Faculty Bibliography

OBJECTIVES/OBJECTIVE:Nordic ski athletes are at increased risk of developing hip pain and dysfunction secondary to femoroacetabular impingement syndrome (FAIS), but it is unclear whether hip symptomatology differs between ski jumping (SJ) and Nordic combined (NC) athletes. The purpose of this study was to compare patient-reported hip pain and dysfunction between elite Nordic ski athletes participating in SJ versus NC. METHODS:A cross-sectional study was conducted involving SJ and NC athletes who competed at the international and U.S. national level during the 2021-2022 season. Subjects were excluded if they had hip surgery within two years prior to enrollment. Subjects were asked to undergo diagnostic workup for FAIS including physical examination and plain radiographic imaging. Subjects were asked to complete a survey that collected information on athletic and training history and to complete the Hip Disability and Osteoarthritis Outcome Score (HOOS). Demographics, athletic/training history, and HOOS sub-scores were compared between the SJ and NC groups using Student's t-test, Wilcoxon rank-sum test, or Fisher's exact test, as appropriate. P-values <0.05 were considered significant. RESULTS:Twenty-four athletes (13 SJ, 11 NC) were included in the study. There were no statistically significant differences in age, sex, BMI, or age of menarche between the two groups (all p>0.05). There were also no statistically significant differences in the number of prior sports participated in, total hours of participation in prior sports, or total hours of training in Nordic specialization (all p>0.05). Among the 18 athletes who underwent physical examination (9 SJ, 9 NC), there were no statistically significant inter-group differences in hip range of motion or incidence of positive impingement tests (all p>0.05). Among the 19 athletes who underwent imaging (9 SJ, 10 NC), there were no statistically significant inter-group differences in the incidence of cam or pincer morphology in at least one hip (all p>0.05). SJ athletes had statistically significantly worse HOOS sub-scores for hip symptoms and stiffness, hip function in sports/recreational activities, and hip-related quality of life compared to NC athletes (all p<0.05). CONCLUSION/CONCLUSIONS:Elite SJ athletes have worse self-reported hip function compared to elite NC athletes despite comparable demographics, athletic history, and duration of ski training. LEVEL OF EVIDENCE/METHODS:IV.

AIMS/UNASSIGNED:The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. METHODS/UNASSIGNED:This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. RESULTS/UNASSIGNED:Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. CONCLUSION/UNASSIGNED:Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

AIMS/UNASSIGNED:The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. METHODS/UNASSIGNED:A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. RESULTS/UNASSIGNED:Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. CONCLUSION/UNASSIGNED:The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

BACKGROUND/UNASSIGNED:The purpose of the current study was to investigate whether pain, function, satisfaction, return to play (RTP), or psychological readiness to RTP differ between sexes post-operatively following SLAP repair. METHODS/UNASSIGNED:A retrospective review of patients who underwent arthroscopic repair of a SLAP tear was performed. The American Shoulder & Elbow Surgeons (ASES) score, Visual Analogue Scale (VAS), Subjective Shoulder Value (SSV), patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. Clinical outcomes were compared between male and female patients. RESULTS/UNASSIGNED:> 0.05). CONCLUSION/UNASSIGNED:There is no difference in clinical outcomes, function, satisfaction, or revision procedures in mid- to long-term follow-up after SLAP repair between male and female patients. This data is useful in the preoperative counselling of patients undergoing arthroscopic management of symptomatic superior labral pathology. LEVEL OF EVIDENCE/UNASSIGNED:III.

Pediatric Lyme arthritis is described but not well-characterized in urban populations. Similarities in clinical features between Lyme and septic arthritis also results in some patients with Lyme arthritis undergoing surgical treatment. The aims of this study are to (1) characterize Lyme arthritis in an urban population and (2) determine what factors predispose patients with Lyme arthritis to undergoing surgery. We performed a retrospective review of children with Lyme arthritis at a single academic institution in New York City from 2016 to 2021. Inclusion criteria were age ≤18 years, involvement of a major joint, and positive Lyme serology. Patients treated with irrigation and debridement were compared to those treated non-surgically using Chi-squared tests with a significance of P < 0.05. A total of 106 children with Lyme arthritis were included. Mean age was 9.5 years; 61.3% were male, and 71.7% were Caucasian. 46.2% lived in regions with an average household income >$100 000; 70.8% had private insurance. Ten patients (9.4%) underwent surgery for suspected septic arthritis. The operative group was more likely to have an elevated heart rate, white blood cell count, C-reactive protein level, erythrocyte sedimentation rate level and synovial cell count (P < 0.05). Patients were more likely to undergo surgery if they presented to the emergency department than to the clinic (P = 0.03). The average time for a Lyme test to result was 43.5 h, averaging 8.7 h after the surgical start time. Lyme arthritis occurs commonly in an urban pediatric population. Surgery is performed in ~10% of Lyme arthritis patients. More efficient diagnostic tests may reduce this rate.

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to know the correct usage and definition of these eponyms. In this first part, we describe the history of eponym usage in paediatric hip radiography; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to paediatric hip radiography.

