. CONCLUSION: Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.

The incidence and pattern of iliopsoas tendinitis following hip arthroscopy.

BACKGROUND: Iliopsoas tendinitis is a known source of extra-articular hip pain and it has been shown to be a common cause of continued hip pain following total hip arthroplasty. While iliopsoas tendinitis after hip arthroscopy is a well-known phenomenon amongst hip arthroscopists, its presentation, course, and treatment has yet to be elucidated. METHODS: An IRB-approved chart review was performed of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between March 2015 and July 2017. No cases of dysplasia were included. All patients had combined cam/pincer impingement as well as labral pathology. Tendinitis patients were identified. Patient demographics, surgical data, time to onset/diagnosis of iliopsoas tendinitis, treatment (oral anti-inflammatories, corticosteroid injection, physical therapy), and resolution of symptoms were recorded. These cases were age- and sex-matched to a control group that did not develop postoperative iliopsoas tendinitis for comparison. Patient outcomes were measured with the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) recorded from the preoperative and 1-year postoperative visits. RESULTS: Of 258 hip arthroscopy cases, 18 cases (7.0%) of postoperative iliopsoas tendinitis were diagnosed under high resolution ultrasound. On average, iliopsoas tendinitis was diagnosed 2.8 ± 1.8 months after surgery. There were no significant differences in age, sex, and BMI between patients that developed IP tendinitis compared to those that did not. No specific procedures were found to be significantly associated with incidence of postoperative IP tendinitis, including capsular closure.18 patients were treated with corticosteroid injection, which provided mild to moderate improvement for 5 (27.8%) patients and completely resolved symptoms for 13 patients (72.2%). Of all 18 patients with postoperative iliopsoas tendinitis confirmed by response to a diagnostic injection, 10 (55.6%) had symptoms improve within 3 months of diagnosis, 2 (11.1%) between 3 and 6 months, 4 (22.2%) between 6 and 12 months, and 2 (11.1%) after 1 year. No patients went on to have surgery for this problem. Patients with iliopsoas tendinitis had lower MHHS (p = 0.04) and NAHS (p = 0.09) scores at their 1-year postoperative visits. CONCLUSIONS: Iliopsoas tendinitis is a common source of pain following arthroscopic hip surgery and can be effectively diagnosed and treated with ultrasound-guided injection. Therefore, surgeons performing arthroscopic procedures of the hip must remain aware of and include it in their differential when encountering patients with hip flexion pain after surgery. Research should be continued to further evaluate the long-term outcomes and return to sport rates of these patients.

Surgical Intervention for Femoroacetabular Impingement Can Lead to Improvements in Both Hip and Back Function in Patients With Coexisting Chronic Back Pain at 1-Year Follow-Up.

PURPOSE: To determine whether patients with coexisting lumbar back pain experience back pain improvement after undergoing hip arthroscopy for femoroacetabular impingement (FAI). METHODS: An institutional review board-approved retrospective chart review compared patients undergoing hip arthroscopy for FAI with lumbar spine back pain to patients solely reporting hip pain. The modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) were recorded preoperatively and at 1-year follow up. The Oswestry Disability Index score, which quantifies disability from lower back pain, and visual analog scale were recorded from the hip-spine cohort alone. Statistical analysis was performed using paired sample t tests with P ≤ .05 considered significant. RESULTS: Sixty-eight patients who underwent hip arthroscopy between November 2016 and October 2018 were enrolled. Thirty-four patients with a mean age of 48.2 ± 14.0 years and body mass index of 26.6 ± 6.6 had a history of back pain and 34 patients were age- and sex-matched for the matched-control (MC) cohort. The MC cohort had lower mHHS and NAHS scores preoperatively. The MC cohort reported a larger increase in the mHHS (P = .01) and NAHS scores (P = .01) postoperatively. More patients in the MC cohort reached minimally clinically important difference with mHHS (P = .003) and NAHS (P = .06). Following surgery, the hip-spine cohort reported a lower Oswestry Disability Index score, indicating minimal disability (P = .01). CONCLUSIONS: Surgical intervention for FAI can lead to improvements in hip and back pain in patients with coexisting lumbar pathology. LEVEL OF EVIDENCE: III, retrospective comparative study.

Effect of Acetaminophen on Postoperative Percocet Use In Hip Arthroscopy: A Randomized Controlled Trial.

