Faculty Bibliography

Anterior ankle impingement is a common cause of chronic ankle pain characterized by altered joint mechanics with considerable deficits in range of motion. The benefits of in-office nano arthroscopy (IONA) include the ability to diagnosis and treat anterior ankle impingement, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office nano arthroscopy for anterior ankle impingement, with special consideration of the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

Achilles tendinopathy is a common inflammatory condition of the Achilles tendon prevalent in the athletic population in which patients present with pain, swelling, and reduced performance exacerbated by physical activity. Operative intervention using either open or percutaneous approaches has traditionally been performed after failure of nonoperative treatment, but less invasive modalities that include endoscopic approaches have been increasingly used. This Technical Note highlights our technique for Achilles paratenon needle tendoscopy in the wide-awake office setting, with accompanying indications for use, advantages, and technical pearls.

Hallux rigidus is a progressive degenerative process of the first metatarsophalangeal joint characterized by altered joint mechanics and formation of dorsal osteophytes. Cheilectomy is the preferred operative intervention at early stages. Technologic advances, patient preference, and cost considerations combine to stimulate the development of minimally invasive and in-office interventions. This Technical Note highlights our technique for needle arthroscopy cheilectomy for hallux rigidus, which can be used either in the operating room or in the wide-awake office setting.

Posterior hindfoot disorders encompass a spectrum of bony, cartilaginous, and soft-tissue pathology. Traditional open surgical techniques have been increasingly replaced by less-invasive arthroscopic and endoscopic approaches. Recent innovations such as the advent of the needle arthroscope continue to push the boundary of minimally invasive interventions. This Technical Note highlights our technique for posterior hindfoot needle endoscopy for common posterior hindfoot pathologies in the wide-awake office setting, including indications, advantages, and technical pearls.

BACKGROUND/UNASSIGNED:The minimal clinically important difference (MCID) is a term synonymous with orthopaedic clinical research over the past decade. The term represents the smallest change in a patient-reported outcome measure that is of genuine clinical value to patients. It has been derived in a myriad of ways in existing orthopaedic literature. PURPOSE/UNASSIGNED:To describe the various modalities for deriving the MCID. STUDY DESIGN/UNASSIGNED:Narrative review; Level of evidence, 4. METHODS/UNASSIGNED:The definitions of common MCID determinations were first identified. These were then evaluated by their clinical and statistical merits and limitations. RESULTS/UNASSIGNED:There are 3 primary ways for determining the MCID: anchor-based analysis, distribution-based analysis, and sensitivity- and specificity-based analysis. Each has unique strengths and weaknesses with respect to its ability to evaluate the patient's clinical status change from baseline to posttreatment. Anchor-based analyses are inherently tied to clinical status yet lack standardization. Distribution-based analyses are the opposite, with strong foundations in statistics, yet they fail to adequately address the clinical status change. Sensitivity and specificity analyses offer a compromise of the other methodologies but still rely on a somewhat arbitrarily defined global transition question. CONCLUSION/UNASSIGNED:This current concepts review demonstrates the need for (1) better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and (2) better study design-namely, until a universally accepted MCID derivation exists, studies attempting to derive the MCID should utilize the anchor-based within-cohort design based on Food and Drug Administration recommendations. Ideally, large studies reporting the MCID as an outcome will also derive the value for their populations. It is important to consider that there may be reasonable replacements for current derivations of the MCID. As such, future research should consider an alternative threshold score with a more universal method of derivation.

PURPOSE/OBJECTIVE:To evaluate the association between postoperative cam lesion measured by the "femoroacetabular impingement resection (FAIR) arc" and 2-year patient outcomes following hip arthroscopy. METHODS:A retrospective review of prospectively gathered data from 2013-2017 was performed. All patients who underwent hip arthroscopy for FAI with ≥ 2-year follow-up were included. Cam FAIR arc measurements were made pre and postoperatively on a 45° Dunn view radiograph. The clinical effect of postoperative cam maximal radial distance (MRD) was assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were divided into subgroups based on relationship to the mean and standard deviations for cam MRD. One half standard deviation above the mean was found to be 3.15 mm. RESULTS:=0.004). Subgroup analysis demonstrated that patients in the cam MRD < 3.15 mm group had significantly higher mHHS (89.7 vs 70.0 p<0.001) and NAHS scores (90.5 vs 72.9, p<0.001) than those in the >3.15 mm group. Additionally, more patients in the <3.15 mm group reached the minimal clinically important difference (MCID) (95.2% vs 78.9%, p=0.048) and were above patient acceptable symptomatic state (PASS) (95.2% vs 52.6%, p<0.001) compared to the >3.15 mm group. CONCLUSION/CONCLUSIONS:Patients with a lower postoperative cam MRD relative to the FAIR arc demonstrated significantly improved outcomes as compared to those with higher postoperative MRD at two-year follow-up.

Although anterior cruciate ligament reconstruction (ACLR) is a generally successful procedure, failure is still relatively common. An increased posterior tibial slope (PTS) has been shown to increase the anterior position of the tibia relative to the femur at rest and under load in biomechanical studies. Increased PTS has also been shown to increase forces on the native and reconstructed ACL. Clinical studies have demonstrated elevated PTS in patients with failed ACLR and multiple failed ACLR, compared with control subjects. Anterior closing-wedge osteotomies have been shown to decrease PTS and may be indicated in patients who have failed ACLR with a PTS of ≥12°. Available clinical data suggest that the procedure is safe and effective, although evidence is limited to case series. This article presents the relevant biomechanics, clinical observational data on the effects of increased PTS, and an algorithm for evaluating and treating patients with a steep PTS.

Symptomatic femoroacetabular impingement is one of the most common hip pathologies in young athletes. Intraoperative fluoroscopy is commonly used during hip arthroscopy to aid with portal placement and resection of the cam and pincer lesions. However, there are currently no universally agreed-on tools to allow for the assessment of adequacy of femoral and acetabular osteoplasty. Despite the general lack of consensus among hip arthroscopists, the senior author recommends using the femoroacetabular impingement resection arc to guide the adequacy of cam and pincer resection in hip arthroscopy. Using intraoperative fluoroscopy, one should aim to create a continuous "Shenton's line"-type arc along the inferior aspect of the anterior-inferior iliac spine and superolateral femoral neck base by resecting any bone that causes a break in the continuity of this arc.

Purpose/UNASSIGNED:To explore the relationship between generalized joint hypermobility and hip labrum width. Methods/UNASSIGNED:and Fisher exact testing as well as linear regression. Results/UNASSIGNED: = .004). Conclusions/UNASSIGNED:Patients with a BTS ≥4 were found to have significantly thinner labra than those with a BTS of <4. Level of Evidence/UNASSIGNED:III, retrospective comparative trial.