Faculty Bibliography

PURPOSE/UNASSIGNED:To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction. METHODS/UNASSIGNED:A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups. RESULTS/UNASSIGNED: = .036). CONCLUSIONS/UNASSIGNED:Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.

PURPOSE:To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up. METHODS:A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria. RESULTS:A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively. CONCLUSIONS:MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up. LEVEL OF EVIDENCE:Level IV, systematic review of Level III and IV studies.

PURPOSE/UNASSIGNED:To systematically examine the effects of radiofrequency (RF) ablation or coblation (controlled ablation) on chondrocyte viability following knee chondroplasty in preclinical literature to determine the effectiveness and safety of RF-based techniques. METHODS/UNASSIGNED:A literature search was performed in September 2022 using PubMed and Scopus using the following search terms combined with Boolean operators: "chondroplasty," "radiofrequency," "thermal," "knee," "chondral defect," "articular cartilage," and "cartilage." The inclusion criteria consisted of preclinical studies examining the effect of RF ablation or coblation on chondrocytes during knee chondroplasty. Exclusion criteria consisted of studies reporting chondroplasty in joints other than the knee, clinical studies, in vitro studies using animal models, case reports, non-full-text articles, letters to editors, surveys, review articles, and abstracts. The following data were extracted from the included articles: author, year of publication, chondral defect location within the knee and chondral characteristics, RF probe characteristics, cartilage macroscopic description, microscopic chondrocyte description, and extracellular matrix characteristics. RESULTS/UNASSIGNED:A total of 17 articles, consisting of 811 cartilage specimens, were identified. The mean specimen age was 63.4 ± 6.0 (range, 37-89) years. Five studies used monopolar RF devices, 7 studies used bipolar RF devices, whereas 4 studies used both monopolar and bipolar RF devices. Time until cell death during ablation at any power was reported in 5 studies (n = 351 specimens), with a mean time to cell death of 54.4 seconds (mean range, 23.1-64) for bipolar RF and 56.3 seconds (mean range, 12.5-64) for monopolar RF devices. Chondrocyte cell death increased with increased wattage, while treatment time was positively correlated with deeper cell death. CONCLUSIONS/UNASSIGNED:In this systematic review, histologic analysis demonstrated that RF-based chondroplasty creates a precise area of targeted chondrocyte death, with minimal evidence of necrosis outside the target zone. Caution must be exercised when performing RF-based chondroplasty due to the risk of cell death with increased application time and wattage. CLINICAL RELEVANCE/UNASSIGNED:Although RF ablation has demonstrated favorable results in preliminary trials, including smoother cartilage and less damage to the surrounding healthy tissue, the risks versus benefits of the procedure are largely unknown. Caution must be exercised when performing RF-based chondroplasty in the clinical setting due to the risk of cell death with increased application time and wattage.

BACKGROUND:Femoral torsion measurements and outcomes are variable throughout the literature and have focused on short-term follow-up. However, there is a paucity of literature investigating clinically meaningful outcomes at midterm follow-up after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). PURPOSE:To quantify femoral version using computed tomography imaging in patients with FAIS and to explore the relationship between version abnormalities and 5-year outcomes after hip arthroscopy. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:Patients who underwent primary hip arthroscopy for FAIS between January 2012 and November 2017 were identified. Patients were included if they had 5-year follow-up with completion of ≥1 patient-reported outcome (PRO) scores and excluded if they had Tönnis grade >1, revision hip surgery, a concomitant hip procedure, a developmental disorder, or a lateral center-edge angle <20°. Torsion groups were defined as severe retrotorsion (<0°), moderate retrotorsion (0.1°-5°), normal torsion (5.1°-20°), moderate antetorsion (20.1°-25°), and severe antetorsion (>25.1°) based on computed tomography measurements. Patient characteristics were analyzed among the torsion cohorts, as were preoperative and 5-year PROs: Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, modified Harris Hip Score, international Hip Outcome Tool, visual analog scale for pain, and visual analog scale for satisfaction. Achievement rates of cohort-specific thresholds for the minimal clinically important difference and Patient Acceptable Symptom State were calculated and compared among cohorts. RESULTS:≥ .161) for any of the PROs among the torsion groups. CONCLUSION:The orientation and severity of femoral torsion at the time of hip arthroscopy for FAIS in this study's cohort did not affect the propensity for clinically meaningful outcome improvement at midterm follow-up.

