A Retrospective Comparative Analysis on the Effect of Tranexamic Acid to Reduce Perioperative Blood Loss in Patients Undergoing Cervical Spine Surgery.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery. SUMMARY OF BACKGROUND DATA: Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery. METHODS: We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT). RESULTS: We found that the use of TXA statistically significantly reduced total perioperative blood loss (P=0.04) and postoperative drain output (P=0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative (P=0.02) and postoperative (P<0.01) blood loss. CONCLUSIONS: This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors. LEVEL OF EVIDENCE: Level III.

Editorial Commentary: Improved Suture Configurations Can Enhance Shoulder Rotator Cuff Healing: The Cuff Doesn't Always Heal-But We Can Nudge It in the Right Direction.

The success of rotator cuff repair is often measured by patient-reported outcomes or structural healing on magnetic resonance imaging. Ideally, we can achieve both a satisfied patient and a healed tendon. Various technical modifications and stitch patterns have been presented in an effort to achieve the perfect rotator cuff repair. It appears the independently popular suture bridge technique and Mason-Allen stitch may do their best work when combined together. First, double-row repair "anchors down" the tendon to its footprint, and suture bridge adds to this concept with double-row compressive interlinking suture. Second, the Mason-Allen stitch, combining a horizontal stich and a simple stitch that passes around the horizontal, leverages the rip-stop concept where an "anchor suture" is included as a suture is passed around friable tendon like steel rebar rods strengthening concrete. In the midst of many factors out of the surgeon's control during the healing process, we are compelled to listen when a change in our technique might actually make a difference.

Acetabular Rim Ossification Variants Are Found in Almost 20% of Patients Presenting With Hip Pain.

Purpose: To determine the prevalence of 4 different types of acetabular rim ossifications, including partial labral ossification or punctate calcification, true os acetabuli, acetabular rim stress fracture, and complete labral ossification, and to determine whether different types of periacetabular ossifications are linked to demographic or radiological factors. Methods: We retrospectively reviewed the medial records of patients presenting for hip-related complaints at 2 sports medicine practices from September 2007 to December 2009. An anteroposterior radiograph of both hips and a lateral radiograph of each hip was obtained for all patients and reviewed for findings of cam and pincer femoroacetabular impingement, degenerative changes (Tönnis grade), and periacetabular calcifications for both hips. These parameters were also evaluated with respect to symptoms, sex, and age. Results: Four hundred ninety-one consecutive patients (982 hips) presented to 2 orthopaedic surgeons at 2 centers for "hip"-related complaints. There were 223 males and 268 females (age 39 ± 14 years). The overall prevalence of periacetabular calcifications in hips was 17.6%, with 56.6% of calcifications in the symptomatic hip and 43.4% in the contralateral hip. Four basic patterns of calcification were identified: punctuate calcifications within the labrum (8.0% hips), large rounded calcifications (os acetabuli) (4.2% hip), large fragments with a vertical line of the superior-lateral acetabular rim, consistent with healed or non-healed stress fracture (2.0% hips), and complete ossification of the labrum (3.4% hips). Overall, male sex (P = .002), increased lateral center-edge angle (P = .046), and higher Tönnis grade (P < .001) statistically predicted the presence of periacetabular ossification. Punctate calcifications were more prevalent in males (P = .002). Higher Tönnis grade (P = .029) and increased alpha angle (P = .046) were more prevalent with os acetabuli. Younger age (P = .001), male sex (P = .048), increased alpha angle (P = .012), and increased lateral center-edge angle (P < .001) were more prevalent in acetabular rim fractures. No factors were statistically significant at predicting the presence of an ossified labrum. Conclusions: Periacetabular calcifications are not uncommon. Four particular patterns of calcification are identified: punctate labral calcifications (8%), larger rounded calcifications (i.e., os acetabuli) (4.2%), acetabular rim stress fractures (2%), and complete ossification of the labrum (3.4%) for a combined prevalence of 17.6% in patients presenting to an orthopaedic surgeon with "hip"-related complaints. Nearly half were in the asymptomatic hip. Male sex had a higher prevalence of periacetabular calcifications. An increased lateral center edge angle and higher Tönnis grade also had a higher prevalence of periacetabular calcifications. Younger male patients are more likely to have acetabular rim stress fractures. Patients with an increased alpha angle have a higher prevalence of os acetabuli and rim stress fractures. Clinical Relevance: This study aims to identify, quantify, and categorize periacetabular calcifications about the hip. Their clinical relationships and relevance have been discussed, but no study has distinctly categorized the various types and their prevalence. This study provides a framework for identification and categorization.

