Faculty Bibliography

OBJECTIVE:There is a high prevalence of femoroacetabular impingement (FAI) amongst elite men's ice hockey players, yet little is known about the hips of players in the National Women's Hockey League (NWHL). The primary purpose of this study was to determine the prevalence of radiographic cam-type FAI in women's professional ice hockey players. The secondary purpose was to analyze the relationship between the cam deformity and both menarchal age and hip range-of-motion (ROM). METHODS:Data were collected for NWHL players during pre-participation physicals. Alpha angles were measured on 45° Dunn radiographs, with alpha angles >55° defined as cam-positive. Pearson correlation coefficients (ρ) were performed to analyze the relationship between alpha angle and both ROM measurements and menarchal age, with statistical significance set at p<0.05. RESULTS:Twenty-six athletes were included. Twenty-four (92%) had alpha angles >55°; 20 players (77%) had bilateral cam deformity. Average menarchal age was 13.8 ±1.7 years. There was a significant association between age of menarche and alpha angle (ρ=0.36, p<0.02). There was no significant association between alpha angle and hip ROM, (p>0.05). CONCLUSION/CONCLUSIONS:Elite women's ice hockey players have a higher prevalence of cam-type morphology than the general population. The positive association between alpha angle and menarchal age lends additional support to the etiological hypothesis of the cam lesion resulting from activity-related stress at the proximal femoral physis during skeletal development. Professional women's ice hockey players have a high risk of developing cam-type morphology, although each player's menarchal age may mediate her individual risk for cam development.

PURPOSE/OBJECTIVE:To evaluate post-operative outcomes and pre-operative risk factors for patients with underlying systemic inflammatory disorders (SID) after hip arthroscopy. METHODS:A retrospective analysis of patients that had undergone hip arthroscopy, with a history of systemic inflammatory disease. This included patients with a diagnosis of lupus, positive ANA, rheumatoid arthritis, psoriatic arthritis, sarcoidosis, inflammatory bowel disease, Reiter Syndrome, mixed connective tissue disease (MCTD). These cases were 1:2 matched to a control group of patients with no history of systemic inflammatory disease based on age and sex. An a-priori power analysis was conducted and A 1:2 case-control ratio was selected in order to increase study power. Inclusion criteria included all skeletally-mature patients with hip pain refractory to non-operative management who underwent hip arthroscopy for labral tears and femoroacetabular impingement (FAI). Skeletally immature patients, those with Tonnis grades of 2 or more (less than 2mm of joint space), hip dysplasia, patients undergoing revision hip arthroscopy, and patients whose pain failed to improve after intra-articular injection were excluded. The primary outcome was rate of revision hip arthroscopy or total hip arthroplasty 24 months after surgery. Secondary outcomes included two patient-reported outcome (PRO) scores, modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS). RESULTS:Twenty patients (21 hip arthroscopy procedures) and 42 controls were included. There was no significant difference in proportion of patients who met failure criteria (28.6% vs 16.7%,p=0.271) or two-year survivorship (76.2% vs 83.3%, p=0.496) between the SID and control groups, respectively. Both groups had a significant improvement in modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS) at 24-months compared to baseline, however, there was no significant difference in mHHS (p=0.28) or NAHS (p=0.22) at 24-months between the two groups. CONCLUSION/CONCLUSIONS:Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared to patients with no history of inflammatory disease. LEVEL OF EVIDENCE/METHODS:This is a retrospective comparative study, Level of Evidence III.

