Editorial Commentary: Complications After Meniscal Surgery Are Rare and Generally Associated With Medical Comorbidity.

Meniscal tears are prevalent and frequently require surgical intervention. This injury affects younger, active patients after acute trauma. Meniscal repair is often indicated. Degenerative tears are more common in elderly patients and are generally treated with partial meniscectomy. Other factors such as chronicity, stability, tear type, and associated injuries may also play a role in the treatment algorithm. In terms of complications, both procedures are generally safe, with a complication rate approximating 1%, but adverse effects such as deep venous thrombosis, pulmonary embolism, surgical-site infection, readmission, and reoperation can occur. Complications are more common in elderly patients. Moreover, recent research shows that complications are associated with medical comorbidities, with smoking, and with longer operating times.

Incorporating patient-specific hip orientation from weightbearing computed tomography affects discrete element analysis-computed regional joint contact mechanics in individuals treated with periacetabular osteotomy for hip dysplasia.

Computational models of the hip often omit patient-specific functional orientation when placing imaging-derived bony geometry into anatomic landmark-based coordinate systems for application of joint loading schemes. The purpose of this study was to determine if this omission meaningfully alters computed contact mechanics. Discrete element analysis models were created from non-weightbearing (NWB) clinical CT scans of 10 hip dysplasia patients (11 hips) and oriented in the International Society of Biomechanics (ISB) coordinate system (NWB-ISB). Three additional models were generated for each hip by adding patient-specific stance information obtained via weightbearing CT (WBCT) to each ISB-oriented model: (1) patient-specific sagittal tilt added (WBCT-sagittal), (2) coronal and axial rotation from optical motion capture added to (1; WBCT-combo), and (3) WBCT-derived axial, sagittal, and coronal rotation added to (1; WBCT-original). Identical gait cycle loading was applied to all models for a given hip, and computed contact stress and contact area were compared between model initialization techniques. Addition of sagittal tilt did not significantly change whole-joint peak (p = 0.922) or mean (p = 0.871) contact stress or contact area (p = 0.638). Inclusion of motion-captured coronal and axial rotation (WBCT-combo) decreased peak contact stress (p = 0.014) and slightly increased average contact area (p = 0.071) from WBCT-sagittal models. Including all WBCT-derived rotations (WBCT-original) further reduced computed peak contact stress (p = 0.001) and significantly increased contact area (p = 0.001). Variably significant differences (p = 0.001-1.0) in patient-specific acetabular subregion mechanics indicate the importance of functional orientation incorporation for modeling applications in which local contact mechanics are of interest.

Evaluation and Management of the Athlete's Hip.

Hip and groin pain is common in athletes, and there are many possible underlying pathologies. It is important to describe athletic hip pathology in the context of sport-specific physiologic loads and biomechanical demands. Three distinct types of athletes with this pathology are collision athletes, hypermobility athletes, and endurance athletes. Although there is considerable overlap between sports, athletes with hip pain should always be evaluated in the context of their sport. Understanding the effect of sport-specific biomechanical demands may help with both diagnosis and treatment of athletic hip pathology; however, each athlete's injury should be analyzed on an individual basis.

Postoperative Bracing after Medial Patellofemoral Ligament Reconstruction.

It is unclear if bracing is necessary after isolated medial patellofemoral ligament reconstruction (MPFLr) for recurrent patellar instability. We hypothesize that patients who did not use a brace will have similar outcomes to those who were braced postoperatively. A retrospective review of patients who underwent isolated MPFLr from January 2015 to September 2020 at a single institution was performed. Those with less than 6 weeks of follow-up were excluded. The braced group was provided a hinged-knee brace postoperatively until the return of quadriceps function, which was determined by the treating physical therapist (brace, "B"; no brace, "NB"). Time to straight leg raise (SLR) without lag, recurrent instability, and total re-operations were determined. Univariate analysis and logistic regression were used to evaluate outcomes (statistical significance, p < 0.05). Overall, 229 isolated MPFLr were included (B: 165 knees, 146 patients; NB: 64 knees, 58 patients). Baseline demographics were similar (all p > 0.05). Median time to SLR without lag was shorter in the NB group (41 days [interquartile range [IQR]: 20-47] vs. 44 days [IQR: 35.5-88.3], p = 0.01), while return to sport times were equivalent (B: 155 days [IQR: 127.3-193.8] vs. NB: 145 days [IQR: 124-162], p = 0.31). Recurrent instability rates were not significantly different (B: 12 knees [7.27%] vs. NB: 1 knee [1.56%], p = 0.09), but the re-operation rate was higher in the brace group (20 knees [12.1%] vs. 0 [0%], p = 0.001). Regression analysis identified brace use (odds ratio [OR]: 19.63, 95% confidence interval [CI]: 1.43-269.40, p = 0.026) and female patients (OR: 2.79, 95% CI: 1.01-7.34, p = 0.049) to be associated with needing reoperation. Recurrent instability rates and return to sport times were similar between patients who did or did not use a hinged knee brace after isolated MPFLr. Re-operation rates were higher in the braced group. Retrospective Comparative Study, Level III.