Calculating Intraoperative Fluid Deficit to Prevent Abdominal Compartment Syndrome in Hip Arthroscopy.

Abdominal compartment syndrome (ACS) is a rare but potentially fatal complication that can occur during hip arthroscopy. This usually occurs as a result of arthroscopic fluid passing into the retroperitoneal space through the psoas tunnel. From the retroperitoneal space, the fluid can then enter the intraperitoneal space through defects in the peritoneum. Previous studies have identified female sex, iliopsoas tenotomy, pump pressure, and operative time as potential risk factors for fluid extravasation. We present a method to measure intraoperative fluid deficit during hip arthroscopy to alert surgeons to possible ACS. Our proposed technique requires diligent intraoperative monitoring of fluid output through various suction devices, including suction canisters, puddle vacuums, and suction mats. The difference is then calculated from the fluid intake from the arthroscopic fluid bags. If the difference is greater than 1500 mL, then the anesthesiologist and circulating nurse are instructed to examine the abdomen for distension every 15 minutes. This, combined with other common symptoms such as hypotension and hypothermia, should alert the surgical team to the development of ACS. Despite limitations to this technique, this approach offers an objective method to calculate intra-abdominal fluid extravasation.

Hair analysis interpretation in post-mortem situations: Key considerations and proposals to overcome main hurdles.

In the analytical challenge of post-mortem toxicological investigations of victim's drug history, hair analysis constitutes a useful tool. Nevertheless, in addition to usual limitations of hair result interpretation, there are additional pitfalls in post-mortem situations. This manuscript aims to address post-mortem hair analysis interpretation difficulties and proposals to overcome them. In post-mortem situations, mainly in cases of putrefaction, additional interpretation pitfalls are related to contamination issues consisting in drug incorporation into hair at the time of death (in case of intoxication and excessive sweating) and/or during the post-mortem period by putrefaction fluids. To overcome these issues, conventionally accepted criteria and considerations that must be taken into account encompass knowledge of death circumstances, confidence in analytical results, hair decontamination steps, segmental hair analysis, concentration consideration (values and hair concentration pattern), bath wash analysis results and observed parent drug/metabolites ratio. Nevertheless, none of these proposals is able to formally discriminate positive hair results related to intakes by the victim in the weeks or months before death, from hair contaminations (including those that occurred at the time of death and/or during the post-mortem period). A promising option could be to associate nails analysis to hair ones.

Landscape and Climatic Variations Shaped Secondary Contacts amid Barn Owls of the Western Palearctic.

The combined actions of climatic variations and landscape barriers shape the history of natural populations. When organisms follow their shifting niches, obstacles in the landscape can lead to the splitting of populations, on which evolution will then act independently. When two such populations are reunited, secondary contact occurs in a broad range of admixture patterns, from narrow hybrid zones to the complete dissolution of lineages. A previous study suggested that barn owls colonized the Western Palearctic after the last glaciation in a ring-like fashion around the Mediterranean Sea, and conjectured an admixture zone in the Balkans. Here, we take advantage of whole-genome sequences of 94 individuals across the Western Palearctic to reveal the complex history of the species in the region using observational and modeling approaches. Even though our results confirm that two distinct lineages colonized the region, one in Europe and one in the Levant, they suggest that it predates the last glaciation and identify a secondary contact zone between the two in Anatolia. We also show that barn owls recolonized Europe after the glaciation from two distinct glacial refugia: a previously identified western one in Iberia and a new eastern one in Italy. Both glacial lineages now communicate via eastern Europe, in a wide and permeable contact zone. This complex history of populations enlightens the taxonomy of Tyto alba in the region, highlights the key role played by mountain ranges and large water bodies as barriers and illustrates the power of population genomics in uncovering intricate demographic patterns.