PURPOSE:To perform a systematic review of studies reporting on minimum 5-year outcomes of patients undergoing primary hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) to determine whether capsular management influences patient-reported outcomes (PROs), rates of clinically significant outcome, and rates of revision surgery or conversion to total hip arthroplasty (THA). METHODS:PubMed, Scopus, and Google Scholar were searched around the terms hip arthroscopy, FAIS, five-year follow-up, and capsule management. Articles available in English, presenting original data, and reporting minimum 5-year follow-up after HA using either PROs or conversion to THA or revision surgery were included. Quality assessment was completed using MINORS assessment. Articles were stratified into unrepaired and repaired capsule cohorts (excluding periportal capsulotomy techniques). RESULTS:Eight articles were included. MINORS assessment ranged from 11-22, with excellent (k = 0.842) inter-rater reliability. Populations without capsular repair were identified in 4 studies including a total of 387 patients, at an age of 33.1 to 38.0 years and follow-up range of 60.0 to 77 months. Populations with capsular repair were identified in 5 studies including a total of 835 patients, at an age range of 33.6 to 43.1 years and follow-up range of 60.0 to 78.0 months. All studies included PROs and all reported significant improvement (P < .05) at the 5-year timepoint, with modified Harris Hip Score (mHHS) being the most frequent (n = 6). No differences were noted between groups regarding any of the measured PROs. Average rates of achieving MCID and PASS for mHHS were similar between patients without capsular repair (MCID 71.1%, PASS 73.7%, n = 1) and with capsular repair (MCID 66.0%-90.6%, PASS 55.3%-87.4%, n = 4). Conversion to THA occurred in 12.8% to 18.5% and 0.0% to 29.0% for patients with an unrepaired and repaired capsule, respectively. Revision HA occurred in 15.4% to 25.5% and 3.1% to 15.4% in unrepaired and repaired capsular patients, respectively. CONCLUSIONS:Patients undergoing hip arthroscopy for FAI had significant improvement in PRO scores at minimum 5-year follow-up, and scores did not differ between patients who underwent capsular repair and those who did not. Similar rates of markers of clinical benefit and THA conversion were achieved by both groups; however, lower rates of revision hip arthroscopy were demonstrated in the capsular repair cohort. LEVEL OF EVIDENCE:Level IV; systematic review of Level II-IV studies.

PURPOSE:To assess 5-year outcomes and survival rate of hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) and to determine achievement rates of clinically significant outcomes. METHODS:Three databases were searched around the following terms: hip arthroscopy, FAIS, and 5-year follow-up. Articles available in English, presenting original data, and reporting minimum 5-year follow-up after primary HA using either patient-reported outcomes (PROs) or conversion to total hip arthroplasty (THA) and/or revision surgery were included. Quality assessment was completed using MINORS assessment, and relative agreement was calculated using Cohen's kappa. RESULTS:Fifteen articles were included. MINORS assessment ranged from 11 to 22, with excellent (k = 0.842) inter-rater reliability between reviewers. 2,080 patients were included at a follow-up range of 60.0-84 months. Labral repair was the most commonly performed procedure (range: 8.0%-100%). All studies included PROs, and all reported statistically significant improvement (P < .05) at the 5-year timepoint. The most frequent PRO was modified Harris Hip Score (mHHS) (n = 8). Nine studies reported on clinically significant outcome achievement, with mHHS being the most common (n = 8). The rate of achieving minimal clinically important difference (MCID) ranged from 64 to 100%, patient-acceptable symptomatic state (PASS) ranged from 45 to 87.4%, and substantial clinical benefit (SCB) ranged from 35.3 to 66%. Conversion to THA and revision surgery varied across studies, with ranges of 0.0%-17.9% (duration: 28.8-87.1 months) and 1.3%-26.7% (duration: 14.8-83.7 months), respectively. The most common definition of failure was conversion to THA or revision (n = 7). Increased age (n = 5) and greater joint degeneration (n = 4) were the most common predictors of clinical failure. CONCLUSIONS:Patients undergoing primary hip arthroscopy for FAIS demonstrated significant improvement at 5-year follow-up, with maintained rates of achievement of MCID, PASS, and SCB. Survival rate of HA at 5 years is overall high, with ranges of 0.0-17.9% and 1.3-26.7% conversion to THA or revision surgery, respectively. Across studies, increased age and greater joint degeneration were the most commonly cited predictors of clinical failure. LEVEL OF EVIDENCE:Level IV, systematic review of Level III and IV studies.