BACKGROUND/UNASSIGNED:Iliopsoas tendinitis is a known source of extra-articular hip pain and it has been shown to be a common cause of continued hip pain following total hip arthroplasty. While iliopsoas tendinitis after hip arthroscopy is a well-known phenomenon amongst hip arthroscopists, its presentation, course, and treatment has yet to be elucidated. METHODS/UNASSIGNED:An IRB-approved chart review was performed of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between March 2015 and July 2017. No cases of dysplasia were included. All patients had combined cam/pincer impingement as well as labral pathology. Tendinitis patients were identified. Patient demographics, surgical data, time to onset/diagnosis of iliopsoas tendinitis, treatment (oral anti-inflammatories, corticosteroid injection, physical therapy), and resolution of symptoms were recorded. These cases were age- and sex-matched to a control group that did not develop postoperative iliopsoas tendinitis for comparison. Patient outcomes were measured with the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) recorded from the preoperative and 1-year postoperative visits. RESULTS/UNASSIGNED: = 0.09) scores at their 1-year postoperative visits. CONCLUSIONS/UNASSIGNED:Iliopsoas tendinitis is a common source of pain following arthroscopic hip surgery and can be effectively diagnosed and treated with ultrasound-guided injection. Therefore, surgeons performing arthroscopic procedures of the hip must remain aware of and include it in their differential when encountering patients with hip flexion pain after surgery. Research should be continued to further evaluate the long-term outcomes and return to sport rates of these patients.

INTRODUCTION/BACKGROUND:Total hip arthroplasty (THA) is often used for displaced femoral neck fracture. In this study, institutional hip arthroplasty data were compared with the National American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data for any differences in outcomes between our hospital, with an integrated hip fracture care pathway, and those of the country as a whole. METHODS:Elective THA was compared with arthroplasty performed for acute fracture. Outcomes for both groups included thromboembolic event (VTE), death, and deep prosthetic infection. RESULTS:Institutional data revealed no increased rate of infection after THA for fracture compared with elective. National Surgical Quality Improvement Program analysis revealed higher infection rates in fracture arthroplasty. There was an increased VTE rate in fracture performed for arthroplasty compared with elective in both institutional and NSQIP data. CONCLUSIONS:When performed at an academic medical center with an integrated care program, THA for fracture can have similar infection rates to elective THA. By contrast, national data showed significantly higher rates of infection and VTE for arthroplasty for fracture compared with elective. The contrast in complication rates may be related to well-functioning comprehensive interdisciplinary pathways. Patient-centered care pathways may be optimal for hip fracture patients.

Meniscus surgery has dramatically changed over the last 20 years. This article reviews the advances and current evidence in meniscus repair.

Objectives: Participation rates in women's ice hockey is increasing in North America. Recent studies have demonstrated an increased prevalence of femoroacetabular impingement (FAI) in elite male ice hockey players, yet little is known about hip pathology of players in the National Women's Hockey League (NWHL). The primary purpose of this study was to determine the prevalence of radiographic FAI in women's professional ice hockey players. The secondary purpose was to analyze the relationship between the presence of radiographic cam deformity and hip ROM, clinical impingement signs and age of menarche.
Method(s): In this IRB-approved study, physical examination and demographic data were prospectively collected for 27 NWHL players. Alpha angles were measured on 45-degree Dunn views with an alpha angle >55degree defined as cam-positive. Pearson correlations were performed to analyze the relationship between alpha angle and ROM measurements, clinical impingement signs and self-reported age of menarche. Players were grouped into those with and without cam impingement and group differences were assessed using the student's t-test. Statistical significance was set at p<0.05.
Result(s): Twenty-seven athletes were included in the study. Nineteen of the 27 players (70%) had radiologic evidence of cam-type impingement with alpha angle >55 degrees; 14 players (52%) had bilateral cam deformity. The average age of menarche was 13.9+/-1.5 years. There was a significant association between age of menarche and right alpha angle (R=0.57, CI [0.16, 0.81], p=0.011), as well as age of menarche and left alpha angle (R=0.48, CI [0.03, 0.77], p=0.039). There was no statistically significant association between alpha angle and any ROM measurement. Additionally, there was no difference in the incidence of clinical impingement for players with or without an alpha angle >55degree.
Conclusion(s): This study suggests that elite female ice hockey players have a significantly higher prevalence of cam-type morphology than the general population. The clinical significance of this radiographic finding is uncertain as the majority of these deformities seem to be asymptomatic. Interestingly, the positive association between alpha angle and age of menarche lends support to the etiological hypothesis that cam lesions are a result of activityrelated stress at the proximal femoral physis. This data suggests that players with earlier menarche (and therefore earlier physeal closure) seem to be less vulnerable to the development of cam deformity of the proximal femur