Providing a computationally derived, mechanically optimised target correction during preoperative planning can improve joint contact mechanics of hip dysplasia treated with periacetabular osteotomy.

AIM: Preoperative identification of acetabular corrections that optimally improve joint stability and reduce elevated contact stresses could further reduce osteoarthritis progression in patients with hip dysplasia who are treated with periacetabular osteotomy (PAO). The purpose of this study was to investigate how providing patient-specific, mechanically optimal acetabular reorientations to the surgeon during preoperative planning affected the surgically achieved correction. METHODS: Preoperative CT scans were used to create patient-specific hip models for 6 patients scheduled for PAO. A simulated acetabular fragment was extracted from the preoperative pelvis model and computationally rotated to simulate candidate acetabular reorientations. For each candidate, discrete element analysis was used to compute contact stresses during walking, which were summed over the gait cycle and scaled by patient age to obtain chronic contact stress-time exposure. The ideal patient-specific reorientation was identified using a cost function that balances minimising chronic stress exposures and achieving surgically acceptable acetabular coverage angles. The optimal reorientation angles and associated contact mechanics were provided to the surgeon preoperatively. After PAO was performed, a model of the surgically achieved correction was created from a postoperative CT scan. Radiographic coverage and contact mechanics were compared between preoperative, optimal, and surgically achieved orientations. RESULTS: While surgically achieved reorientations were not significantly different from optimal reorientations in radiographically measured lateral (p = 0.094) or anterior (p = 0.063) coverage, surgically achieved reorientations had significantly (p = 0.031) reduced total contact area compared to optimal reorientations. The difference in lateral coverage and peak chronic exposure between surgically achieved and optimal reorientations decreased with increasing surgeon experience using the models (R² = 0.758, R2 = 0.630, respectively). CONCLUSIONS: Providing hip surgeons with a patient-specific, computationally optimal reorientation during preoperative planning may improve contact mechanics after PAO, which may help reduce osteoarthritis progression in patients with hip dysplasia.

Incidence and risk factors for non-union of the superior ramus osteotomy when hip dysplasia is treated with periacetabular osteotomy.

Periacetabular osteotomy (PAO) is a well-established surgical treatment for hip dysplasia. Few studies report risk factors for the development of superior ramus osteotomy non-union. The purpose of this investigation was to document the incidence and risk factors for this complication. We identified 316 consecutive hips that underwent PAO for symptomatic acetabular dysplasia with a minimum 1-year radiographic follow-up. We developed and validated a technique to measure the superior ramus osteotomy location on anterior-posterior (AP) pelvis radiographs and computed tomography. Logistic regression with generalized estimating equations was used to evaluate the relationships between odds of non-union and potential demographic and radiographic predictor variables in univariate and multivariate analyses. Twenty-nine (9.2%) hips developed superior ramus non-union. Age {median [interquartile range (IQR)] 23 years (18-35) healed versus 35 years (26-40) non-united, P = 0.001}, pre-operative lateral center-edge angle (LCEA) [16° (11-20) healed versus 10° (6-13) non-united, P < 0.001] and the distance from the superior ramus osteotomy to the ilioishial line [15.8 mm (13.2-18.7) healed versus 18.1 mm (16.2-20.5) non-united, P < 0.001] varied significantly between groups. Using multivariate analysis, moderate-to-severe dysplasia [LCEA < 15°, odds ratio (OR) 5.95, standard error (SE) 3.32, 95% confidence interval (CI) 1.99-17.79, P = 0.001], increased age (5-year increase, OR 1.29, SE 3.32, 95% CI 1.105-1.60, P-value = 0.018) and distance from the ilioishial line (3-mm increase, OR 1.67, SE 0.22, 95% CI 1.29-2.18, P < 0.001) were at increased risk of developing non-union. Superior ramus osteotomy non-union is common after PAO. Older age, moderate-to-severe dysplasia, and more medial osteotomy location were independent risk factors for non-union. Consideration should be made in high-risk patients for a more lateral superior ramus osteotomy and adjuvant medical and surgical interventions.