BACKGROUND:Children with suspected fractures are typically evaluated with multiple x-rays. This approach can add time, discomfort, and radiation exposure without clinical benefit. The purpose of this study was to determine whether a focused radiographic protocol could reduce the number of x-rays performed without missing any fractures. METHODS:Pediatric patients presenting at 2 sites within an academic medical center [urgent care (UC) and the emergency department(ED)] for a suspected fracture were identified. There were 495 patients (UC, 409; ED, 86) over a 3-month period. A retrospective chart review was performed to characterize the standard x-rays performed. Using this data, a simplified protocol was developed and distributed. Subsequently, 333 patients (UC, 259; ED, 74) were evaluated over the same period 1-year later. The main outcome measures included the final diagnosis, the total number of x-rays, the number of anatomic areas imaged, visit length, and the time for additional trips to radiology. Charts were reviewed to identify any missed injuries. Welch 2-sample t tests and Fisher exact tests were used for statistical analysis. RESULTS:After implementing the radiographic protocol, there was a significant reduction in the number of x-ray views, 3.4 versus 5.1 (P<0.001). There was a decrease in imaging of multiple anatomic areas with the largest reduction occurring in patients presenting with elbow injuries (9% vs. 44%, P<0.001). No difference was found in the rate of patients sent back to radiology (6% vs. 7%, P=0.67). However, among patients presenting with outside imaging, significantly fewer were sent to radiology for additional x-rays (29% vs. 50%, P<0.01). CONCLUSION/CONCLUSIONS:A simple radiographic protocol for evaluating pediatric patients with suspected fractures safely led to a decrease in the overall number of x-rays without missing any injuries. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

OBJECTIVE/UNASSIGNED:Femoroacetabular impingement (FAI) appears common in ice hockey, but there is a lack of data examining pincer-type impingement in women's ice hockey athletes. The objective of this study was to assess the prevalence of pincer-type impingement in National Women's Hockey League (NWHL) athletes. Our hypothesis was that there would be an increased prevalence of pincer impingement in these athletes. METHODS/UNASSIGNED:Data were gathered for a team of NWHL players, and age, gender, and body mass index (BMI) matched controls were also retrospectively collected. All subjects were above 18 years of age. Control patients were excluded if they had undergone prior hip surgery, were greater than age 30, or had BMI greater than 35. Radiographs of both groups were assessed for lateral center edge angle (LCEA), Tönnis angle, and crossover sign. Tönnis angle <0 or LCEA >40 degrees was considered pincer morphology. An alpha angle >55 degrees was considered cam morphology. RESULTS/UNASSIGNED:Thirty-seven NWHL players and 37 female controls were included. Overall 32% of the players had a pincer lesion in either hip based on LCEA, 8% had a Tönnis angle <0, and 22% had a crossover sign in either hip compared to 9%, 19%, and 13% for the controls, respectively. None of these findings were significantly different between the groups (p > 0.05). An alpha angle ≥55 degrees in either hip was found in 84% of players, but lateral Dunn images for alpha angle measurements were not available for the control group. CONCLUSIONS/UNASSIGNED:Pincer-type morphology and crossover signs were present in a larger portion of NWHL players than has been reported in the general population, but these findings were not statistically different than in the control group. Cam-type morphology was even more prevalent in these athletes and may be related to age at menarche due impingement at the physis prior to closure.

UNLABELLED:Bulletin of the Hospital for Joint Diseases 2022;80(4):252-6252 Bloom DA, Gonzalez M, Hurley ET, Kingery MT, Carter CW, Jazrawi LM, Strauss EJ. Sex-based differences in outcomes of tibial tubercle anteromedi- alization. Bull Hosp Jt Dis. 2022;80(4):252-6. Abstract Background: Previous research has demonstrated sex- based differences in patient-reported outcomes of orthopedic surgical procedures. The hypothesis of the current study was that females would have inferior patient-reported outcomes to their male peers following a tibial tubercle anteromedial- ization (AMZ) procedure for both patellofemoral instability and cartilage defects. METHODS:Patients who had undergone AMZ for isolated osteochondral defect or patellofemoral instability with a minimum follow-up time of 1 year were identified. They were then asked to complete several patient-reported outcome questionnaires that were then statistically analyzed. RESULTS:Overall, 109 patients were included in this study. Seventy-nine patients (72.5%) were female with a mean follow-up duration of 3.4 ± 2.0 years. Forty-seven females had AMZ for patellar instability while 32 females had AMZ for osteochondral defects. There were no statistically signifi- cant differences between sexes with respect to concomitant procedures performed, visual analog scale (VAS) pain score, or patient reported outcome (PRO) scores at follow-up (p > 0.05). There was no statistically significant difference with respect to outcomes between the sexes for AMZ overall and when isolating the sexes based on indication. CONCLUSION/CONCLUSIONS:This study demonstrates that female patients undergoing AMZ have short-term clinical and functional outcomes that are not significantly different to those reported in males.

➤/UNASSIGNED:Sports participation can improve gait, muscle strength, and functional abilities in patients with a wide variety of disabilities. Para athletes are also at substantial risk for injury during sports participation. ➤/UNASSIGNED:Ambulant athletes with cerebral palsy are at risk for soft-tissue injuries about the knee as well as foot and ankle injuries. Wheelchair athletes are at risk for osteoporotic fractures and shoulder girdle injuries. Limb-deficient athletes are prone to low back pain and overuse injuries of the contralateral extremity. ➤/UNASSIGNED:Para athletes are vulnerable to abuse during sports participation, and physicians should promptly report any possible abuse or mistreatment. ➤/UNASSIGNED:Orthopaedic surgeons should understand disability and sport-specific risk factors for injury in para athletes in order to initiate early management and injury prevention protocols.