Editorial Commentary: Osteochodral Autograft and Allograft Show Favorable Outcomes for High-Grade Hip Femoral Cartilage Lesions, but Caution Is Required for Impaction Injuries and Osteonecrosis.

Articular cartilage defects of the hip pose therapeutic challenges. Among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome, more than 20% may have partial- or full-thickness chondral damage, and patients with high-grade (International Cartilage Repair Society grade 3 or 4) damage who undergo arthroscopic treatment of femoroacetabular impingement syndrome have higher rates of reoperation at 10-year follow-up. Arthroscopic and open techniques have been developed to translate cartilage restoration options initially developed in the knee for use in the hip. Arthroscopic options include chondroplasty, microfracture, biologic cartilage scaffolds, autologous chondrocyte implantation, and minced cartilage autograft (albeit more commonly in the acetabulum than the femoral head). Open techniques include autologous chondrocyte grafting, osteochondral autograft transfer (including mosaicplasty), osteochondral allograft transplantation, and arthroplasty. Open osteochondral allograft and autograft transplantation show improved patient-reported outcomes and forestall arthroplasty in young patients with high-grade cartilage defects of the femoral head. A recent review shows survivorship of 70% to 87.5% for allograft and 61.5% to 96% for autograft. At the same time, outcomes are not universally positive, particularly for patients with posttraumatic impaction injuries and high-grade osteonecrosis. Until further data better clarify the indications and contraindications, widespread adoption of open cartilage transplantation to the femoral head should be approached with caution, especially for older patients, in whom the gold standard of total hip arthroplasty has excellent survivorship at long-term follow-up.

Batter's Shoulder: All-Knotless Posterior Labral Repair With Retensionable Anchors for Treatment of Batter's Shoulder.

Batter's Shoulder is a unique injury that may be associated with recurrent microtrauma followed by acute subluxation of the humeral head on the posterior glenoid edge, leading to posterior labral tears. Early identification of this injury is critical, as it may be treated with conservative nonsurgical treatments prior to labral tear onset. If conservative treatment fails and pain persists, surgical options include arthroscopic fixation to reapproximate the posterior labrum to the glenoid and restore capsular tension. Previous studies have shown the benefit of using knotless suture anchors in arthroscopic shoulder fixation. This technical note demonstrates that Batter's Shoulder is a unique injury associated with posterior labral tears of the shoulder and provides a contemporary method of arthroscopic fixation of a posterior labral tear using retensionable knotless all-suture anchors.

Primary follicular lymphoma of the prostate co-existing with grade group 5 prostatic adenocarcinoma and presenting as a PI-RADS lesion 4 on mpMRI.

Primary prostatic lymphoma is an exceedingly rare entity comprising less than 0.09% of all prostatic cancers with follicular lymphoma making up only 12% as a subset. To our knowledge, primary follicular lymphoma co-existing with high grade prostatic adenocarcinoma presenting as a PI-RADS lesion 4 on mpMRI has not been previously described. We report the case of a 73-year-old male who presented with mildly elevated PSA and lower urinary tract symptoms. Prostate needle biopsy revealed low grade follicular lymphoma juxtaposed with high grade prostatic adenocarcinoma. The patient has been treated with radiation therapy for adenocarcinoma and is under observation for lymphoma progression.

Adding Lateral Retinacular Release to Medial Patellofemoral Ligament Reconstruction Fails to Demonstrate Clinical Benefit Compared With Isolated Medial Patellofemoral Ligament Reconstruction.