Correlation of the Single-Assessment Numeric Evaluation (SANE) Score With Hip-Specific Patient-Reported Outcome Measures.

PURPOSE: The purpose of this study was to determine if the Single-Assessment Numeric Evaluation (SANE) score correlates with existing validated hip-specific patient-reported outcome measures (PROMs), including the Modified Harris Hip Score (mHHS), the International Hip Outcome Tool (IHOT-33), the Hip Outcome Score, Activities of Daily Living subscale (HOS-ADL), and the Hip Outcome Score, Sport-Specific subscale (HOS-SS), for patients preparing to undergo hip arthroscopy for treatment of femoroacetabular impingement syndrome (FAIS). METHODS: A single surgeon's operative database was retrospectively reviewed to identify patients undergoing primary hip arthroscopy for treatment of FAIS from April 2018 to October 2019. Patient-specific factors including age, sex, body mass index (BMI), and duration of symptoms were collected. Preoperative SANE, mHHS, IHOT-33, HOS-ADL, and HOS-SS scores were analyzed. Statistical analysis using Pearson correlation was performed to identify the relationship between the SANE score and the mHHS, IHOT-33, HOS-ADL, and HOS-SS, preoperatively. RESULTS: 154 patients were included in the study. The mean mHHS was 54.4 ± 11.7; mean IHOT-33 score was 32.7 ± 15.0; mean HOS-SS 42.9 ± 23.7; and mean HOS-ADL was 63.3 ± 1. The mean SANE score was 36.7 ± 19.9. The Simple Hip Score was directly correlated with the mHHS (P < .01), the IHOT-33 (P < .01); the HOS-ADL (P < .01), and the HOS-SS (P < .01). The mean patient age was 35.9 years; 109 (70.8%) were female and 45 (29.2%) were male. Average patient BMI was 26.9. At the time of patient completion of the questionnaire, the majority of patients (65%) had been having symptoms for >1 year. CONCLUSION: The SANE score was strongly correlated with mHHS, IHOT-33, HOS-ADL, and HOS-SS in the preoperative setting for patients undergoing hip arthroscopy for treatment of FAIS. Given its simplicity, SANE may be a valuable tool for rapid assessment of joint function and pain in this patient population. LEVEL OF EVIDENCE: IV, therapeutic case series.

Patient-specific factors are associated with severity of chondrolabral injury in patients with femoroacetabular impingement.

PURPOSE: The purpose of this study was to evaluate the relationship between patient-specific factors, preoperative radiographic findings, and the presence and severity of chondrolabral damage identified during hip arthroscopy for femoroacetabular impingement. METHODS: Between 2014 and 2017, patients who underwent hip arthroscopy for FAI and labral tear were retrospectively reviewed. Patient-specific variables including age, gender, BMI, LCEA, and alpha angle were collected. Surgical reports were reviewed for labral tear position and size, as well as severity of acetabular and femoral chondromalacia. RESULTS: There were 205 patients who met inclusion criteria with a mean age of 33 years (range 15-66), BMI 26.5 (range 15.9-44.5), LCEA 32.2° (range 21.0°-56.0°) and alpha angle 59.1° (range 33.0°-86.0°). Greater age (p = 0.023), alpha angle (p = 0.011) and male gender (p < 0.001) significantly correlated with high-grade acetabular chondral damage. Increased LCEA (p < 0.001), increased alpha angle (p = 0.012), and greater age (p = 0.002) were significantly associated with increased labral tear size. CONCLUSIONS: Greater age, male gender, increased BMI and increased alpha angle were associated with more advanced acetabular chondromalacia. Additionally, greater age, increased LCEA, and increased alpha angle was associated with larger labral tear size. LEVEL OF EVIDENCE: IV.

Para-acetabular Radiopaque Densities in Patients With Femoroacetabular Impingement: A Retrospective Assessment of Prevalence and Characteristics.

