Editorial Commentary: Hip Arthroscopy Benefits Patients With Tönnis Grade 0 or 1 Hip Arthritis and Is Not Recommended for Grade 3: Optimal Treatment of Femoroacetabular Impingement Syndrome for Grade 2 Arthritis May Be Determined by Age and Body Mass Index.

Femoroacetabular impingement syndrome (FAIS) is a possible cause of early osteoarthritis, and restoration of normal anatomy can potentially prevent future major cartilage damage. Symptomatic cam lesions can lead to debonding of articular cartilage, resulting in superolateral cartilage lesions in 93% of patients. Patients with pincer lesions often exhibit cartilage lesions in the anterior and superolateral glenoid rim. Whereas the efficacy of prophylactic surgery remains uncertain, surgical intervention appears to yield superior short-term clinical outcomes compared with conservative treatment. Yet, there is a relatively high prevalence of asymptomatic individuals in the general population with either cam (25%) or pincer (67%) deformities, so prophylactic treatment of asymptomatic patients cannot be recommended. Symptomatic FAIS patients with Tönnis grades 0 and 1 (minimal hip arthritis) benefit from hip arthroscopy. Patients with higher grades of osteoarthritis may be unsuitable hip arthroscopy candidates and face a higher risk of conversion to hip replacement. The existing evidence regarding the treatment of patients with FAIS and Tönnis grade 2 or higher remains inconclusive. Generally, surgery tends to have favorable outcomes for younger patients with a normal body mass index, whereas nonsurgical alternatives should be explored in cases with severe joint space narrowing, Tönnis grade 3, and bilateral cartilage lesions.

Editorial Commentary: A Delphi Expert Consensus Provides Clarity On Diagnosis, Treatment, Rehabilitation and Return-To-Sports for Posterior Shoulder Instability.

Posterior shoulder instability (PSI) is an uncommon condition accounting for 2-12% of shoulder instability cases. However, PSI might be more common and possibly accounts for up to 24% of all young, active patients treated for shoulder instability. The etiology of PSI is complex and multifactorial, making accurate diagnosis, classification and treatment challenging. The accurate diagnosis of PSI is problematic and varies with symptoms ranging from pain, decreased strength or endurance to mechanical symptoms such as clicking or popping and only a minority of patients present after a posterior shoulder dislocation. Appropriate imaging is necessary and should include radiographs and advanced imaging with MRI, preferably MRI arthrography. The goal of treatment is to reduce pain, improve function, and prevent or reduce recurrence. Both surgical and conservative treatment is demanding and both osseous and soft tissue pathology needs to be addressed adequately. Typically, a conservative approach should be considered first for the first six months, with a focus on proprioceptive exercises, strengthening of the dynamic stabilizers and improving scapulothoracic mechanics. The primary indication for surgery is recurrent symptoms. Controversies exist regarding the choice between open and arthroscopic stabilization of soft tissue defects, the treatment of the McLauglin lesion and the management of osseous defects.

Editorial Commentary: High-Platelet-Dose Platelet-Rich Plasma May Be the Nonoperative Treatment of Choice for Knee Osteoarthritis.

Knee osteoarthritis (OA) affects 30% of individuals older than 60 and 40% older than 70 years old. The incidence of radiologic knee OA is 373 per 10,000 person-years, but symptomatic knee OA registers at a considerably lower rate of 50 per 10,000 person-years. For symptomatic cases that are not candidates for surgical intervention, various treatment options include exercise, weight loss, pharmacologic management, bracing, physical therapy, oral supplementation, and intra-articular injection with corticosteroids, hyaluronic acid, or orthobiologics such as platelet-rich plasma (PRP). Recent network meta-analysis has affirmed the superiority of PRP over the other alternatives. It appears that a mean absolute platelet count in the final product of less than 2,500 × 106 is not effective, whereas an average platelet count of greater than 5,000 × 106 displays a positive clinical effect at both 6 and 12 months. Yet, aspects like the definition of PRP, whether activation is necessary, the frequency of injections, the optimal dosage, and the preparation method remain unclear.

Editorial Commentary: Platelet-Rich Plasma for Musculoskeletal Conditions Is Supported by a Large Number of Clinical Studies, Particularly for Knee Osteoarthritis.