Purpose: To compare functional outcomes and failure rates between medial patellofemoral ligament (MPFL) reconstructions with and without lateral retinacular release (LRR) at minimum 1-year follow up. Methods: A retrospective review identified consecutive patients from 2013 to 2019 at a single center who met all of the following inclusion criteria: at least 1 confirmed patellar dislocation, patellar tilt (evidenced by tight retinaculum on operative examination or patellar tilt on radiographs), underwent either MPFL reconstruction alone or combined with LRR, had available preoperative documentation and imaging, and were at least 1 year out of surgery. Patients were excluded if they had previous surgery to the ipsilateral limb or had any concomitant procedure performed. Demographics and preoperative imaging were evaluated. Failure rates and functional outcome scores were obtained including Kujala, Patient-Reported Outcomes Measurement Information System, International Knee Documentation Committee, Single Assessment Numeric Evaluation, and Knee injury and Osteoarthritis Outcome Scores. Clinical failure was defined as revision MPFL reconstruction on the affected knee or at least 1 instance of postoperative patellar dislocation. Results: A total of 18 patients underwent isolated MPFL reconstruction (mean follow-up = 29.3 ± 8.3 months, range = 15.1-42.8 months), and 31 underwent MPFL reconstruction combined with LRR (mean follow up = 36.0 ± 11.3 months, range = 14.0-51.9 months). At final follow-up, there were no statistical differences between the isolated MPFL and MPFL combined with LRR cohorts for any of the functional outcome scores (P > .05 for all). At the time of final follow-up, no patients who underwent isolated MPFL and 19.3% (n = 6) or patients undergoing MPFL combined with LRR experienced clinical failure (P = .073), as defined by subsequent patellar dislocation or revision MPFL reconstruction. Of these, 2 patients underwent revision MPFL reconstructions with distal tubercle transfer for borderline abnormal TT:TG (i.e., >15 mm). Conclusions: MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up. In addition, there were no differences in rates of achieving MCID between both groups. Level of Evidence: Level III, retrospective cohort study.

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol.

Purpose: To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery. Methods: This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM. Results: The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function. Conclusions: No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery. Level of Evidence: Level III, retrospective comparative study.

Evaluation of Mid-term Outcomes Following Shoulder Hemiarthroplasty for Avascular Necrosis of the Humeral Head in Patients 40 Years and Younger.

In order to evaluate postoperative function and failure rates among younger patients undergoing hemiarthroplasty for humeral head avascular necrosis (AVN), data from patients < 40 years treated between December 2008 - January 2018 was retrospectively analyzed. Pain was assessed preoperatively and at final follow up using a visual analogue scale (VAS). The American Shoulder and Elbow Surgeons (ASES) standardized assessment, single assessment numeric evaluation (SANE) score, and patient satisfaction were assessed at final follow up, as well as surgical revision rates. In total, eight shoulders were included in the final analysis, with a follow up of 6.6 + 3.6 years. Analysis indicated a statistical improvement in VAS pain (p = 0.001), while comparison of postoperative function between surgical and non-surgical limbs did not demonstrate statistical differences in SANE or ASES averages (p > 0.05). At final follow up, 25% of patients expressed dissatisfaction; however, there were no cases of revision surgery. In conclusion, younger patients undergoing hemiarthroplasty for humeral head AVN experienced pain improvement and no revisions at short-to-mid-term follow up, but one-in-four indicated dissatisfaction. Level of evidence: IV, case series. (Journal of Surgical Orthopaedic Advances 32(2):118-121, 2023).

Editorial Commentary: Legacy Patient-Reported Outcome Measures Are Superior to Patient-Reported Outcomes Measurement Information System for Assessing Function After Hip Arthroscopy.

Patient-reported outcome measures (PROMs) are critical tools in hip preservation research for evaluating the efficacy of current treatments, as well as identifying risk factors associated with suboptimal outcomes. These measures have been used for quality improvement, for monitoring of health plan performance, and even for reimbursement models. Over the past 2 decades, legacy hip outcome scores have been developed that are patient-centric and evaluate hip-specific function after surgery. There has been a recent trend in using the Patient-Reported Outcomes Measurement Information System (PROMIS), a tool developed by the National Institutes of Health for evaluating PROMs, in the field of hip arthroscopy. However, on the basis of the evidence in the literature, it is unlikely that PROMIS is superior to legacy PROMs regarding evaluation of hip function, nor is it as responsive to quantifying meaningful changes in function that are important to patients. As such, clinicians and researchers alike should likely continue using legacy PROMs to evaluate patients' functional outcomes after hip arthroscopy while continuing to explore the clinical applications of other PROMIS domains.