The use of ulnar collateral ligament (UCL) repair with concomitant internal bracing for throwing athletes is a viable treatment option, but must take into account tear location, ligament quality, the expected length of the athlete's career, desire to advance to the next level of competition, and age. There has been increased interest in repair of UCL injuries in overhead athletes due to advancements in surgical technique, as well as improved technologies of anchor and suture material. In addition, return to sport can be accelerated compared to reconstruction. In this Technical Note, we demonstrate an ulnar collateral ligament repair technique, with internal bracing augmentation for high-grade partial proximal tears in the throwing athlete that is reliable, strong, and easily reproducible.

Although historically overlooked, medial meniscus posterior root (MMPR) tears are now increasingly recognized as a substantial cause of biomechanical impairment and morbidity. MMPR tears, when left untreated, are strongly correlated to meniscal extrusion and ultimately lead to altered kinematics and loading functionally equivalent to a total meniscectomy. To prevent progressive joint degeneration and alleviate pain while re-establishing native joint kinematics, MMPR repair is generally recommended in appropriately selected patients. In this Technical Note, the authors describe a detailed checklist with 10 crucial points of emphasis when performing the gold-standard transtibial pull-out repair of the MMPR, with an additional centralization stitch, providing technical pearls backed up by previous literature and ample experience treating this condition.

BACKGROUND:Limited literature exists regarding how postoperative physical therapy (PT) may affect outcomes in patients with femoroacetabular impingement syndrome (FAIS) undergoing hip arthroscopy. Additionally, it is unknown how PT measures relate to traditional orthopaedic patient-reported outcomes (PROs). PURPOSE:To evaluate how the duration of PT may correlate with outcomes in patients with FAIS using both the Lower Extremity Functional Scale (LEFS) and standard orthopaedic PRO measures. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:Patients from a single institution who underwent primary hip arthroscopy for FAIS between 2013 and 2016 were identified. Patients with a minimum 2-year follow-up and fully documented PT notes were included and stratified into 3 cohorts based on timing of PT discharge: 0 to 3 months, 3 to 6 months, and 6 to 12 months. Predictive regression models were developed to analyze the rate of improvement (ROI) in LEFS score as it relates to (1) postoperative day (POD) and (2) postoperative PT session number. Two-year PROs were collected, correlated with LEFS scores, and compared among cohorts. RESULTS:= 0.459). CONCLUSION:Patients undergoing hip arthroscopy for FAIS derived substantial benefit from each PT visit during their first 13 PT sessions and then a smaller, yet still meaningful benefit from sessions 13 through 27. After session 40, or approximately 4.5 to 5 months, patients no longer benefited from additional PT sessions. Based on PRO scores, patients discharged from PT between 3 and 6 months had the best 2-year outcomes. LEFS score had moderate correlation with orthopaedic PRO scores.

The contemporary treatment of hamstring avulsions has been evolving, as more patients are being identified as having persistently symptomatic partial hamstring tears recalcitrant to nonoperative treatment. The endoscopic hamstring repair allows surgeons improved visualization of the footprint, as well as safe dissection of the sciatic nerve. The present technique article provides a step-by-step technical note to allow for safe and effective surgical treatment of partial hamstring tears.