Platelet-rich plasma (PRP) represents a biological treatment for various musculoskeletal conditions. Over the past 20 years, publications regarding the treatment of orthopaedic conditions with PRP have shown a 4-fold increase. Several systematic reviews and meta-analyses have demonstrated that PRP is effective and often superior to other treatment modalities. However, the value of these studies is somehow limited as high risk of bias, study heterogeneity, and low levels of certainty compromise the validity of their conclusions. In this scenario, expert consensus studies can be useful and allow pooling of expert opinion in a scientific manner. Using the modified Delphi technology, it was determined that the definition of PRP, whether leukocyte rich or poor, is still not clear. In addition, it remains unclear whether PRP should be activated, how often it should be injected, what the ideal dose is and how to prepare PRP. Despite these uncertainties, the use PRP for various orthopaedic conditions, in particular for the treatment of knee osteoarthritis, is supported by a large number of clinical studies. However, its use remains an unsolved controversy, and the foundation of a biologics association is a step in the right direction to develop standards and foster research with regards to the safety, clinical efficacy, and clinical applications of orthobiologics. In summary, there is no strong consensus, but many individual statements result in a strong consensus rating.

Editorial Commentary: Recurrence Rates Following Arthroscopic Bankart Repair Differ Among Contact and Collision Sports and Are Higher in Collision Sports.

Collision and contact sports athletes are at higher risk of shoulder dislocations. In collision sports such as boxing, ice hockey, rugby, football, and various martial arts, the athlete purposely hits or collides with other athletes or objects with substantial force, whereas in contact sports such as basketball, field hockey, wrestling, and soccer, the athlete makes regular contact with other athletes but with substantially less force. Return-to-sports rates following arthroscopic shoulder stabilization are above 90%. Risk factors for a recurrent shoulder dislocation include younger age, previous dislocations, generalized hyperlaxity, an instability severity index score above 3, off-track lesions, glenoid bone loss, and participation in contact and collision sports. However, data from a recent study have shown that the rate of recurrence varies among different contact sports as both kinematics and kinetics are clearly different. Ice hockey (ES, 0.72) has been identified as the collision sport with the highest recurrence rate. Wrestling (ES, 0.33), rugby (ES, 0.23), martial arts (ES, 0.20), and boxing (ES, 0.18) had similar recurrence rates, but the effect sizes were 3 times lower when compared to ice hockey. The lowest recurrence rates were observed in field hockey (ES, 0.04), football (ES, 0.06), and soccer (ES, 0.06). The sample size was sufficient, but the moderate risk of bias and study quality suggest that the true effect will most likely be markedly different from the estimated effect. Although common sense dictates that recurrence rates should be different, scientific evidence is not supporting this motion, and the findings should be viewed with some caution.

Micro-Fragmented Adipose Tissue Demonstrates Comparable Clinical Efficacy to Other Orthobiologic Injections in Treating Symptomatic Knee Osteoarthritis: A Systematic Review of Level I to IV Clinical Studies.

PURPOSE: To perform a systematic review of clinical outcomes in patients who underwent treatment with micro-fragmented aspirated tissue for symptoms of knee osteoarthritis. METHODS: Medline, Embase, Scopus, and Google Scholar were screened for studies from 2000 to 2023. Risk of bias (ROB) was assessed using the Cochrane Collaboration's tools and the Risk Of Bias In Non-randomised Studies-of Interventions tool. Study quality was assessed with the modified Coleman Methodology Score and Methodological Index for Non-Randomized Studies score. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS: Twenty-one studies were included. One study had a high ROB, 1 had a critical ROB, 3 had serious ROB, and 16 had a moderate ROB. The mean Coleman score was 58, demonstrating fair study quality; the Methodological Index for Non-Randomized Studies score had a mean value of 13, indicating overall fair quality. Best evidence synthesis revealed moderate evidence. The visual analog scale score improved from 5.2 to 3.2 at 6 and 12 months. Knee injury and Osteoarthritis Outcome Score (KOOS) activities of daily living subscore improved from 58.8 to 70.2 at 6 months and 67.5 at 12 months. KOOS pain subscore improved from 54.3 to 70.2 at 6 months and 72.4 at 12 months. KOOS quality of life subscore improved from 33.1 to 43.6 at 6 months and 42.9 at 12 months. KOOS sports subscore improved from 23.7 to 43.6 at 6 months and 57.4 at 12 months. KOOS symptoms subscore improved from 55.3 to 70.1 at 6 months and 67.9 at 12 months. The Western Ontario and McMaster Universities Osteoarthritis Index score steadily increased from 61.8 at baseline to 78.4 at 12 months. CONCLUSIONS: micro-fragmented aspirated tissue injection therapy for the treatment of symptomatic knee osteoarthritis is effective and improves pain and functional outcomes. Moderate study quality combined with a moderate risk of bias, moderate certainty of evidence, and moderate best synthesis evidence reduces external validity. Therefore, the results should be interpreted with a degree of caution. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Cadaveric Biomechanical Laboratory Research Can Be Quantitatively Scored for Quality With the Biomechanics Objective Basic Science Quality Assessment Tool: The BOBQAT Score.