Patient-Reported Outcomes and Reoperation Rates Following Lumbar Tubular Microdecompression: Six-year Follow-Up.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To report reoperation rates after lumbar tubular microdecompression (LTM) and to compare patient-reported outcomes (PROs) six years after surgery between those who did and did not need revision at the index level. SUMMARY OF BACKGROUND DATA: Long-term data describing PROs and reoperation rates after LTMs are lacking. MATERIALS AND METHODS: Patients with lumbar spinal stenosis underwent one or more of three LTM procedures. Demographic, PROs [Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain], and reoperation data were collected. Failure of an index LTM was defined as any revision surgery at the index level. Revision LTM at a different level was not considered failure. Failure and revision LTM incidence at a different level and cumulative incidence were prospectively collected up to six years. Mixed effects linear regressions with 95% CIs were performed to assess potential differences in ODI and reported VAS back and leg pain between patients that reported failure and those that did not. RESULTS: A total of 418 patients were included with median follow-up of 3.0 (1.9, 4.1) years. In all, 25% had a reoperation by six years. Sixty-five (16%) failed and 35 (9%) underwent a second LTM at another level. Cumulative failure incidence was 9% within the first two years. Failure patients had a statistically higher ODI [12.1 (95% CI, 3.2, 20.1) and VAS back [2.3 (95% CI, 0.9, 3.8)] and leg pain [1.6 (95% CI, 0.2, 3.1)] throughout follow-up. The overall dural tear rate was 7.2%. CONCLUSIONS: LTM is an effective treatment for lumbar spinal stenosis with sustained six-year PROs. Most failures occur within two years postoperatively and stabilize to 4% yearly incidence by year 5. The yearly incidence of reoperation with LTM stabilizes at 3% by year 6 postoperatively. LEVEL OF EVIDENCE: 2.

Senior Military Rank Is Associated With Higher Rates of Return to Running and Unrestricted Activity Among Military Servicemembers After Surgical Repair of Patellar Tendon Rupture at 1-Year Follow-up.

Purpose: To evaluate 1-year outcomes in active-duty servicemembers who underwent patellar tendon rupture repair and to identify baseline variables associated with return to activity. Methods: We performed a retrospective review of all active-duty servicemembers undergoing primary patellar tendon rupture repair between 2009 and 2014. All patients had a minimum 12-month follow-up. Demographic variables were recorded, as well as ability to return to impact activities and remain on active-duty status. Rates of recurrent rupture and revision surgery were identified. Univariate analysis was performed to assess relations between outcomes and baseline variables. Results: A total of 123 patients met the inclusion criteria (average age, 33.5 ± 6.6 years; 99% male patients) with a mean follow-up period of 4.3 ± 2.2 years. Whereas 67.4% of patients returned to running at an average of 8.3 months from index surgery, only 42.4% of patients resumed unrestricted occupational function. Higher rates of return to running were observed among patients with senior military rank (P = .046). Senior military rank was also associated with a higher rate of return to unrestricted active-duty status (P = .006). Logistic regression analysis showed an association between postoperative pain (odds ratio [OR], 0.684; 95% confidence interval [CI], 0.56-0.84; P < .001) and return to running, between postoperative pain (OR, 0.77; 95% CI, 0.60-0.98; P = .033) and return to active duty, and between rank (OR, 2.06; 95% CI, 1.04-4.07; P = .037) and return to active duty. Patients who sustained injuries during deployment had a higher rate of recurrent rupture (26.1% vs 9.3%, P = .028). Conclusions: At 1-year follow-up, approximately two-thirds of military servicemembers undergoing primary patellar tendon repair had returned to running after surgery, whereas fewer than one-half returned to full military duty. Younger age and more senior military rank were associated with higher rates of return to running. Additionally, servicemembers of higher rank, particularly officers, had statistically higher rates of return to unrestricted activity. Level of Evidence: Level IV, therapeutic case series.

Prediction of Admission Costs Following Anterior Cervical Discectomy and Fusion Utilizing Machine Learning.

