Preoperative Paralabral Cysts Predict More Significant Chondral Damage but Not 2-Year Functional Outcomes Following Arthroscopic Labral Repair

PURPOSE

To investigate whether paralabral cysts identified incidentally on preoperative magnetic resonance imaging/arthrography predict 2-year functional outcomes after arthroscopic acetabular labral repair.

METHODS

Prospectively collected data for patients undergoing primary hip arthroscopy by a single surgeon from 2014 to 2020 were retrospectively reviewed. Included patients were ≥18 years and completed baseline patient-reported outcome measures (PROMs) with additional follow-up at 3, 6, 12, and 24 months. Exclusion criteria were labral debridement, hip dysplasia, advanced hip osteoarthritis (Tönnis > 1), or previous ipsilateral hip surgery. Patients were stratified based on the presence of paralabral cysts identified on magnetic resonance imaging/arthrography. Primary outcomes were International Hip Outcome Tool and modified Harris Hip Score. Secondary outcomes included other PROMs and the visual analog pain scale. Outcomes were compared between cohorts using linear mixed-effects models and Fisher's exact tests. Sensitivity analyses accounted for preoperative PROMs, nonlinear improvement trajectories, and relevant baseline characteristics.

RESULTS

Of the 182 included hips (47.8% female; mean ± standard deviation age, 36.9 ± 11.4), 30 (16.4%) had paralabral cysts. During the 2-year study period, there were no significant differences between patients with and without paralabral cysts in terms of International Hip Outcome Tool scores (weighted difference = 1.60; 95% confidence interval [CI], -5.09, 8.28; P = .64), modified Harris Hip Scores (weighted difference = 0.56; 95% CI, -4.16, 5.28; P = .82), or any secondary outcomes (except for HOS-Sports Subscale at 3 months [mean difference = -11.85; 95% CI, -22.85, -0.84; P = .035]). Furthermore, there were no significant differences in clinically meaningful outcomes (P > .05 for all), revision rates (P > .99), or conversion to total hip arthroplasty between cohorts (P > .99). These results held across all sensitivity analyses.

CONCLUSIONS

Although preoperative paralabral cysts were associated with worse cam impingement and more severe chondral damage observed intraoperatively, they did not predict 2-year functional outcomes or clinically meaningful improvements, suggesting that incidentally discovered paralabral cysts are not a contraindication for arthroscopic labral repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Association Between Chondrolabral Junction Breakdown and Conversion to Total Hip Arthroplasty After Hip Arthroscopy for Symptomatic Labral Tears: Minimum 8-Year Follow-up

BACKGROUND

Arthroscopic treatment of femoroacetabular impingement (FAI) and symptomatic labral tears confers short- to midterm benefits, yet further long-term evidence is needed. Moreover, despite the physiological and biomechanical significance of the chondrolabral junction (CLJ), the clinical implications of damage to this transition zone remain understudied.

PURPOSE

To (1) report minimum 8-year survivorship and patient-reported outcome measures after hip arthroscopy for FAI and (2) characterize associations between outcomes and patient characteristics (age, body mass index, sex), pathological parameters (Tönnis angle, alpha angle, type of FAI, CLJ breakdown), and procedures performed (labral management, FAI treatment, microfracture).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This retrospective cohort study included patients who underwent primary hip arthroscopy for symptomatic labral tears secondary to FAI by a single surgeon between 2002 and 2013. All patients were ≥18 years of age with minimum 8-year follow-up and available preoperative radiographs. The primary outcome was conversion to total hip arthroplasty (THA), and secondary outcomes included revision arthroscopy, patient-reported outcome measures, and patient satisfaction. CLJ breakdown was assessed using the Beck classification. Kaplan-Meier estimates and weighted Cox regression were used to estimate 10-year survivorship (no conversion to THA) and identify risk factors associated with THA conversion.

RESULTS

In this study of 174 hips (50.6% female; mean age, 37.8 ± 11.2 years) with mean follow-up of 11.1 ± 2.5 years, the 10-year survivorship rate was 81.6% (95% CI, 75.9%-87.7%). Conversion to THA occurred at a mean 4.7 ± 3.8 years postoperatively. Unadjusted analyses revealed several variables significantly associated with THA conversion, including older age; higher body mass index; higher Tönnis grade; labral debridement; and advanced breakdown of the CLJ, labrum, or articular cartilage. Survivorship at 10 years was inferior in patients exhibiting severe (43.6%; 95% CI, 31.9%-59.7%) versus mild (97.9%; 95% CI, 95.1%-100%) breakdown of the CLJ (P < .001). Multivariable analysis identified worsening CLJ breakdown (weighted hazard ratio per 1-unit increase, 6.41; 95% CI, 3.11-13.24), older age (1.09; 95% CI, 1.04-1.14), and higher Tönnis grade (4.59; 95% CI, 2.13-9.90) as independent negative prognosticators (P < .001 for all).

CONCLUSION

Although most patients achieved favorable minimum 8-year outcomes, several pre- and intraoperative factors were associated with THA conversion; of these, worse CLJ breakdown, higher Tönnis grade, and older age were the strongest predictors.

The Effect of Pelvic Incidence on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement and Acetabular Labral Tears

BACKGROUND

In the setting of femoroacetabular impingement (FAI), decompression osteoplasties reconcile deleterious loading patterns caused by cam and pincer lesions. However, native variations of spinopelvic sagittal alignment may continue to perpetuate detrimental effects on the labrum, chondrolabral junction, and articular cartilage after hip arthroscopy.