PURPOSE: The purpose of this study was to develop a quality appraisal tool for the assessment of cadaveric biomechanical laboratory and other basic science biomechanical studies. METHODS: For item identification and development, a systematic review of the literature was performed. The content validity index (CVI) was used either to include or exclude items. The content validity ratio (CVR) was used to determine content validity. Weighting was performed by each panel member; the final weight was either up- or downgraded to the closest of 5% or 10%. Face validity was scored on a Likert scale ranked from 1 to 7. Test-retest reliability was determined using the Fleiss kappa coefficient. Internal consistency was assessed with Cronbach's alpha. Concurrent criterion validity was assessed against the Quality Appraisal for Cadaveric Studies scale. RESULTS: The final Biomechanics Objective Basic science Quality Assessment Tool (BOBQAT) score included 15 items and was shown to be valid, reliable, and consistent. Five items had a CVI of 1.0; 10 items had a CVI of 0.875. For weighting, 5 items received a weight of 10%, and 10 items a weight of 5%. CVR was 1.0 for 6 items and 0.75 for 9 items. For face validity, all items achieved a score above 5. For test-retest reliability, almost-perfect test-retest reliability was observed for 10 items, substantial agreement for 4 items, and moderate agreement for 1 item. For internal consistency, Cronbach's alpha was calculated to be 0.71. For concurrent criterion validity, Pearson's product-moment correlation was 0.56 (95% confidence interval [CI] = 0.38-0.70, P = .0001). CONCLUSION: Cadaveric biomechanical and laboratory research can be quantitatively scored for quality based on the inclusion of a clear and answerable purpose, demographics, specimen condition, appropriate bone density, reproducible technique, appropriate outcome measures, appropriate loading conditions, appropriate load magnitude, cyclic loading, sample size calculation, proper statistical analysis, results consistent with methods, limitations considered, conclusions based on results, and disclosure of funding and potential conflicts. CLINICAL RELEVANCE: Study quality assessments are important to evaluate internal and external validity and reliability and to identify methodological flaws and misleading conclusions. The BOBQAT score will help not only in the critical appraisal of cadaveric biomechanical studies but also in guiding the designs of such research endeavors.

Return to Sports Following Sports-Related Concussion in Collision Sports: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: To perform a Delphi consensus for return to sports (RTS) following sports-related concussion (SRC). METHODS: Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS: Individualized graduated RTS protocols should be used. A normal clinical, ocular and balance examination with no more headaches, and asymptomatic exertional test allows RTS. Earlier RTS can be considered if athletes are symptom free. The Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening are recognized as useful tools to assist in decision-making. Ultimately RTS is a clinical decision. Baseline assessments should be performed at both collegiate and professional level and a combination of neurocognitive and clinical tests should be used. A specific number of recurrent concussions for season-or career-ending decisions could not be determined but will affect decision making for RTS. CONCLUSIONS: Consensus was achieved for 10 of the 25 RTS criteria: early RTS can be considered earlier than 48 to 72 hours if athletes are completely symptom-free with no headaches, a normal clinical, ocular and balance examination. A graduated RTS should be used but should be individualized. Only 2 of the 9 assessment tools were considered to be useful: Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening. RTS is mainly a clinical decision. Only 31% of the baseline assessment items achieved consensus: baseline assessments should be performed at collegiate and professional levels using a combination of neurocognitive and clinical tests. The panel disagreed on the number of recurrent concussions that should be season- or career-ending. LEVEL OF EVIDENCE: Level V, expert Opinion.