STUDY DESIGN: Retrospective case series. OBJECTIVE: Predict cost following anterior cervical discectomy and fusion (ACDF) within the 90-day global period using machine learning models. BACKGROUND: The incidence of ACDF has been increasing with a disproportionate decrease in reimbursement. As bundled payment models become common, it is imperative to identify factors that impact the cost of care. MATERIALS AND METHODS: The Nationwide Readmissions Database (NRD) was accessed in 2018 for all primary ACDFs by the International Classification of Diseases 10th Revision (ICD-10) procedure codes. Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics, such as volume of procedures performed and wage index, were also queried. Readmissions within 90 days were identified, and cost of readmissions was added to the total admission cost to represent the 90-day healthcare cost. Machine learning algorithms were used to predict patients with 90-day admission costs >1 SD from the mean. RESULTS: There were 42,485 procedures included in this investigation with an average age of 57.7±12.3 years with 50.6% males. The average cost of the operative admission was $24,874±25,610, the average cost of readmission was $25,371±11,476, and the average total cost was $26,977±28,947 including readmissions costs. There were 10,624 patients who were categorized as high cost. Wage index, hospital volume, age, and diagnosis-related group severity were most correlated with the total cost of care. Gradient boosting trees algorithm was most predictive of the total cost of care (area under the curve=0.86). CONCLUSIONS: Bundled payment models utilize wage index and diagnosis-related groups to determine reimbursement of ACDF. However, machine learning algorithms identified additional variables, such as hospital volume, readmission, and patient age, that are also important for determining the cost of care. Machine learning can improve cost-effectiveness and reduce the financial burden placed upon physicians and hospitals by implementing patient-specific reimbursement.

Evaluation of additional causes of hip pain in patients with femoroacetabular impingement syndrome.

Femoroacetabular impingement syndrome (FAIS) is an increasingly prevalent pathology in young and active patients, that has contributing factors from both abnormal hip morphology as well as abnormal hip motion. Disease progression can be detrimental to patient quality of life in the short term, from limitations on sport and activity, as well as the long term through early onset of hip arthritis. However, several concurrent or contributing pathologies may exist that exacerbate hip pain and are not addressed by arthroscopic intervention of cam and pincer morphologies. Lumbopelvic stiffness, for instance, places increased stress on the hip to achieve necessary flexion. Pathology at the pubic symphysis and sacroiliac joint may exist concurrently to FAIS through aberrant muscle forces. Additionally, both femoral and acetabular retro- or anteversion may contribute to impingement not associated with traditional cam/pincer lesions. Finally, microinstability of the hip from either osseous or capsuloligamentous pathology is increasingly being recognized as a source of hip pain. The present review investigates the pathophysiology and evaluation of alternate causes of hip pain in FAIS that must be evaluated to optimize patient outcomes.

Prediction of total healthcare cost following total shoulder arthroplasty utilizing machine learning.

BACKGROUND: Given the increase in demand in treatment of glenohumeral arthritis with anatomic total (aTSA) and reverse shoulder arthroplasty (RTSA), it is imperative to improve quality of patient care while controlling costs as private and federal insurers continue its gradual transition toward bundled payment models. Big data analytics with machine learning shows promise in predicting health care costs. This is significant as cost prediction may help control cost by enabling health care systems to appropriately allocate resources that help mitigate the cause of increased cost. METHODS: The Nationwide Readmissions Database (NRD) was accessed in 2018. The database was queried for all primary aTSA and RTSA by International Classification of Diseases, Tenth Revision (ICD-10) procedure codes: 0RRJ0JZ and 0RRK0JZ for aTSA and 0RRK00Z and 0RRJ00Z for RTSA. Procedures were categorized by diagnoses: osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN), fracture, and rotator cuff arthropathy (RCA). Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics were included, such as volume of procedures performed by the respective hospital for the calendar year and wage index, which represents the relative average hospital wage for the respective geographic area. Unplanned readmissions within 90 days were calculated using unique patient identifiers, and cost of readmissions was added to the total admission cost to represent the short-term perioperative health care cost. Machine learning algorithms were used to predict patients with immediate postoperative admission costs greater than 1 standard deviation from the mean, and readmissions. RESULTS: A total of 49,354 patients were isolated for analysis, with an average patient age of 69.9 ± 9.6 years. The average perioperative cost of care was $18,843 ± $10,165. In total, there were 4279 all-cause readmissions, resulting in an average cost of $13,871.00 ± $14,301.06 per readmission. Wage index, hospital volume, patient age, readmissions, and diagnosis-related group severity were the factors most correlated with the total cost of care. The logistic regression and random forest algorithms were equivalent in predicting the total cost of care (area under the receiver operating characteristic curve = 0.83). CONCLUSION: After shoulder arthroplasty, there is significant variability in cumulative hospital costs, and this is largely affected by readmissions. Hospital characteristics, such as geographic area and volume, are key determinants of overall health care cost. When accounting for this, machine learning algorithms may predict cases with high likelihood of increased resource utilization and/or readmission.