BACKGROUND: Femoroacetabular impingement (FAI) syndrome is a common source of hip pain associated with chondrolabral injury. There is a subset of patients with FAI syndrome who present with radiopaque densities (RODs) adjacent to the acetabular rim. PURPOSE: To evaluate the prevalence, characteristics, and patient-specific factors associated with RODs adjacent to the acetabulum in patients treated with hip arthroscopy for symptomatic FAI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between November 2014 and March 2018, a total of 296 patients who underwent hip arthroscopy for FAI with a labral tear were reviewed retrospectively. Patient-specific variables were collected, including age, sex, lateral center-edge angle (LCEA), and alpha angle. Imaging (computed tomography) and surgical reports were reviewed for the location and characteristics of RODs, as well as subsequent labral treatment technique. Patients were excluded if they were treated for extra-articular hip pathology, had a revision procedure, or had a diagnosis other than FAI with a labral tear. No patient was excluded for any history of systemic inflammatory disease. Binary logistic regression was used to compare age, LCEA, and alpha angle for patients with or without radiopaque fragments. An alpha level of 0.05 was used to indicate statistical significance. RESULTS: A total of 204 patients met inclusion criteria; 33 patients (16.2%; 16 males, 17 females) had para-acetabular RODs. There were no statistically significant differences in age (P = .82), sex (P = .92), LCEA (P = .24), or alpha angle (P = .10) among patients with or without an ROD. Of the 33 patients, 29 (87.9%) had fragments in the anterosuperior quadrant. Overall, 31 patients (93.9%) were treated with labral repair in addition to correction of the underlying bony impingement, while 2 patients (6.1%) underwent focal labral debridement owing to poor labral tissue quality around the RODs. Twenty-five patients (76%) had identifiable RODs, which were excised at the time of surgery. The mean (± SD) ROD size measured on axial and coronal computed tomography imaging was 6.3 ± 5.5 mm and 4 ± 4.5 mm, respectively. CONCLUSION: Age, sex, LCEA, and alpha angle were not predictive of the presence of para-acetabular RODs. Approximately one-sixth of all patients with FAI had RODs identified on computed tomography, which were typically located at the anterosuperior acetabulum. The majority of hips with para-acetabular RODs were amenable to labral repair. The relative prevalence and lack of predictive patient-specific indicators for these fragments suggest that a high degree of suspicion is necessary when evaluating patients with FAI.

Factors associated with high pain catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome.

The purpose of this study was to determine if physical, mental health and patient-specific factors are associated with increased Pain Catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Patients who underwent primary hip arthroscopy for FAIS were retrospectively analyzed. Patients were included if they completed a standard pre-operative questionnaire which included the Pain Catastrophizing Scale (PCS), VAS and 12-Item Short Form Survey (SF-12) Physical and Mental Composite Scores. Patient-specific variables including age, gender, BMI, tobacco use, number of allergies, pre-operative opioid use and diagnosis of depression or anxiety were recorded. Multiple linear regression was performed to assess for a relationship between physical and mental health scores, patient-specific variables, and a 'High Catastrophizing' PCS score. One-hundred and sixty-eight patients were included in this study. Patients with a PCS score of 22 or above were categorized as 'High Catastrophizing'. The variables included in the multiple linear regression model statistically significantly predicted high pain catastrophizing, F(10,149) = 4.75, P < 0.001, R 2 = 0.4. SF-12 Physical and Mental Composite Scores and a mental health illness diagnosis added statistically significantly to the prediction, P < 0.005. Pre-operative hip arthroscopy patients with better general physical and mental health, as measured by the SF-12, and those without mental health illness are less likely to having higher pain catastrophizing scores. Age, gender, BMI, visual analog pain scale (VAS), tobacco use, number of allergies and pre-operative opioid use were not independently associated with elevated pain catastrophizing scores. These findings may be helpful when interpreting PCS scores and counseling patients prior to arthroscopic hip surgery.

The Learning Curve in Hip Arthroscopy: Effect on Surgical Times in a Single-Surgeon Cohort.