On-Field and Pitch-Side (Sideline) Assessment of Sports Concussion in Collision Sports: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: To perform a Delphi consensus for on-field and pitch-side assessment of sports-related concussion (SRC). METHODS: Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus, or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS: Loss of consciousness (LOC) or suspected LOC, motor incoordination/ataxia, balance disturbance, confusion/disorientation, memory disturbance/amnesia, blurred vision/light sensitivity, irritability, slurred speech, slow reaction time, lying motionless, dizziness, headaches/pressure in the head, falling to the ground with no protective action, slow to get up after a hit, dazed look, and posturing/seizures were clinical signs of SRC and indicate removal from play. Video assessment is helpful but should not replace clinical judgment. LOC/unresponsiveness, signs of cervical spine injury, suspicion of other fractures (skull/maxillo-facial), seizures, Glasgow Coma Scale score <14 and abnormal neurologic examination findings are indications for hospitalization. Return to play should only be considered when no clinical signs of SRC are present. Every suspected concussion should be referred to an experienced physician. CONCLUSIONS: Consensus was achieved for 85% of the clinical signs indicating concussion. On-field and pitch-side assessment should include the observation of the mechanism, a clinical examination, and cervical spine assessment. Of the 19 signs and red flags requiring removal from play, consensus was reached for 74%. Normal clinical examination and HIA with no signs of concussion allow return to play. Video assessment should be mandatory for professional games but should not replace clinical decision-making. Sports Concussion Assessment Tool, Glasgow Coma Scale, vestibular/ocular motor screening, Head Injury Assessment Criteria 1, and Maddocks questions are useful tools. Guidelines are helpful for non-health professionals. LEVEL OF EVIDENCE: Level V, expert opinion.

Editorial Commentary: High Tibial Osteotomy May Not Be Required With Medial Meniscus Root Repair.

Meniscal root tears are defined as tears within 10 mm of their attachment and are more commonly observed in middle-aged patients. They have been named the silent epidemic and are equivalent to a total meniscectomy. Basic science studies have shown that posterior meniscus root repairs restore both contact area and pressure to its native state. The role of an additional high tibial osteotomy is not clear yet. High tibial osteotomies are commonly used to correct varus malalignment, a condition that is often observed with these tears. However, an additional osteotomy does not seem to offer any additional clinical benefits with regards to clinical and radiologic outcomes. It also has no effect with regards to contact pressure and contact area and is not related to the degree of deformity correction.

Editorial Commentary: From Lateral Release and Medial Plication to Complex Medial Patellofemoral Ligament Reconstruction Techniques: Medial Quadriceps Tendon Femoral Ligament Reconstruction Is the Most Anatomic Repair.

Patella instability and dislocation are common in younger patients, and 1 in 5 patients are at risk of recurrent dislocations. Conservative treatment should be considered for first dislocations unless other concomitant injuries are present. Historically, lateral patella release and medial plication techniques were used for repair but have been superseded by medial patellofemoral ligament reconstruction. Overconstraint is a potential problem and often related to nonanatomic femoral tunnel position and graft tension, which could result in increased patellar contact pressures and graft failure. The medial quadriceps tendon-femoral ligament reconstruction technique (MQTFL) avoids patellar tunnels without the risk of patella fracture. When comparing medial patellofemoral ligament, MQTFL, and the combination of both techniques in a cadaver model, MQTFL resulted in less constraint with no differences for patellar contact pressures. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair.

Treatment of Degenerative Meniscus Tears.