PURPOSE: To determine whether postoperative acetaminophen reduced narcotic consumption following hip arthroscopy for femoroacetabular impingement. METHODS: This was a single-center randomized controlled trial. Opioid-naïve patients undergoing hip arthroscopy for femoroacetabular impingement were randomized into 2 groups. The control group received our institution's standard of care for postoperative pain control, 28 tablets of 5 mg/325 mg oxycodone-acetaminophen prescribed as 1 to 2 tablets every 6 hours as needed for pain, whereas the treatment group were prescribed 650 mg acetaminophen every 6 hours for pain, with 5 mg/325 mg oxycodone-acetaminophen prescribed for breakthrough pain. Patients were instructed to be mindful of taking no more than 3 g of acetaminophen in a 24-hour limit. If this limit was reached, oxycodone 5 mg would be prescribed. They were contacted daily and asked to report opioid use as well as their level of pain using the visual analog pain scale. RESULTS: Our institution enrolled 86 patients, 80 of whom completed the study (40 control, 40 treatment). There were no statistically significant differences with respect to patient demographics and patient-specific factors between groups (age at time of surgery, sex, American Society of Anesthesiologists classification, or body mass index). In addition, there was no statistically significant difference with respect to visual analog scale pain between groups preoperatively (P = .64) or at 1-week follow up (P = .39). The treatment group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (6.325 pills treatment vs 5.688 pills control, P = .237). CONCLUSIONS: The findings of this randomized controlled trial suggest that postoperative acetaminophen may have no effect on reducing the number of narcotic pills consumed by opioid-naïve patients following hip arthroscopy in the setting of reduced opioid-prescribing on the part of orthopaedic surgeons. Furthermore, the results of this study suggest surgeons may reduce postoperative narcotic prescribing without reducing patient satisfaction following hip arthroscopy. LEVEL OF EVIDENCE: II randomized control trial.

Pain catastrophizing is associated with increased physical disability in patients with anterior knee pain.

INTRODUCTION: The traditional nociceptive approach to pain identifies the mind and body as functionally separate. However, the biopsychosocial model accounts for the impact of social, psychological and physical factors on the patient experience. The purpose of this study was to determine the relationship between diagnosis, physical disability, and psychological distress among patients with anterior knee pain-one of the most common complaints in an orthopedic clinic. METHODS: This was a single-center, cross-sectional study. Patients presenting for initial evaluation of knee pain completed the Pain Catastrophizing Scale, Kujala Anterior Knee Pain Scale, and SF-12 questionnaires. Statistical analysis was performed using SPSS Version 24. RESULTS: 207 patients, 108 (52.2%) females and 99 (47.8%) males, with a mean age 44.5 ± 15.4 years were enrolled. The osteoarthritis cohort had the highest pain catastrophizing score (17 ± 14.5), lowest Kujala score (48.3 ± 18.1), lowest SF-12 PCS (37.5 ± 8.3), and lowest SF-12 MCS (50.8 ± 11.0). Across all diagnoses, there was a statistically significant negative correlation between the total Pain Catastrophizing Score (PCS) and the Kujala, SF-12 Physical, and SF-12 Mental Component Scores. Bivariate and multivariate analysis demonstrated a correlation between PCS and duration of symptoms and African-Americans. The Kujala and SF-12 PCS demonstrated a statistically significant correlation with age, smoking, and the Asian Indian ethnicity. The SF-12 MCS showed a significant relationship with the Asian Indian ethnicity. Bivariate analysis also showed a statistically significant relationship between the SF-12 PCS and the SF-12 MCS. CONCLUSION: Knee pain patients presenting to an orthopedic sports medicine clinic demonstrate diminished physical quality of life and psychological reserves. This study determined an association between catastrophizing behavior and other patient reported outcomes measuring pain, physical distress, quality of life and mental/emotional well-being. To optimize patient outcomes, psychological domain should be managed contemporaneously to orthopedic pathology.

Outcomes of Preoperative Opioid Usage in Hip Arthroscopy: A Comparison With Opioid-Naïve Patients.

PURPOSE: To compare postoperative outcomes between opioid-naïve patients and patients with a history of preoperative opioid usage undergoing hip arthroscopy. The secondary purpose is to determine whether preoperative opioid users consumed more oral morphine milligram equivalents than opioid-naïve patients following surgery. METHODS: This is a single-center, retrospective analysis comparing outcomes and postoperative opioid usage between patients with and without a history of preoperative opioid use. Inclusion criteria included patients ≥18 years, Tönnis grade 0 or 1, imaging consistent with FAI or labral pathology, and a diagnosis of symptomatic FAI requiring hip arthroscopy. Patient outcomes were compared throughout a 2-year follow-up using the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS). RESULTS: In total, 17 patients were evaluated in each cohort. The mean age of the study cohort and control cohort were 52.0 ± 9.4 years and 51.2 ± 12.2 years, respectively. Female patients were 58.8% (n = 10) of both cohorts. Non-naïve patients had a lower preoperative Nonarthritic Hip Score (P = .05) and a greater VAS at their 6-month and 1-year (P < .001) postoperative visits. Naïve patients reported greater modified Harris Hip Scores 2 years postoperatively (P < .001). The study cohort was prescribed greater levels of oral morphine equivalents at the postoperative 1-year visit (P = .05). Opioid-naïve patients were more likely to reach minimally clinically important difference and patient acceptable symptom state of VAS at a faster rate. At the 2-year follow-up, 11.8% of opioid-naïve patients continued to take opioids compared with 58.8% from the non-naïve group for persistent hip pain (P < .001). CONCLUSIONS: We determined that preoperative opioid usage in patients undergoing hip arthroscopy is associated with inferior outcomes compared with opioid-naïve patients. In addition, preoperative opioid users are likely to continue the use of opioid medications postoperatively and at greater doses than opioid-naïve patients. LEVEL OF EVIDENCE: 3, retrospective comparative study.