PURPOSE: To quantify the effect of the learning curve in performing hip arthroscopy for femoroacetabular impingement (FAI) and labral tears on total operating room time, including times for setup, surgery, and wake up, during a single surgeon's initial hip arthroscopy procedures. METHODS: A single surgeon's case list was retrospectively reviewed to identify all primary hip arthroscopy surgeries between November 1, 2018, and February 28, 2018, for the treatment of FAI and labral tears. Surgical times were recorded, including total room time; surgical time; setup time; and wake-up time. Linear regression was used to evaluate the relationship of these times relative to case number in the series. In addition, the series was divided into 3 sequential groups to further compare these times. RESULTS: In total, 225 patients were included in the study. The mean total room time for all cases was 155.4 minutes, 95% confidence interval ([CI] 150.9-160.0); mean surgical time was 115.6 minutes (95% CI 111.5-119.8), and mean setup time was 32.6 minutes (95% CI 31.8-33.4). Decreasing surgical time was associated with advancing number in the case series (P < .001, R2 = 0.36). Decreasing total room time was accordingly associated with advancing number in the case series (P < .001, R2 = 0.34). There were no significant differences in setup time and wake-up time as the case series advanced. When groups of 75 sequential cases were compared, significant decreases in surgical and total room time were noted between the first and second groups (P < .001) but not between the second and third groups (P = .52). Increasing complexity of surgeries was noted as the series advanced, including capsular closure and subspine decompression. CONCLUSIONS: This study supports the existence of a substantial learning curve for hip arthroscopy in the treatment of FAI and labral tears. Our findings suggest decreasing surgical time as the surgeon advances through the learning curve, with the initial 75 procedures requiring longer time to perform than subsequent cases. CLINICAL RELEVANCE: Hip arthroscopy is a technically demanding procedure. Understanding the long duration of the hip arthroscopy learning curve is helpful for surgeons considering the addition of hip arthroscopy to their practice.

Acetabular Subchondral and Cortical Perforation During Labral Repair With Suture Anchors: Influence of Portal Location, Curved Versus Straight Drill Guides, and Drill Starting Point.

PURPOSE: To evaluate the impact of the portal used for drilling, the position of the drill guide on the acetabular rim, and the use of straight versus curved drill guides on drill perforation of the acetabular subchondral bone and the outer cortex of the acetabulum. METHODS: Sixty acetabular models were marked at the 3-, 2-, 1-, 12-, and 11-o'clock positions. Simulated anterior, anterolateral, and distal anterolateral accessory (DALA) portals were created. Twelve groups of 5 acetabula were drilled at each clock-face position using all combinations of variables. RESULTS: A total of 38 of 300 drillings (12.7%) perforated the subchondral bone, and 45 of 300 (15%) breached the outer cortex. Drilling from the anterior, anterolateral, and DALA portals perforated the acetabular subchondral bone on 21 of 100 attempts (21%), 17 of 100 attempts (17%), and 0 of 100 attempts (0%), respectively (P < .001), and perforated the outer acetabular cortex on 36 of 100 attempts (36%), 1 of 100 attempts (1%), and 8 of 100 attempts (8%), respectively (P < .001). The use of a curved or straight drill guide did not make a statistically significant difference. Drilling with a starting point on the acetabular rim perforated the acetabular subchondral bone on 29 of 150 attempts (19.3%) compared with 9 of 150 attempts (6%) when the starting point was 2 mm removed from the acetabular rim (P < .001). CONCLUSIONS: The use of the DALA portal and a drill starting point slightly off the acetabular rim was associated with the lowest rate of acetabular subchondral perforation and is recommended to reduce the risk of iatrogenic chondral injury. CLINICAL RELEVANCE: Iatrogenic chondral injury is a relatively common complication of hip arthroscopy. Increased awareness of factors associated with drill perforation during suture anchor placement can help surgeons mitigate this risk.

Joint Space Narrowing in Patients with Femoroacetabular Impingement: A Matched Cohort Study of Military versus Civilian Patients.

