The Air-Lift Technique for Improving Ease and Safety When Establishing the Modified Midanterior Portal in Hip Arthroscopy.

Hip arthroscopy continues to increase in popularity and has an ever-expanding range of indications; however, the steep learning curve introduces significant risk of iatrogenic chondrolabral injury when accessing the joint and establishing arthroscopic portals. This article presents a technique for establishing the modified midanterior portal and is particularly useful when the available space is tight. We present "the air-lift" as a safe and simple adjunct to standard portal creation when performing hip arthroscopy in the supine position.

Proximal Anterolateral Accessory Portal Use Improves Peripheral Compartment Access and Capsular Management with T-Capsulotomy.

One of the primary goals of hip arthroscopy for femoroacetabular impingement (FAI) syndrome is precise removal of pathologic FAI morphology while protecting and restoring the normal soft tissue anatomy. Adequate visualization is a key foundation of precise removal of FAI morphology and varying types of capsulotomies are frequently used to achieve necessary exposure. Anatomic and outcomes studies have influenced an increasing appreciation for repairing these capsulotomies. Thus one of the central technical challenges of hip arthroscopy is achieving both goals of capsule preservation and adequate visualization. Various techniques have been described, including suture-based capsule suspension, portal placement, and T-capsulotomy. The following technique describes how the proximal anterolateral accessory portal can be added to a capsule suspension and T-capsulotomy technique to improve visualization and facilitate repair.

Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison With the Transtibial and Anteromedial Portal Techniques.

BACKGROUND: Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most commonly used technique for pubescent patients. The transtibial (TT) drilling technique creates vertical and central femoral tunnels to minimize the physeal area of injury at the expense of a nonanatomic femoral tunnel. The hybrid TT (HTT) technique offers the potential of an anatomic femoral position with tunnel geometry similar to that using the TT technique. PURPOSE/HYPOTHESIS: The purpose was to perform a radiographic comparison of the HTT technique with TT and anteromedial portal (AM) techniques in adolescent patients undergoing transphyseal ACL reconstruction. It was hypothesized that femoral tunnels created during HTT would be similar to TT tunnels but significantly more vertical and central than AM tunnels. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively screened primary transphyseal ACL reconstructions performed in adolescents at our institution between 2013 and 2019. The youngest 20 eligible patients were selected from each technique cohort: TT, AM, and HTT. Postoperative radiographs were assessed for the coronal femoral tunnel angle, as well as the location of the tunnel-physis penetration on the anteroposterior and lateral views. Physeal lesion surface area was calculated. Data were compared among the 3 groups using 1-way analysis of variance followed by pairwise comparisons. RESULTS: Included were 47 patients with a mean ± SD age of 14.3 ± 1.2 years (n = 9 with TT, 18 with AM, and 20 with HTT techniques). The coronal tunnel angle was significantly more vertical in the TT (60.7° ± 7.2°) and HTT (54.4° ± 5.7) groups as compared with the AM group (48.8° ± 5.9; P = .0037 and P = .02, respectively). There was no significant difference between the TT and HTT groups (P = .066). The only significant finding regarding femoral tunnel location was that the HTT tunnels (28.9% ± 4.8%) penetrated the physis more centrally than did the AM tunnels (20.0% ± 5.1%; P = .00002) on lateral radiographs. CONCLUSION: The HTT technique presents an option for transphyseal ACL reconstruction, with femoral tunnel obliquity and estimated physeal disruption similar to that of the TT technique and significantly less than that of the AM technique. The HTT technique also results in the most central physeal perforation of all techniques, predominantly in the sagittal plane.

Synovial Cell Count Poorly Predicts Septic Arthritis in the Presence of Crystalline Arthropathy.