BACKGROUND:There is evidence to suggest that liposomal bupivacaine (LB) is an effective component of a multimodal pain regimen for total joint arthroplasty (TJA). Obesity has been associated with chronic pain following TJA. This study assessed whether early postoperative pain is affected by body mass index (BMI), and whether the standard LB dose has similar effects on obese vs nonobese patients. METHODS:A retrospective analysis of 2629 primary TJA over a 12-month period was conducted, with LB used in half of this group. Patients were further classified as nonobese (BMI < 30) or obese (BMI ≥ 30). Pain scores and narcotic use were recorded. Independent-sample t-tests were used for continuous variables and chi-squared analyses for categorical variables. A multivariate regression analysis was performed. RESULTS:Significantly less narcotic was required on postoperative days (POD) 0 and 1 in patients receiving LB compared to those who did not in both obese and nonobese patient groups. On POD 2, obese and nonobese patients had an increase in narcotic requirement, which was significant in obese patients. A regression analysis found that on POD 0 and POD 1, lack of LB use, obesity, and younger age were independently associated with increased narcotic use. CONCLUSION/CONCLUSIONS:While narcotic requirement of obese and nonobese patients decreased on POD 0 and POD 1 with initiation of LB at our institution, all patients demonstrated increased narcotic requirement on POD 2 which was statistically and clinically significant in obese patients. Further studies are needed to determine the optimal pain regimen in the growing obese population undergoing TJA.

Increasingly, inflammatory mediators are considered crucial to the onset and perpetuation of tendinopathy. We sought evidence of interleukin 17A (IL-17A) expression in early human tendinopathy and thereafter, explored mechanisms whereby IL-17A mediated inflammation and tissue remodeling in human tenocytes. Torn supraspinatus tendon (established pathology) and matched intact subscapularis tendon (representing 'early pathology') along with control biopsies were collected from patients undergoing shoulder surgery. Markers of inflammation and IL-17A were quantified by RT-PCR and immunohistochemistry. Human tendon cells were derived from hamstring tendon obtained during ACL reconstruction. In vitro effects of IL-17A upon tenocytes were measured using RT-PCR, multiplex cytokine assays, apoptotic proteomic profiling, immunohistochemistry and annexin V FACS staining. Increased expression of IL-17A was detected in 'early tendinopathy' compared to both matched samples and non-matched control samples (p < 0.01) by RT-PCR and immunostaining. Double immunofluoresence staining revealed IL-17A expression in leukocyte subsets including mast cells, macrophages and T cells. IL-17A treated tenocytes exhibited increased production of proinflammatory cytokines (p < 0.001), altered matrix regulation (p < 0.01) with increased Collagen type III and increased expression of several apoptosis related factors. We propose IL-17A as an inflammatory mediator within the early tendinopathy processes thus providing novel therapeutic approaches in the management of tendon disorders.

MicroRNA (miRNA) has the potential for cross-regulation and functional integration of discrete biological processes during complex physiological events. Utilizing the common human condition tendinopathy as a model system to explore the cross-regulation of immediate inflammation and matrix synthesis by miRNA we observed that elevated IL-33 expression is a characteristic of early tendinopathy. Using in vitro tenocyte cultures and in vivo models of tendon damage, we demonstrate that such IL-33 expression plays a pivotal role in the transition from type 1 to type 3 collagen (Col3) synthesis and thus early tendon remodelling. Both IL-33 effector function, via its decoy receptor sST2, and Col3 synthesis are regulated by miRNA29a. Downregulation of miRNA29a in human tenocytes is sufficient to induce an increase in Col3 expression. These data provide a molecular mechanism of miRNA-mediated integration of the early pathophysiologic events that facilitate tissue remodelling in human tendon after injury.