INTRODUCTION: Decreased hip joint space has been associated with poorer outcomes after hip arthroscopy. The purpose of this study was to determine if a difference exists in hip joint degenerative findings in military versus civilian patients with FAI. METHODS: A single surgeon's case series was reviewed to identify all patients undergoing primary hip arthroscopy for treatment of FAI. All active duty military personnel were included in the study group. A cohort of civilian patients matched for age, gender, lateral center edge (LCE) angle, and alpha angle was identified and included as the control group. The hip joint space was measured at the medial and lateral extents of the acetabular sourcil and the center of the sourcil. The Tonnis grade for osteoarthritis was recorded for each patient. Labral tear size as well as femoral head and acetabular chondromalacia grading were obtained from operative records. RESULTS: A total of 229 patients that underwent primary hip arthroscopy for FAI were identified. 46(20.1%) were active duty military personnel. A well-matched cohort of 46 civilian patients was identified. There was no statistical difference in age (35.0, 34.7 years), gender (31 males, 15 females in both groups), BMI (26.8, 27.6), LCE angle (31.0, 31.5), and alpha angle (64.9, 64.9) between the civilian and military groups. Joint space was narrower in the military group in each of the three measured locations (Superomedial 3.8 mm vs 4.2 mm, p = 0.025; Superior 4.0 mm vs 4.4 mm, p = 0.013; Superolateral 4.4 mm vs 4.9 mm, p = 0.043). CONCLUSION: Military patients with FAI may have increased joint space narrowing compared to otherwise similar civilian patients. Femoral and acetabular chondromalacia are found in similar frequencies in military and civilian populations, however the grading system utilized accounts for the presence but not the size of high grade lesions. LEVEL OF EVIDENCE: Level 3.

Brachial distal biceps injuries.

Distal biceps injuries are a relatively uncommon clinical condition that typically affect middle-aged males. They commonly occur due to an eccentric overload as the arm is forced from a flexed to extended position. Patients may experience an acute 'pop' and present with arm pain, swelling, and ecchymosis. Treatment options include nonoperative management or surgical repair. The aim of this concise review of distal biceps ruptures is to examine the relevant anatomy, clinical evaluation, diagnosis, and treatment options for these injuries.

Accuracy and Reliability of a Simple Calculation for Measuring Glenoid Bone Loss on 3-Dimensional Computed Tomography Scans.

PURPOSE: To establish the accuracy and reliability of the circle-line method (CLM) of measuring glenoid bone loss; to compare the CLM calculation with a traditionally used method of calculating a ratio; and to evaluate surgeons' ability to estimate the amount of glenoid bone loss before performing any calculations. METHODS: Three-dimensional reconstructions of computed tomography scans of consecutive patients with anterior instability and glenoid bone loss were reviewed by 13 surgeons blinded to the diagnosis. The reviewers made estimations of bone loss before creating any measurements by viewing the available computed tomography scan as well as the 3-dimensional reconstructions. They selected an en face view of the glenoid to create a best-fit circle. Bone loss calculation with a traditional linear method as well as a CLM calculated by algebraic geometry was completed. The CLM requires calculation of the diameter of a best-fit circle on the glenoid, as well as the length of a single line along the circle representing the line of bone loss. All methods were compared with a computerized method of tracing the area of the glenoid within a best-fit circle. Interobserver and intraobserver calculations were performed. Analysis-of-variance testing was used to compare the estimates of bone loss versus the CLM-calculated bone loss. Tukey post hoc analysis was used to define the accuracy of the CLM calculation compared with a more traditional method of calculating bone loss. RESULTS: Bone loss estimations were significantly different from CLM-calculated bone loss in all cases except those with greater than 25% bone loss. The CLM was more accurate in all types of bone loss except cases of greater than 25% bone loss. Interobserver reliability was very good for the glenoid diameter measurement and moderate for the CLM. Intraobserver reliability ranged from moderate to good for all methods of measurement. CONCLUSIONS: Surgeon estimations of glenoid bone loss, as well as traditional line-measurement calculations, are inconsistent and unreliable for accurate determination of the optimal surgical treatment for anterior shoulder instability. The CLM is a simple, reproducible, and accurate method for determining glenoid bone loss and does not require specialized software or imaging protocols. LEVEL OF EVIDENCE: Level II, diagnostic study.