The Effect of State-Level Prescription Opioid Legislation on Patient Outcomes After Lumbar Tubular Microdecompression.

BACKGROUND: In the United States, a statewide legislation titled the Strengthen Opioid Misuse Prevention (STOP) Act was enacted in 2017 to limit prescription opioid use and reduce dependence. The impact of state legislation curbing opioid prescription on outcomes after spine surgery is unknown. STUDY DESIGN: Case series. METHODS: Data from consecutive patients undergoing lumbar tubular microdecompression for symptomatic lumbar spine stenosis from June 2016 to June 2019 were retrospectively analyzed. Cases between June 2016 and December 2017 represent the group before the STOP act (pre-STOP), while cases between January 2018 and June 2019 represent the group after legislation enactment (post-STOP). Preoperative and postoperative patient functional scores including the EuroQol-Five Dimensions Index, Oswestry Disability Index (ODI), and the visual analog scale (VAS) for back and leg pain were compared between both groups. The meaningful clinically important difference (MCID) was calculated for each score and was compared between both groups as well. RESULTS: A total of 147 patients met inclusion criteria, with 86 in the pre-STOP group and 61 in the post-STOP group. Analysis of postoperative scores demonstrated statistically lower VAS leg pain score averages in the post-STOP group (P < 0.05). Higher trends in achieving MCID among the post-STOP group were observed; however, the differences between both groups were not statistically significant (P > 0.05 for all). Additionally, there were no statistical differences in rates of unplanned pain-related clinic visits and emergency department (ED) visits, as well as no differences in the number of pain-related calls within 90 days after surgery between both groups. CONCLUSION: The enactment of state legislation to curb the prescribing of opioids for postoperative pain did not negatively affect the rate of achieving clinically meaningful outcomes among patients undergoing lumbar tubular microdecompression for spinal stenosis. Additionally, decreasing the amount of opioids prescribed for postoperative pain does not increase the number of unplanned clinic or ED visits due to pain within 90 days after surgery.

Hip Arthroscopic Microfracture Augmented With Platelet-Rich Plasma-Infused Micronized Cartilage Allograft Significantly Improves Functional Outcomes.

PURPOSE: To evaluate functional outcomes and survivorship in patients at 1 year after undergoing arthroscopic microfracture augmented with hyaline allograft for symptomatic chondral defects of the hip. METHODS: Consecutive patients with and without prior hip procedures presenting with Outerbridge grade IV chondral lesion of the acetabulum or femoral head were prospectively followed. Patients underwent hip microfracture augmented with hyaline allograft suspended in autologous platelet-rich plasma between October 2016 and April 2018. Extent of cartilage degeneration was quantified using the chondromalacia severity index (CMI). Patient functional scores, including Tegner, Hip Outcome Score-Activities of Daily Living (HOS-ADL), Sport-Specific Subscale (HOS-SSS), modified Harris Hip Score (mHHS), and Nonarthritic Hip Score (NAHS) were collected preoperatively and at minimum 1-year postoperatively. Minimal clinically important difference (MCID) was analyzed. Statistical significance was established at P < .05. Pearson's coefficient analysis was performed to identify preoperative variables correlated with clinical outcomes. RESULTS: Fifty-seven patients (86.4%) had minimum 1-year follow-up and were included in the final analysis, with a mean age and body mass index (BMI) of 38.3 ± 9.1 years and 27.7 ± 4.9 kg/m2, respectively. Comparison of baseline and postoperative score averages demonstrated significant improvements in Tegner scores (3.7 ± 2.9 vs 5.1 ± 2.6; P = .003), HOS-ADL (63.3 ± 16.4 vs 89.1 ± 14.5; P < .001), HOS-SSS (40.8 ± 20.4 vs 79.5 ± 21.6; P < .001), mHHS (61.5 ± 16.2 vs 87.0 ± 17.7; P < .001), and NAHS (56.6 ± 14.9 vs 78.7 ± 18.3; P < .001). The percentage of patients who achieved MCID for HOS-ADL, HOS-SSS, mHHS, and NAHS were 89.8%, 83.0%, 75.6%, and 81.6%, respectively. Overall, 91.8% of patients met the threshold for achieving MCID in at least one outcome score. Of the 57 patients, 5 (8.8%) failed clinically, with 1 (1.8%) undergoing revision surgery and 4 (6.9%) undergoing conversion to total hip arthroplasty. There was a direct correlation between preoperative alpha angle and postoperative HOS-ADL. Femoral chondral lesion size and CMI inversely correlated with postoperative HOS-ADL. CONCLUSIONS: Treatment of hip chondral defects with microfracture and hyaline allograft augmentation demonstrated excellent survivorship and significantly improved patient report outcomes at 1 year. LEVEL OF EVIDENCE: IV, retrospective case series.