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.

Return to Sport After Knee Injuries in Collegiate Wrestling.

Background: Wrestling is known to be a sport of relatively high injury incidence, and knee injuries account for a large percentage of those injuries. Treatment of these injuries varies considerably depending on injury and wrestler characteristics, leading to variability in complete recovery and return to sport (RTS). The purpose of this study was to evaluate injury trends, treatment strategies, and RTS characteristics after knee injuries in competitive collegiate wrestling. Methods: NCAA Division I collegiate wrestlers who sustained knee injuries between January 2010 and May 2020 were identified using an institutional Sports Injury Management System (SIMS). Wrestling-related knee, meniscus, and patella injuries were identified, and treatment strategies were documented to investigate potential recurrent injury trends. Descriptive statistics were used to quantify the number of days, practices, and competitions missed, return to sport times, and recurrent injuries among wrestlers. Results: Overall, 184 knee injuries were identified. After excluding non-wrestling injuries (n=11), 173 injuries remained (77 wrestlers). The mean age at time of injury was 20.8 ± 1.4 years, and the mean BMI was 25.9 ± 3.8 kg/m2. There were 135 primary injuries (74 wrestlers), which consisted of 72 (53%) ligamentous injuries, 30 (22%) meniscus injuries, 14 patellar injuries (10%), and 19 other injuries (14%). The majority of ligamentous injuries (93%) and patellar injuries (79%) were treated non-operatively, while the majority of meniscus tears (60%) underwent surgery. Twenty-three wrestlers (22%) sustained recurrent knee injuries, of which 76% were treated non-operatively after their initial injury. Recurrent injuries consisted of 12 (32%) ligamentous injuries, 14 (37%) meniscus injuries, eight (21%) patellar injuries, and four (11%) other injuries. Fifty percent of recurrent injuries were treated operatively. When comparing recurrent injuries to primary injuries, recurrent injuries had a significantly longer return to sport time (Recurrent 68.3 ± 96.0 days vs. Primary 26.0 ± 56.4 days, p=0.01). Conclusion: The majority of NCAA Division I collegiate wrestlers who sustained knee injuries were initially treated non-operatively, and approximately one in five wrestlers sustained recurrent injuries. Return to sport time was significantly increased after a recurrent injury. Level of Evidence: IV.

Radiographically successful periacetabular osteotomy does not achieve optimal contact mechanics in dysplastic hips.

BACKGROUND: Optimal correction of hip dysplasia via periacetabular osteotomy may reduce osteoarthritis development by reducing damaging contact stress. The objective of this study was to computationally determine if patient-specific acetabular corrections that optimize contact mechanics can improve upon contact mechanics resulting from clinically successful, surgically achieved corrections. METHODS: Preoperative and postoperative hip models were retrospectively created from CT scans of 20 dysplasia patients treated with periacetabular osteotomy. A digitally extracted acetabular fragment was computationally rotated in 2-degree increments around anteroposterior and oblique axes to simulate candidate acetabular reorientations. From discrete element analysis of each patient's set of candidate reorientation models, a mechanically optimal reorientation that minimized chronic contact stress exposure and a clinically optimal reorientation that balanced improving mechanics with surgically acceptable acetabular coverage angles was selected. Radiographic coverage, contact area, peak/mean contact stress, and peak/mean chronic exposure were compared between mechanically optimal, clinically optimal, and surgically achieved orientations. FINDINGS: Compared to actual surgical corrections, computationally derived mechanically/clinically optimal reorientations had a median[IQR] 13[4-16]/8[3-12] degrees and 16[6-26]/10[3-16] degrees more lateral and anterior coverage, respectively. Mechanically/clinically optimal reorientations had 212[143-353]/217[111-280] mm2 more contact area and 8.2[5.8-11.1]/6.4[4.5-9.3] MPa lower peak contact stresses than surgical corrections. Chronic metrics demonstrated similar findings (p ≤ 0.003 for all comparisons). INTERPRETATION: Computationally selected orientations achieved a greater mechanical improvement than surgically achieved corrections; however, many predicted corrections would be considered acetabular over-coverage. Identifying patient-specific corrections that balance optimizing mechanics with clinical constraints will be necessary to reduce the risk of osteoarthritis progression after periacetabular osteotomy.