Degenerative meniscus tears are generally atraumatic and a normal part of aging. They are typically observed in middle-aged or older people. Tears are often associated with knee osteoarthritis and degenerative changes. The medial meniscus is most commonly torn. The tear pattern is normally complex with significant fraying but other tear patterns, such as horizontal cleavage, vertical, longitudinal, and flap tears, as well as free-edge fraying are also observed. The onset of symptoms is usually insidious although the majority of tears are not symptomatic. Initial treatment should always be conservative and include physical therapy, NSAIDs, topical treatment, and supervised exercise. In overweight patients, weight loss can decrease pain and improve function. Injections, including viscosupplemenation and the use of orthobiologics, can be considered in the presence of osteoarthritis. Several international orthopaedic societies have issued guidelines for progression to operative management. Mechanical symptoms of locking and catching, acute tears with clear evidence of trauma and persistent pain with failure of nonoperative treatment are considered for operative management. Arthroscopic partial meniscectomy is the most commonly performed treatment for most degenerative tears. However, repair is considered for appropriately selected tears, with special emphasis on surgical technique and patient selection. Treatment of chondral pathology at the time of surgery for meniscus tears is controversial, although a recent Delphi Consensus statement concluded that debridement of loose cartilage fragments may be considered.

Editorial Commentary: Diagnosis, Treatment, Rehabilitation and Return to Sport After Ulnar Collateral Ligament Injury: Agreement Does not Equal Consensus.

Tommy John surgical reconstruction for ulnar collateral ligament injuries was first described by Frank Jobe in 1974. Although he estimated the chance for successful return very low, John, famous baseball pitcher, was able to return to play for another 14 years. Modern techniques and better understanding of anatomy and biomechanics have now resulted in a return-to-play rate of more than 80%. Ulnar collateral ligament injuries occur mainly in overhead athletes. Generally, partial tears can be treated nonoperatively, but in baseball pitchers, success rates are less than 50%. Complete tears often require surgery. Primary repair or reconstruction are feasible options, and the choice will depend not only on the clinical scenario, but also the surgeon. Unfortunately, the current evidence is not convincing, and a recent expert consensus study exploring diagnosis, treatment options, rehabilitation, and return to sports showed agreement among the experts, but not necessarily a consensus.

Editorial Commentary: Autologous and Synthetic Bone Fillers for Medial Open-Wedge High Tibial Osteotomy Have No Effect on Clinical Outcomes But Autologous Graft Promotes Complete Bony Union.

In contrast to closed-wedge high tibial osteotomy, medial based open-wedge high tibial osteotomy produces gaps of various sizes. Synthetic bone void fillers are an attractive option to close these gaps, potentially increase bone union, decrease time to union, and improve clinical outcomes. Autologous bone grafts are the accepted standard and result in reliable and reproducible outcomes. However, harvesting of autologous bone requires an additional procedure and is associated with potential complications. The use of synthetic bone void fillers could theoretically avoid these issues and reduce operating times. The current evidence suggests that autologous bone grafting has higher union rates but is not associated with better clinical and functional outcomes. Unfortunately, the certainty of evidence to support the use of bone void fillers is low, and the question of whether bone grafting of the gap should be performed in medial based open-wedge high tibial osteotomies cannot be answered with confidence.

Corticosteroid injections for the treatment of lateral epicondylitis are superior to platelet-rich plasma at 1 month but platelet-rich plasma is more effective at 6 months: an updated systematic review and meta-analysis of level 1 and 2 studies.

BACKGROUND: The purpose of this study was to perform a systematic review and meta-analysis of studies comparing local injections of either platelet-rich plasma (PRP) or corticosteroid for the treatment of lateral elbow epicondylitis. METHODS: A systematic review of MEDLINE, Embase, Scopus, and Google Scholar was performed, and all level 1 and 2 randomized studies from 2000 to 2022 were included. Clinical symptoms, patient perceived outcomes, and pain were assessed by the DASH (disabilities of the arm, shoulder and hand questionnaire) and pain by the visual analog scale (VAS). Publication bias and risk of bias were assessed using the Cochrane Collaboration's tools. The modified Coleman Methodology Score (CMS) and the GRADE system were used to assess the quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS: Thirteen studies were included in the analysis. Five studies had a high risk of bias, and the risk of bias across studies was assessed as unclear. There was no publication bias identified. Two of the four GRADE domains (inconsistency of results, imprecision of results) were downgraded to low quality, and the final GRADE assessment was downgraded to a low quality of evidence. The mean CMS score was 62.8, indicating fair quality. The pooled estimate for VAS at 1 month favored corticosteroids (P = .75) but favored PRP at three (P = .003) and six months (P = .0001). The pooled estimate for the DASH score favored corticosteroids at 1 month (P = .028) but favored PRP at three (P = .01) and six months (P = .107) CONCLUSION: The results of this meta-analysis suggest that PRP has no advantage over steroid injections within the first month of treatment, but that it is superior to steroids at both 3 and 6 months. These results also suggest that corticosteroids have a short-term beneficial effect during the early treatment period, although the quality of the available evidence is not very robust in support of this finding. However, these findings must all be viewed with caution as the high risk of bias and moderate to low quality of the included studies may not justify a recommendation of one treatment over another.