No false elevation in ankle brachial index in patients with tibial plateau fractures and vascular risk factors.

Objectives: The ankle brachial index (ABI) is a useful tool in detection of lower extremity vascular injury. However, diabetes mellitus (DM), chronic kidney disease (CKD), and peripheral vascular disease (PVD) may affect extremity perfusion leading to possible false elevation of the ABI value. If true in trauma patients, this can affect initial evaluation, diagnostics, and management. We therefore explored mean ABI values in tibial plateau fractures of patients with vascular risk factors to help determine whether there is a difference. Design: This is a retrospective chart review of patients sustaining tibial plateau fractures with a specific ABI value recorded in the medical record. Patients were identified as either having vascular risk factors or not and data analysis performed to determine if their ABI differed and whether they were more likely to have a vascular injury. Results: 282 acute tibial plateau injuries with specific ABI values were identified, 46 of which carried the risk factors in question. The average risk factor group ABI was 0.95 ±â€¯0.15 versus those without risk factors 1.0 ±â€¯0.15 (p = 0.057). No patient with risk factors required a vascular intervention or four-compartment fasciotomy. Conclusions: This study shows no statistical significance between the presenting ABI of patients with risk factors such as DM, CKD, or PVD and those without those risk factors who sustained acute tibial plateau fractures. Therefore, in general the ABI still holds as a useful screening tool for evaluation of vascular insult in the setting of acute lower extremity trauma.

Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction.

Despite advancements in our understanding of anterior cruciate ligament (ACL) injury prevention and nonsurgical management, ACL reconstruction continues to occur at an alarming rate. Among athletic patients, individuals participating in basketball, soccer, and football have the highest incidence of ACL injury, often requiring surgical intervention. To ensure the optimal treatment strategy for return to sport and prevention of secondary graft re-tear, it is important to tailor to the specific demands of the injured athlete and apply evidence-based best practices and rehabilitation principles. The purpose of this review is to provide readers with a brief background regarding ACL injuries, a focused review of clinical outcome studies after ACL reconstruction, and an updated framework with expert-guided recommendations for postoperative rehabilitation and return to sporting activity. Currently, there is no gold standard for rehabilitation after ACL reconstruction, highlighting the need for robust studies evaluating the best modalities for athlete rehabilitation, as well as determining the efficacy of new tools for improving therapy including blood flow restriction therapy and neuromuscular electrical stimulation. Based on clinical experience, a renewed focus on objective, criteria-based milestones may maximize the ability of return to preinjury levels of athletic function.

Intraoperative Automated Radiographic Visualization Tool Allows for Higher Accuracy of Cam Lesion Resection When Used by Novice Surgeons for Arthroscopic Femoroplasty: Lowering the Learning Curve.