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.

Joint contact stress improves in dysplastic hips after periacetabular osteotomy but remains higher than in normal hips.

AIM: The purpose of this study was to use computational modeling to determine if surgical correction of hip dysplasia restores hip contact mechanics to those of asymptomatic, radiographically normal hips. METHODS: Discrete element analysis (DEA) was used to compute joint contact stresses during the stance phase of normal walking gait for 10 individuals with radiographically normal, asymptomatic hips and 10 age- and weight-matched patients with acetabular dysplasia who underwent periacetabular osteotomy (PAO). RESULTS: Mean and peak contact stresses were higher (p < 0.001 and p = 0.036, respectively) in the dysplastic hips than in the matched normal hips. PAO normalised standard radiographic measurements and medialised the location of computed contact stress within the joint. Mean contact stress computed in dysplastic hips throughout the stance phase of gait (median 5.5 MPa, [IQR 3.9-6.1 MPa]) did not significantly decrease after PAO (3.7 MPa, [IQR 3.2-4.8]; p = 0.109) and remained significantly (p < 0.001) elevated compared to radiographically normal hips (2.4 MPa, [IQR 2.2-2.8 MPa]). Peak contact stress demonstrated a similar trend. Joint contact area during the stance phase of gait in the dysplastic hips increased significantly (p = 0.036) after PAO from 395 mm2 (IQR 378-496 mm2) to 595 mm2 (IQR 474-660 mm2), but remained significantly smaller (p = 0.001) than that for radiographically normal hips (median 1120 mm2, IQR 853-1444 mm2). CONCLUSIONS: While contact mechanics in dysplastic hips more closely resembled those of normal hips after PAO, the elevated contact stresses and smaller contact areas remaining after PAO indicate ongoing mechanical abnormalities should be expected even after radiographically successful surgical correction.

The Incidence and Outcomes Following Treatment of Capsulolabral Adhesions in Hip Arthroscopy: A Systematic Review.

Background: To perform a systematic review to evaluate the incidence of capsulolabral adhesions following hip arthroscopy (HA) for femoroacetabular impingement (FAI); including risk factors and post-treatment outcomes. Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we queried PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for English-language studies with minimum 6-month follow-up after primary or revision HA for FAI, which reported the incidence of capsulolabral adhesions. Potential adhesion risk factors, such as anchor type used and protocol for capsule closure, were assessed. Pre-operative and post-operative modified Harris Hip Score (mHHS) values were compared in studies that reported them. Results: Thirty-seven articles were included (24 primary HA; 13 revision HA). There were 6747 patients who underwent primary HA (6874 hips; 3005 female, 44%). The incidence of capsulolabral adhesions, confirmed surgically during revision HA, was low. Patients undergoing surgical treatment reported postoperative improvement per modified Harris Hip Scores. Data for 746 patients undergoing second revision HA (761 hips; 449 female, 60%), showed an incidence of adhesions greater than that of primary HA patients. Conclusion: While the incidence of symptomatic capsulolabral adhesions after primary hip arthroscopy is low; revision hip arthroscopy is strongly associated with adhesion development. Lysis of adhesions in primary hip arthroscopy patients reliably improved patient-reported outcomes. Level of Evidence: IV.

Sex Differences in Patient-Reported Outcomes Following Surgical Hip Preservation Interventions: A Systematic Review and Meta-Analysis.