Surgical treatment is not superior to nonoperative treatment for displaced proximal humerus fractures: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing conservative to surgical treatment of displaced proximal humerus fractures. METHODS: We performed a systematic review of Medline, Embase, Scopus, and Google Scholar articles comparing surgical treatment to conservative treatment, including all level 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were evaluated. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the quality of the body of evidence, and heterogeneity was assessed using χ2 and I2 statistics. Twenty-two studies were incorporated into the analysis. Ten studies had a high risk of bias, and all included studies were of low quality. RESULTS: The pooled estimates failed to identify differences for clinical outcomes (P = .208), abduction (P = .275), forward flexion (P = .447), or external rotation (P = .696). Complication rates between groups were significantly lower (P = .00001) in the conservative group. CONCLUSIONS: This meta-analysis demonstrated that there were no statistically significant differences for either clinical outcomes or range of motion between surgically managed and conservatively treated displaced proximal humerus fractures. The overall complication rate was 3.3 times higher, following surgical treatment. The validity of this result is compromised by the high risk of bias and very low level of certainty of the included studies, and the conclusion must therefore be interpreted with caution.

Arthroscopic treatment and subacromial decompression of calcific tendinitis without removal of the calcific deposit results in rapid resolution of symptoms and excellent clinical outcomes in commercial airline pilots and cabin crew.

PURPOSE: The purpose of this study was to report the results of subacromial arthroscopic decompression (SAD) without removal of the calcific deposits in patients with calcifying tendinitis. METHODS: All patients between 2016 and 2019 were included if they were aged between 18 and 60 years and had an isolated calcific deposit. The Constant-Murley score (CMS), Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, the Shoulder Pain and Disability Index (SPADI), the simple shoulder test (SST), and the single assessment numeric evaluation (SANE) were used for assessment. Time to return to work was recorded. RESULTS: 24 patients (13 pilots, 11 cabin crew) with a mean age of 47.1 ± 7.8 years were included. Quick Dash improved from 68.8 preoperative, to 8.4 at 3 months, and 0.1 at 24 months. CMS improved from 37.4 preoperative, to 83 at 3 months, and 94 at 24 months. SPADI improved from 73.8 preoperative, to 5.4 at 3 months, and 1 at 24 months. SST improved from 22.5 preoperative, to 94.2 at 3 months, and 100 at 24 months. SANE improved from 33.5 preoperative, to 78.7 at 3 months, and 95.6 at 24 months. MCID, SCB, and PASS reached values above 83% at 3 months and 100% at 6 months, with the exception of SANE which reached 29% at 3 months and plateaued to 96% at 6 months. The mean time to return to work was 7.1 ± 2.1 weeks. Pilots returned at a mean of 6.9 ± 1.8 weeks; cabin crew returned to work at a mean of 7.8 ± 2.5 weeks. CONCLUSIONS: The results of this study suggest excellent short- and mid-term clinical outcomes can be achieved in patients with calcific tendinitis undergoing arthroscopic debridement and subacromial decompression without removal of calcific deposits. In this patient population, early surgical intervention was a potentially viable alternative to nonoperative treatment, and allowed early return to work.

Clinical outcomes for grades III-V acromioclavicular dislocations favor double-button fixation compared to clavicle hook plate fixation: a systematic review and meta-analysis.