PURPOSE: To compare the accuracy of conventional fluoroscopy versus an intraoperative radiographic visualization tool in assisting a novice and experienced hip arthroscopist in comprehensive cam correction to a desired alpha angle (AA). METHODS: A cadaveric study was performed using 28 hemi-pelvises with cam-type deformity (AA > 55˚) measured on anteroposterior, lateral, and Dunn-view radiographs. Two fellowship-trained hip arthroscopists each performed 14 arthroscopic femoroplasties. The specimens were randomly assigned: 14 of the procedures were performed by the experienced surgeon, with 7 using the automated radiographic visualization tool (Guided Femoroplasty) and 7 using routine fluoroscopy (Control). The same number of hips was assigned to the novice surgeon, completing 7 femoroplasties with and without the visualization tool. Each hip was imaged before and after femoroplasty in 6 different positions using intraoperative fluoroscopy to evaluate head-neck offset. Femoroplasty AAs were compared between groups with and without visualization tool use, as well as between surgeons. One-way analysis of variance analysis was performed to evaluate the consistency of cam resection. RESULTS: For the experienced hip arthroscopist, comparison of Guide Femoroplasty and Control groups resulted in similar accuracy when compared to the controls, with post-femoroplasty AA averages ranging from 41.4° ± 3.8˚ to 44.8° ± 2.8˚ (P = .511) and 40.2° ± 5.3˚ to 45.6° ± 2.2˚ (P = .225), respectively. For the novice hip arthroscopist, the Guided Femoroplasty group had higher accuracy, with post-femoroplasty AA averages ranging from 42.8° ± 2.6˚ to 46.1° ± 7.2˚(P = .689) with and 39.8° ± 3.1˚ to 51.9° ± 8.1˚ (P = .001) without the visualization tool. Comparison of procedure time did not show any statistically significant difference between the use of the radiographic visualization tool and controls for either surgeon (P > .05 for all). CONCLUSIONS: Femoroplasty with and without the use of automated radiographic visualization tool results in accurate cam resection when used by both the experienced and novice surgeon. However, higher accuracy was observed when resecting to a desired AA performed by a novice surgeon using the visualization tool. Additionally, use of the visualization tool did not result in longer procedure times for either surgeon. CLINICAL RELEVANCE: The impact of incomplete cam resections and over-resection on patient outcomes in the literature has led to the recent development of automated intraoperative radiographic visualization tools that allow for assistance of cam resection accuracy for the treatment of femoroacetabular impingement syndrome. This cadaveric study demonstrates that femoroplasty with the use of an intraoperative automated radiographic visualization tool may result in more accurate cam resections.

Prolonged Postoperative Opioid Use After Arthroscopic Femoroacetabular Impingement Syndrome Surgery: Predictors and Outcomes at Minimum 2-Year Follow-up.

BACKGROUND: The association between prolonged postoperative opioid use on outcomes after hip preservation surgery is not known. PURPOSE: To compare minimum 2-year patient-reported outcomes (PROs) between patients who required ≥1 postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) versus patients who did not require a refill and to identify preoperative predictors for patients requiring ≥1 postoperative opioid refill. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data from consecutive patients who underwent arthroscopic surgery for FAIS between January 2012 and January 2017 were analyzed. Multivariate regression analysis was performed to classify patient and radiographic variables as predictive of requiring ≥1 opioid prescription refill after surgery. Patients completed the following PROs preoperatively and at 2-year follow-up: Hip Outcome Score- Activities of Daily Living subscale (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and 100-point visual analog scale (VAS) for pain and satisfaction. Scores were compared between patients needing additional prescription opioids and those who did not. RESULTS: A total of 775 patients, of whom 141 (18.2%) required ≥1 opioid prescription refill, were included in the analysis. Patients requiring opioid refills had significantly lower 2-year postoperative PRO scores compared with patients not requiring refills: HOS-ADL (79.9 ± 20.3 vs 88.7 ± 14.9), HOS-SS (64.6 ± 29.5 vs 78.2 ± 23.7), mHHS (74.2 ± 21.1 vs 83.6 ± 15.9), iHOT-12 (63.6 ± 27.9 vs 74.9 ± 24.8), and VAS satisfaction (73.4 ± 30.3 vs 82.2 ± 24.9), as well as significantly more pain (26.8 ± 23.4 vs 17.9 ± 21.8) (P ≤ .001 for all). Predictors of requiring a postoperative opioid refill included patients with active preoperative opioid use (odds ratio, 3.12 [95% confidence interval, 1.06-9.21]; P = .039) and larger preoperative alpha angles (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .03). CONCLUSION: Patients requiring ≥1 opioid prescription refill after hip arthroscopy for FAIS had lower preoperative and 2-year PRO scores when compared with patients not requiring refills. Additionally, active opioid use at the time of surgery was found to be predictive of requiring additional opioids for pain management.