Background: Female patients undergoing hip preservation surgery often have inferior patient-reported outcome scores (PROs), raising concerns about the clinical benefit of hip preservation surgery in women. Comparison of preoperative and postoperative PROs, and change in PROs, for female versus (vs.) male hip preservation patients was completed via systematic review. Methods: In accordance with PRISMA guidelines, the MEDLINE, Cochrane Central, and Em-base databases were searched. Level I-IV studies of patients undergoing surgical intervention for femoroacetabular impingement (FAI) and/or developmental dysplasia of the hip (DDH) with at least two years of postoperative follow-up were included. Sex-stratified PRO scores or outcome information had to be included. Results: We identified 32 hip preservation studies evaluating sex-related PRO differences, and/or providing sex-specific PRO data. The quantitative analysis of 24 studies (1843 patients) was stratified by DDH status. The modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL), and Hip Outcome Score-Sport-Specific subscale (HOS-SSS) were assessed. Patients undergoing surgery for FAI only were 52.1% female (n= 806/1546). As predicted, women had lower preoperative PRO scores, however, they had significantly greater improvements in HOS-ADL (20.14±4.41 vs. 26.00±0.35, p<0.05) and HOS-SSS (33.21± 0.71 vs. 38.33± 0.46, p<0.05) compared to males. Similar results were found in the DDH cohort of 330 patients (72.1% female): females had lower preoperative PRO scores, but significantly greater improvement of mHHS (22.68±0.45 vs. 10.60±1.46, p<0.01). Conclusion: The present review suggests that men undergoing surgery for FAI and/or DDH tend to have higher preoperative and postoperative PRO scores. However, it appears that women often have greater preoperative to postoperative improvement in PRO scores. This finding is strongest in surgical treatment of DDH. Level of Evidence: III.

Does preoperative gabapentin or intraoperative ketorolac influence postoperative pain following hip arthroscopy?

Optimization of perioperative analgesia has important implications for patient satisfaction and short-term outcomes. This study's purpose is to assess if preoperative gabapentin or intraoperative ketorolac influences postoperative pain or time to discharge following hip arthroscopy. In total, 409 patients who underwent hip arthroscopic femoroplasty and/or acetabuloplasty with a single surgeon for femoroacetabular impingement were retrospectively reviewed (September 2017 to February 2021). The effect of preoperative gabapentin or intraoperative ketorolac on postoperative visual analog scale (VAS) pain scores, perioperative opioids in morphine milligram equivalents (MMEs), time in post-anesthesia care unit (PACU), second-stage recovery and time to discharge was assessed using unadjusted and adjusted t-tests, and generalized linear models controlling for operative time, traction time, preoperative MME, intraoperative MME and postoperative MME were compared between the groups of gabapentin to no gabapentin and ketorolac to no ketorolac. There was no difference in first PACU VAS pain score, final PACU VAS score, VAS pain score prior to discharge, average VAS pain score or pain level on follow-up call in the unadjusted or adjusted analysis for the preoperative gabapentin or intraoperative ketorolac groups. Females had higher first PACU VAS pain score (6.05 versus 5.15 P = 0.0026), final PACU VAS pain score (4.43 versus 3.90, P = 0.0045), final VAS pain score prior to discharge (3.87 versus 3.03, P < 0.001) and average postoperative pain score (4.60 versus 4.03, P < 0.001), but no difference in VAS pain score on follow-up call following surgery. Gabapentin or ketorolac was not associated with decreased VAS pain scores or time to discharge after hip arthroscopy.

Arthroscopic Decompression of the Anterior Inferior Iliac Spine.