Traditional Versus Congruent Arc Latarjet Technique: Effect on Surface Area for Union and Bone Width Surrounding Screws.

PURPOSE: To compare the surface area available for bony contact and the width of bone on each side of the Latarjet fixation screws in the traditional Latarjet technique versus the congruent arc modification of the Latarjet technique. METHODS: Computed tomographic scans of 24 shoulders in patients with glenohumeral instability who underwent multiplanar reconstruction measurements with multiple dimensions of the coracoid. The surface area of the coracoid available for bony contact with the anterior glenoid and width of bone on each side of a 3.5-mm screw was compared for the traditional Latarjet technique versus the congruent arc modification. RESULTS: The surface area available for bony contact to the anterior glenoid was 5.65 ± 1.08 cm2 using the traditional Latarjet technique compared with 3.64 ± 0.93 cm2 using the congruent arc modification of the Latarjet technique (P < .001). The mean width of bone on each side of a 3.5-mm screw was 7.1 ± 1.0 mm using the traditional Latarjet technique compared with 4.1 ± 1.0 mm using the congruent arc modification (P < .001). CONCLUSIONS: The traditional Latarjet technique has greater bony contact with the glenoid and greater bone width on each side of the screws compared with the congruent arc modification of the Latarjet technique. This potentially allows for a larger surface for healing in the traditional Latarjet technique. Moreover, because of smaller width of the bone around the screw, the congruent arc modification is potentially less tolerant of screw-positioning error compared with the traditional Latarjet technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparison of Glenoid Version and Posterior Humeral Subluxation in Patients With and Without Posterior Shoulder Instability.

PURPOSE: To evaluate glenoid version and humeral subluxation on preoperative multiplanar imaging of patients who underwent surgery for posterior glenohumeral instability compared with a matched group of patients who had shoulder surgery for other pathology. METHODS: All patients over a 2-year period who underwent surgery for posterior instability had preoperative magnetic resonance (MR) imaging or MR arthrogram reviewed. Patients undergoing shoulder surgery for reasons other than instability were identified as a control group and matched by sex, laterality, and age. Measurement of glenoid version and percentage of humeral subluxation was performed by 2 reviewers after completing a tutorial. Reviewers were blinded to diagnosis and to whether or not the patients were in the experimental or control group. RESULTS: There were 41 patients in each group. The average glenoid version in the control group was 5.6° of retroversion (standard deviation [SD] 3.0), and the average humeral subluxation was 54% (SD 5.1%). In the experimental group, the average glenoid version was 8.1° of retroversion (SD 5.0). The average humeral subluxation in the experimental group was 56% (SD 6.8%). Student t test revealed a statistically significant difference in glenoid version (P = .009) but not humeral subluxation (P = .25). Intra- and inter-rater reliability was measured by the intraclass correlation coefficient and found to have an excellent Fleiss rating with regard to both measurements. CONCLUSIONS: Glenoid retroversion is significantly increased in patients with symptomatic posterior labral tears compared with a control group. However, there was no statistically significant difference between the groups with regard to posterior humeral subluxation and, therefore, is not a reliable indicator of the presence or absence of symptomatic posterior shoulder instability. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Hip Instability: Current Concepts and Treatment Options.

Instability of the hip can manifest in a wide range of settings, with presenting symptoms including subtle discomfort at end range of motion or more dramatic dislocation of the joint. It can result from traumatic injury with dislocation or subluxation; atraumatic capsular laxity; structural bony abnormality, such as acetabular dysplasia; and iatrogenic injury. Initial treatment of the concentrically reduced joint often begins with physical therapy to strengthen dynamic stabilizers and to allow time for resolution of acute symptoms. Surgical treatment is aimed at repairing injured soft tissue structures, including static stabilizers, and addressing underlying bony structural deficiencies.