INTRODUCTION: The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing double-button suture fixation to hook plate fixation for types III-IV acromioclavicular joint dislocation. METHODS: Systematic review of Medline, Embase, Scopus, and Google Scholar, including all levels 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. MINORS and modified Coleman Methodology Score (CMS) were used to assess within study quality. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS: Fifteen studies were included. Three of the four included LOE II and eleven of the LOE III studies had a high risk of bias. Study quality was considered poor and fair for 67% by MINORS criteria and 93% for CMS criteria. The pooled estimate (SMD 0.662) for all clinical outcomes was statistically significant and in favor of button repair (p = 0.0001). The pooled estimate (SMD 0.662) for all VAS pain scores was statistically significant, again in favor of button repair (p = 0.001). CONCLUSIONS: The results of this meta-analysis demonstrated significantly better outcomes of button repair for acute ACJ dislocations when compared to clavicle hook plate. Button repair is also associated with a 2.2 times lower risk for complications. However, risk of bias is high, and study quality within and between studies was low. These results, therefore, must be viewed with caution. LEVEL OF EVIDENCE: Level III; systematic review and meta-analysis.

Surgical treatment of proximal humerus fractures: a systematic review and meta-analysis.

INTRODUCTION: The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing surgical interventions for proximal humerus fractures. METHODS: Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1-3 studies from 2000 to 2022 comparing surgical treatment with ORIF, IM nailing, hemiarthroplasty, total and reverse shoulder arthroplasty (RTS) was conducted. Clinical outcome scores, range of motion (ROM), and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS: Thirty-five studies were included in the analysis. Twenty-five studies had a high risk of bias and were of low and very low quality. Comparisons between ORIF and hemiarthroplasty favored ORIF for clinical outcomes (p = 0.0001), abduction (p = 0.002), flexion (p = 0.001), and external rotation (p = 0.007). Comparisons between ORIF and IM nailing were not significant for clinical outcomes (p = 0.0001) or ROM. Comparisons between ORIF and RTS were not significant for clinical outcomes (p = 0.0001) but favored RTS for flexion (p = 0.02) and external rotation (p = 0.02). Comparisons between hemiarthroplasty and RTS favored RTS for clinical outcomes (p = 0.0001), abduction (p = 0.0001), and flexion (p = 0.0001). Complication rates between groups were not significant for all comparisons. CONCLUSIONS: This meta-analysis for surgical treatment of proximal humerus fractures demonstrated that ORIF is superior to hemiarthroplasty, ORIF is comparable to IM nailing, reverse shoulder arthroplasty is superior to hemiarthroplasty but comparable to ORIF with similar clinical outcomes, ROM, and complication rates. However, the study validity is compromised by high risk of bias and low level of certainty. The results should therefore be interpreted with caution. Ultimately, shared decision making should reflect the fracture characteristics, bone quality, individual surgeon's experience, the patient's functional demands, and patient expectations. LEVEL OF EVIDENCE: Level III; systematic review and meta-analysis.

Editorial Commentary: Hip Arthroscopy for Femoroacetabular Impingement in Patients With Borderline Dysplasia Does Not Result in Inferior Outcomes Compared With Outcomes in Patients Without Dysplasia: Do Not Fear.

The treatment of adult borderline hip dysplasia remains challenging and continues to be a subject of controversy. The preferred treatment for hip instability and acetabular undercoverage is periacetabular osteotomy. However, patients with painful hips and associated femoroacetebular impingement, microinstability, or no instability may benefit from arthroscopic surgery. Short-term studies have reported favorable clinical outcomes. Traditionally, the lateral center-edge angle was used to determine hip dysplasia. More recently the femoro-epiphyseal acetabular roof (FEAR) index was introduced as a measure for borderline dysplasia. In general, a FEAR index of less than 5° indicates hip instability. When using a FEAR index of more than 2° as a cut-off for hip instability and borderline dysplasia, arthroscopic hip surgery can achieve very similar clinical outcomes to patients with a FEAR index of less than 2°. However low and unequal sample sizes have potentially resulted in both type I and II errors, reducing internal study validity. Although this may be a step in the right direction, further high-quality studies are required to understand patients' characteristics on diagnosis, prognosis, outcomes of surgical interventions, and long-term disease progression for adult borderline hip dysplasia.