Background: Pathologic contact between the femoral neck and anterior inferior iliac spine (AIIS or subspine) often occurs concomitantly with femoroacetabular impingement, contributing to hip pain and dysfunction1-4. We perform arthroscopic AIIS decompression to alleviate this source of extra-articular impingement and eliminate a potential cause of persistent pain following primary hip arthroscopy5-7. Description: After identifying abnormal AIIS morphology on preoperative false-profile radiographs and/or 3D computed tomography, we utilize a beaver blade to make a small incision in the proximal capsule and rectus femoris tendon. This peri-capsulotomy window grants access to the subspine region. We then shuttle an arthroscopic burr into place within this window and begin debriding the subspine deformity under direct visualization. Fluoroscopy is utilized intraoperatively to ensure adequate resection, using intraoperative false-profile views achieved by canting the C-arm approximately 40°. Resection is considered adequate when the AIIS deformity is no longer readily apparent on false-profile views and when intraoperative range-of-motion testing confirms no further impingement with hip hyperflexion. Alternatives: Femoroacetabular impingement can be treated nonoperatively with use of physical therapy and activity modification8; however, outcomes following nonoperative treatment are inferior to those following hip arthroscopy, according to various studies9-12. There are no known alternative treatments specific to subspine impingement. Rationale: As patients with subspine deformities progress through hip flexion, the femoral neck collides with the AIIS, limiting range of motion. As such, subspine deformities have been shown to be more common in dancers and other high-flexion athletes13,14. Additionally, studies have demonstrated that low femoral version of <5° is associated with increased contact between the distal femoral neck and the AIIS. This pathologic contact can occur even in the absence of an obvious subspine deformity15. In both of these patient populations, surgeons should have a high suspicion for subspine impingement, and a subspine decompression should be performed during hip arthroscopy in order to maximize patient outcomes. Expected Outcomes: This is a safe procedure that, if performed when indicated, can improve outcomes following primary hip arthroscopy. A recent systematic review found a pooled complication risk of 1.1%, a pooled revision risk of 1.0%, and significant postoperative improvements in patient-reported outcome measures16. Important Tips: Suspect subspine impingement in high-flexion athletes and patients with low femoral version, even in the absence of an obvious deformity.Ensure adequate visualization of the entire subspine deformity by creating a pericapsular window.Confirm thorough resection with use of fluoroscopic imaging intraoperatively, including false-profile views demonstrating absent subspine deformity. Acronyms and Abbreviations: FAI = femoroacetabular impingementAP = anteroposterior, refers to the technique used to obtain one of the pelvic radiographs3D CT = three-dimensional computed tomographyLCEA = lateral center-edge angle, a measurement used to quantify severity of hip dysplasiaOR = operating roomAlpha = alpha angle, a measurement used to measure femoral head-neck offset and assess the severity of a cam deformityIc = iliocapsularisRFd = direct head of rectus femorisRFr = reflected head of rectus femorisCap = hip capsuleGMi = gluteus minimusmHHS = modified Harris Hip ScoreHOS-ADL = Hip Outcome Score - Activities of Daily LivingHOS-SSS = Hip Outcome Score - Sports Specific Subscale.

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.

Can Patients Read, Understand, and Act on Online Resources for Anterior Cruciate Ligament Surgery?

Background: Patients undergoing elective procedures often utilize online educational materials to familiarize themselves with the surgical procedure and expected postoperative recovery. While the Internet is easily accessible and ubiquitous today, the ability of patients to read, understand, and act on these materials is unknown. Purpose: To evaluate online resources about anterior cruciate ligament (ACL) surgery utilizing measures of readability, understandability, and actionability. Study Design: Cross-sectional study; Level of evidence, 4. Methods: Using the term "ACL surgery," 2 independent searches were performed utilizing a public search engine (Google.com). Patient education materials were identified from the top 50 results. Audiovisual materials, news articles, materials intended for advertising or medical professionals, and materials unrelated to ACL surgery were excluded. Readability was quantified using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index, and Gunning Fog Index. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) was utilized to assess the actionability and understandability of materials. For each online source, the relationship between its Google search rank (from first to last) and its readability, understandability, and actionability was calculated utilizing the Spearman rank correlation coefficient (ρS). Results: Overall, we identified 68 unique websites, of which 39 met inclusion criteria. The mean Flesch-Kincaid Grade Level was 10.08 ± 2.34, with no website scoring at or below the 6th-grade level. Mean understandability and actionability scores were 59.18 ± 10.86 (range, 33.64-79.17) and 34.41 ± 22.31 (range, 0.00-81.67), respectively. Only 5 (12.82%) and 1 (2.56%) resource scored above the 70% adequate PEMAT-P threshold mark for understandability and actionability, respectively. Readability (lowest P value = .103), understandability (ρS = -0.13; P = .441), and actionability (ρS = 0.28; P = .096) scores were not associated with Google rank. Conclusion: Patient education materials on ACL surgery scored poorly with respect to readability, understandability, and actionability. No online resource scored at the recommended reading level of the American Medical Association or National Institutes of Health. Only 5 resources scored above the proven threshold for understandability, and only 1 resource scored above it for actionability.

Outcomes Following Primary Anterior Cruciate Ligament Reconstruction Using a Partial Transphyseal (Over-the-Top) Technique in Skeletally Immature Patients.