Introduction: A synovial cell count greater than 50,000/mm3 is the threshold most commonly used to diagnose septic arthritis. This lab value may be nonspecific in the setting of crystalline arthropathy. The purpose of this study was to evaluate the accuracy of diagnosing septic arthritis using a synovial cell count cut-off of 50,000/mm3 in the setting of crystalline arthropathy. Methods: This was a retrospective review of joint aspirations performed between July 1st, 2013 and June 30th, 2016. Synovial fluid samples were evaluated for cell count, crystals, Gram stain, and culture. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the synovial markers were calculated. Results: During the study period, 738 joint aspirations were sent for testing, of which 358 aspirations in 348 patients met inclusion criteria. There were 49 (13.7%) cases of culture-positive septic arthritis, and 47 patients underwent surgical irrigation and debridement. Gout and pseudogout crystals were present in 163 aspirates (45.5%). Three joints (0.8% overall rate) had concomitant crystalline arthropathy and septic arthritis, each of which had a synovial WBC ≥85,000/mm3. Increasing the WBC count cutoff to 85,000/mm3 demonstrated a specificity of 100%, but a PPV of 12.0%. Conclusions: A cut-off of 85,000/mm3 may be more appropriate to diagnose concomitant septic arthritis and crystalline arthropathy. We recommend medical management and observation in patients with crystal-positive joint aspirations unless the synovial cell count is elevated above 85,000/mm3. Prospective studies using this treatment guideline are needed to evaluate its validity and accuracy.

Editorial Commentary: Stump Sparing or Footprint Exposing? Management of the Tibial Remnant During Posterior Cruciate Ligament Reconstruction.

Surgical management of an isolated grade III posterior cruciate ligament tear has been enveloped in debate since the first reconstruction technique report was written by Hey Groves in 1919. With the evolution of arthroscopy, party lines have been drawn over tibial inlay versus transtibial techniques, as well as single- versus double-bundle techniques. More subtle controversy exists regarding autograft versus allograft, outside-in versus inside-out drilling, and treatment of the tibial footprint of the posterior cruciate ligament. New remnant-sparing techniques, using a trans-septal posterior portal, may augment biology, maintain better proprioception, and mitigate abrasive wear at the "killer turn." However, longer-term comparative studies will be necessary to determine the existence of any clinically significant improvement in outcome.

Is Acromioplasty Ever Indicated During Rotator Cuff Repair?

Based on data from a national healthcare insurance carrier in the United States between 2010 and 2012, orthopedic surgeons performed an acromioplasty procedure on 73 to 76% of their arthroscopic rotator cuff repairs. This has remained a prevalent arthroscopic adjunct despite the controversies disputing the role and etiology of external impingement on symptomatic rotator cuff disease. Within the past decade, several randomized studies have demonstrated negligible benefits with acromioplasty performed alongside rotator cuff repair, with no significant differences in either patient-reported outcome scores or retear rates). Conversely, other authors have suggested higher rates of reoperation with rotator cuff repair alone. Critical shoulder angle, an objective measure of lateral acromion extension and glenoid inclination that is considered a gauge of external impingement, has demonstrated an association with rotator cuff tears; Despite this, patient-reported outcomes do not consistently correlate with critical shoulder angle or other variants in acromial morphology after arthroscopic full-thickness rotator cuff repair. Evidenced-based data is currently lacking to support routine use of acromioplasty in all cases of rotator cuff repair. However, the current available studies do present design flaws, namely statistical underpowering, particularly in type III acromion morphology; inadequate short-term follow-up; lack of imaging data to assess cuff healing; and insensitive outcome measures to capture the theorized benefits of subacromial decompression. Additionally, several relevant merits of acromioplasty have been reported, including decreased abrasive wear with prominent type III acromial morphology, release of natural growth factors to improve rotator cuff healing, and improved visualization during rotator cuff repair. Further evaluation is needed to determine the correct indications for acromioplasty in the setting of cuff repair. Current data would indicate that acromioplasty can be used safely at the discretion of the operating surgeon based on preoperative and intraoperative findings.