Everything pectoralis major: from repair to transfer.

Background: Pectoralis major ruptures are increasing in incidence primarily due to an increase in awareness, activity level among young males between 20 and 40 years of age, and use of anabolic steroids. Although the majority of pectoralis major ruptures are acute injuries, many chronic ruptures are unrecognized and it is imperative to understand the proper evaluation of these injuries, as well as the appropriate treatment for acute and chronic ruptures.Purpose: Pectoralis major ruptures can lead to deformity and physical disability if left untreated. This review paper discusses both acute and chronic ruptures as well as indications for nonoperative treatment and operative treatment to give the reader the best understanding of this diagnosis and proper management.Methods: A systematic review of the literature was performed using a search of electronic databases. Search terms such as pectoralis major rupture, pectoralis major repair, pectoralis major tendon transfer, and pectoralis major nonoperative treatment were used. Case reports, systematic reviews, prospective and retrospective studies were included to provide a comprehensive review. The only exclusion criteria consisted of studies not published in English. This review article includes the anatomy and biomechanics of the pectoralis major muscle, proper evaluation of the patient, operative and nonoperative treatment of acute and chronic pectoralis major ruptures, and outcomes of the recommended treatment.Conclusion: Nonoperative treatment is indicated for patients with medical comorbidities, older age, incomplete tears, or irreparable damage. Patients treated non-operatively have been shown to lose strength, but regain full range of motion. Patients with surgery before 6 weeks reported better outcomes than patients with surgery between 6 and 8 weeks. The chronicity of the rupture (>8 weeks) increases the likelihood of reconstruction, involving the use of autografts or allografts. Patients treated with delayed repair had significantly better strength, satisfaction, and outcomes than patients with nonoperative treatment. The pectoralis tendon can also be transferred in patients with rotators cuff tears, atrophy, or significant functional limitation. Tendon transfers have been shown to have unpredictable outcomes, but overall satisfactory results.

Short-Term Clinical Outcomes of High Tibial Osteotomy with the iBalance HTO System.

PURPOSE: High tibial osteotomy (HTO) is an invaluable tool in the treatment of a variety of conditions in active patients with varus malalignment of the knee. The polyetheretherketone (PEEK) iBalance HTO system has been designed to make the osteotomy safer, more reproducible, and avoid metal hardware related complications. The purpose of this study was to evaluate short-term outcomes in patients who underwent an open wedge high tibial osteotomy with the iBalance HTO system. METHODS: We identified patientswho underwent HTO using iBalance with a minimum of 2-year follow-up. Medical records were reviewed for demographics, Workers Compensation and no-fault insurance claims, history of smoking, concomitant procedures, degree of correction, and complications. Patient outcomes using Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS) were recorded before undergoing HTO and compared with those recorded after a 2-year follow-up. Statistical analysis was performed using paired sample t-tests with p < 0.05 considered significant. RESULTS: Twenty-three patients with mean age of 44.9 (± 8.48) were identified. The mean correction angle was 9.9° (range: 5° to 15°). Sixteen patients underwent a concomitant procedure. The average follow-up was 2 years (range: 2 to 3.5 years). Six patients reported a positive history of smoking. The mean preoperative KOOS scores of symptoms, pain, activities of daily living (ADL), sport, and quality of life were 14 (± 18.5), 53.1 (± 14.8), 69.1 (± 21.7), 29.2 (± 22.0), and 30.0 (± 20.0), respectively. The mean preoperative VAS score was 5.5 (± 2.5). At follow-up, the mean scores of symptoms, pain, ADL, sport, and quality of life all improved to 67.53 (± 24.9), 68.06 (± 23.4), 75.74 (± 25.3), 45.91 (± 36.1), and 43.47 (± 33.4), respectively. The mean VAS at follow-up was 1.9 (± 2.1). There was a significant increase (p < 0.05) in all KOOS categories, except ADL. Additionally, there was a statistical difference between smoking and change in ADL score. Former smokers demonstrated an average decrease of 10.3 points, increasing their disability, and nonsmokers increased 15.3 points on the KOOS ADL scale, decreasing their disability. There were three complications (DVT, cellulitis, and serosanguinous drainage) within a month after the procedure. There were three complications, including a revision HTO, pes anserine bursitis, and lateral hamstring tendinitis, within the 2-year follow up including one revision after 1 year. Five patients went on to total knee arthroplasty at an average of 3 years (range: 1 to 5 years). CONCLUSION: This study suggests that the iBalance medial opening wedge HTO system implant can be used with comparable outcomes to traditional methods, however the conversion rate to total knee arthroplasty may be higher than previously reported. This appears to be unrelated to implant choice and likely related to extended indications for the procedure in younger patients refusing knee arthroplasty. The iBalance medial opening wedge HTO system has shown to be safe, removing many of the complications existing with other osteotomy implant options. Our findings highlight the importance of additional studies in order to investigate the risk factors causing progression from HTO to TKA.