Background: The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients is increasing, with ACL reconstruction preferred in this population due to reported chondroprotective benefits. Due to concerns with growth disturbance following ACL reconstruction in skeletally immature patients, various physealsparing and partial transphyseal techniques have been developed. Currently, there is no consensus on the most effective ACL reconstruction technique in skeletally immature patients. The purpose of the current study was to report the outcomes of a partial-transphyseal over-the-top (OTT) ACL reconstruction in a cohort of skeletally immature patients. Methods: All patients with radiographic evidence of open tibial and femoral physes that underwent primary ACL reconstruction using a partial-transphyseal OTT technique between 2009-2018 at a single tertiary-care institution with at least twelve months of clinical follow-up were retrospectively reviewed. Patient demographics, physical examination findings, graft ruptures, return to sport, and Tegner activity levels were analyzed. Statistical significance was defined as p<0.05. Results: Overall, 11 males and 1 female (12 knees) with a mean age of 12.8±1.8 (range: 10-16) years were included in the study. The mean postoperative follow-up of the cohort was 2.3±1.2 (range: 1.1-5.2) years. All ACLs were reconstructed with hamstring autograft with allograft augmentation utilized in a single patient. There were two cases of ACL graft rupture (16.7%). All patients were able to return to the same or higher level of sporting activity at an average of 7.4+2.7 months. There were no cases of clinically significant longitudinal or angular growth disturbance. Conclusion: Partial transphyseal ACL reconstruction using a transphyseal tibial tunnel and an extra-articular OTT technique on the femur in skeletally immature patients affords minimal risk of growth disturbance with a graft rupture rate consistent with what has been reported in this high-risk population. All patients were able to return to sport at the same or higher level. Level of Evidence: IV.

FEAR index in predicting treatment among patients with femoroacetabular impingement and hip dysplasia and the relationship of femoral version.

The Femoro-Epiphyseal Acetabular Roof (FEAR) index is a newer measurement to identify the hip instability with borderline acetabular dysplasia. The purpose of this study is to (i) validate the FEAR index in determining the stability of the hip in patients who have previously been treated surgically for femoroacetabular impingement (FAI) and/or developmental dysplasia of the hip (DDH) and (ii) to examine the relationship between the FEAR index and femoral version, lateral center edge angle, Tönnis angle and alpha angle (AA). Patient demographics and radiographic measurements of 215 hips (178 patients), 116 hips treated with hip arthroscopy for FAI and 99 hips treated with periacetabular osteotomy (PAO) for DDH were compared between groups. The sensitivity and specificity of the FEAR index to detect the surgical procedure performed (PAO or hip arthroscopy) was calculated, and a threshold value was proposed. Pearson's correlation coefficients were used to describe the relationships between the FEAR index, femoral version and other radiographic measurements. The FEAR index was higher in patients with DDH versus FAI (DDH: 2.81 ± 0.50° versus FAI: -1.00 ± 0.21°, P < 0.001). A FEAR index threshold value of 3° had a sensitivity and specificity of 80% and 81%, respectively, for correctly predicting the surgical procedure performed. Femoral version was positively associated with the FEAR index in the setting of DDH (r = 0.36, P = 0.001) but not FAI (r = 0.02, P = 0.807). A FEAR index of 3° predicted treatment with 80% sensitivity and 81% specificity. In addition, femoral version significantly correlates with the FEAR index in the setting of DDH but not FAI.

Effect of modeling femoral version and head-neck offset correction on computed contact mechanics in dysplastic hips treated with periacetabular osteotomy.

While correction of dysplastic acetabular deformity has been a focus of both clinical treatment and research, concurrent femoral deformities have only more recently received serious attention. The purpose of this study was to determine how including abnormalities in femoral head-neck offset and femoral version alter computationally derived contact stresses in patients with combined dysplasia and femoroacetabular impingement (FAI). Hip models with patient-specific bony anatomy were created from preoperative and postoperative CT scans of 20 hips treated with periacetabular osteotomy and femoral osteochondroplasty. To simulate performing only a PAO, a third model was created combining each patient's postoperative pelvis and preoperative femur geometry. These three models were initialized with the femur in two starting orientations: (1) standardized template orientation, and (2) using patient-specific anatomic landmarks. Hip contact stresses were computed in all 6 model sets during an average dysplastic gait cycle, an average FAI gait cycle, and an average stand-to-sit activity using discrete element analysis. No significant differences in peak contact stress (p = 0.190 to 1), mean contact stress (p = 0.273 to 1), or mean contact area (p = 0.050 to 1) were identified during any loading activity based on femoral alignment technique or inclusion of femoral osteochondroplasty. These findings suggest that presence of abnormal femoral version and/or head-neck offset deformities are not themselves predominant factors in intra-articular contact mechanics during gait and stand-to-sit activities. Inclusion of modified movement patterns caused by these femoral deformities may be necessary for models to adequately capture the mechanical effects of these clinically recognized risk factors for negative outcomes.