Cartilage Restoration of Bipolar Lesions Within the Patellofemoral Joint Delays Need for Arthroplasty: A Systematic Review of Rates of Failure.

PURPOSE: The purpose of the present review is to systematically review the available literature for failure rates and complications of cartilage restoration of bipolar chondral defects in the patellofemoral (PF) joint to assess the ability to treat these lesions without arthroplasty. METHODS: PubMed and MEDLINE databases were queried between 2000 to 2020 using the keywords "osteochondral" and "knee" and "microfracture," "autologous chondrocyte implantation (ACI)," or "transplantation." Patient selection included patients with bipolar chondral lesions of the patellofemoral joint that were treated with cartilage restoration procedures. Treatment of PF joints were reviewed for surgical indications/technique, rates of failure, defect characteristics, and time to failure. For the purposes of this study, failure was defined by each individual author on their respective studies. RESULTS: After screening 1,295 articles, there were 8 publications analyzed quantitatively and 10 articles analyzed both quantitatively and qualitatively. A total of 249 knees involved bipolar lesions of the patellofemoral joint. The weighted average age was 36.5 ± 10.4 years, and weighted average follow-up was 89.0 ± 31.7 months. There were failures in 0% to 50% of cases, revision procedures in 0% to 10% of cases, conversion to arthroplasty in in 0% to 50% of cases, and unsatisfactory outcome without revision in 0% to 8.3% of cases. The range in average failure rate was 0% to 50.0% (I2 = 68.0%), whereas the range in average time to failure was 2.9 to 6.8 years (I2 = 79.0%). CONCLUSION: From the available data, established cartilage restoration procedures may provide favorable patient-reported function, avoidance of secondary surgery, and joint preservation in at least 80% of patients at short- to mid-term follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Cartilage Restoration for Tibiofemoral Bipolar Lesions Results in Promising Failure Rates: A Systematic Review.

PURPOSE: The purpose of the present study is to systematically review the available literature for management of bipolar lesions within the tibiofemoral joint and determine whether tibiofemoral cartilage restoration is an effective treatment modality. METHODS: PubMed and MEDLINE databases were queried between 2000 and 2020 using the following keywords: "osteochondral" and "knee" and "microfracture," "autologous chondrocyte implantation (ACI)," or "transplantation." Articles were reviewed for the presence of a bipolar or "kissing" tibiofemoral lesion and reported lesion size, concomitant procedures, failure rates, and time to failure. RESULTS: After screening 1,295 articles, there were 4 articles available for analysis and a total of 152 knees involving the management of bipolar tibiofemoral lesions. Age ranged from 14 to 60 years, and mean follow-up was between 12 and 240 months. There was 1 retrospective cohort study (36 knees) and 3 case series (mean, 38.7 ± 17.5 knees). There were 58 knees treated with bipolar osteochondral allograft (OCA) transplantation, 58 knees treated with bipolar ACI, 20 knees treated with femoral OCA and tibial debridement, and 16 knees treated with femoral OCA and tibial microfracture. There were 37 failures (24.3%): 16 patients (10.5%) were converted to unicompartmental or total knee arthroplasty, 4 restorative procedures (2.6%) were revised, and 8 patients (1.6%) had unsatisfactory outcomes only. The remaining 15 failures (9.9%) had an unspecified combination of objective failure. The mean rate of failure ranged between 0% and 44.1% (I 2 = 83.2%). The mean time to failure ranged between 2.7 and 4.1 years (I 2 = 79.1%). CONCLUSIONS: Cartilage restoration, through both ACI and OCA, had failure rates between 0% and 44% in patients with bipolar lesions of the tibiofemoral compartment. Although a higher level of evidence is required to prove efficacy, the current study demonstrates midterm survivorship rates between 55% and 100%, which may delay the need for secondary arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.