PURPOSE

To evaluate the effect of pelvic incidence (PI) on postoperative outcomes after hip arthroscopy for acetabular labral tears in the setting of FAI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective query of prospectively collected data identified patients ≥18 years of age who underwent primary hip arthroscopy for FAI and acetabular labral tears between February 2014 and January 2022, with 3-, 6-, 12-, and 24-month follow-ups. Measurements for PI, pelvic tilt (PT), sacral slope (SS), and acetabular version were obtained via advanced diagnostic imaging. Patients were stratified into low-PI (<45°), moderate-PI (45°≤ PI ≤ 60°), and high-PI (>60°) cohorts. Patient-reported outcome measures (PROMs), clinically meaningful outcomes (ie, minimal clinically important difference, Patient Acceptable Symptom State, substantial clinical benefit, and maximal outcome improvement), visual analog scale (VAS) pain scores, and patient satisfaction were compared across cohorts.

RESULTS

A total of 74 patients met eligibility criteria and were stratified into low-PI (n = 28), moderate-PI (n = 31), and high-PI (n = 15) cohorts. Correspondingly, patients with high PI displayed significantly greater values for PT (P = .001), SS (P < .001), acetabular version (P < .001), and acetabular inclination (P = .049). By the 12- and 24-month follow-ups, the high-PI cohort was found to have significantly inferior PROMs, VAS pain scores, rates of clinically meaningful outcome achievement, and satisfaction relative to patients with moderate and/or low PI. No significant differences were found between cohorts regarding rates of revision arthroscopy, subsequent spine surgery, or conversion to total hip arthroplasty.

CONCLUSION

After hip arthroscopy, patients with a high PI (>60°) exhibited inferior PROMs, rates of achieving clinically meaningful thresholds, and satisfaction at 12 and 24 months relative to patients with low or moderate PI. Conversely, the outcomes of patients with low PI (<45°) were found to match the trajectory of those with a neutral spinopelvic alignment (45°≤ PI ≤ 60°). These findings highlight the importance of analyzing spinopelvic parameters preoperatively to prognosticate outcomes before hip arthroscopy for acetabular labral tears and FAI.

Operative management of rotator cuff tears: identifying disparities in access on a national level

BACKGROUND

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status.

METHODS

Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears.

RESULTS

This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004).

CONCLUSION

There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

BACKGROUND

The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion.

PURPOSE

To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA).

RESULTS

A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up.

CONCLUSION

After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.

Using a Combined All-Inside, Inside-Out, and Outside-In Technique to Repair Bucket-Handle Medial Meniscal Tears Without a Safety Incision

We describe a combined all-inside, inside-out, and outside-in technique for the repair of unstable bucket-handle medial meniscal tears. Notably, a greater incidence of neurovascular complications has been associated with meniscal repair techniques that employ an accessory skin incision, especially when damage involves the body of the medial meniscus. However, with the operative knee in relative extension, passing inside-out needles anteromedial to the posterior horn and posterior to the semitendinosus tendon and saphenous nerve allows for the needles to exit the posteromedial knee through a "safe zone." Therefore, we reduce iatrogenic damage by avoiding the necessity of a large safety incision while still maintaining suture placement versatility and meniscal fragment stabilization. Thus, the objective of this Technical Note is to outline an efficient technique for treating bucket-handle medial meniscal tears that yields a strong, durable repair while avoiding damage to adjacent neurovascular structures and eliminating the need for a posteromedial safety incision.

Labral Reconstruction via Capsular Augmentation Maintains Perfusion to the Acetabular Labrum and Locally Transferred Autograft: An in Vivo Laser Doppler Flowmetry Analysis

Background

The purpose of the present study was to examine the effects of arthroscopic labral repair with capsular augmentation on blood flow in vivo with use of laser Doppler flowmetry (LDF) to measure microvascular perfusion of the labrum and autograft tissue.

Methods

The present prospective case series included patients ≥18 years old who underwent arthroscopic acetabular labral repair with capsular augmentation; all procedures were performed by a single surgeon between 2018 and 2022. The LDF probe measured microvascular blood flow flux within 1 mm3 of the surrounding labral and capsular tissue of interest. Mean baseline measurements of flux were compared with readings immediately following capsular elevation and after completing labral augmentation. Blood flux changes were expressed as the percent change from the baseline measurements.

Results

The present study included 41 patients (24 men [58.5%] and 17 women [41.5%]) with a mean age (and standard deviation) of 31.3 ± 8.4 years, a mean BMI of 24.6 ± 3.4 kg/m2, a mean lateral center-edge of angle 35.3° ± 4.9°, a mean Tönnis angle of 5.8° ± 5.8°, and a mean arterial pressure of 93.7 ± 10.9 mm Hg. Following capsular elevation, the mean percent change in capsular blood flow flux was significantly different from baseline (-9.24% [95% confidence interval (CI), -18.1% to -0.04%]; p < 0.001). Following labral augmentation, the mean percent change in labral blood flow flux was significantly different from baseline both medially (-22.3% [95% CI, -32.7% to -11.9%]; p < 0.001) and laterally (-32.5% [95% CI, -41.5% to -23.6%]; p = 0.041). There was no significant difference between the changes in medial and lateral perfusion following repair (p = 0.136).

Conclusions

Labral repair with capsular augmentation sustains a reduced blood flow to the native labrum and capsular tissue at the time of fixation. The biological importance of this reduction is unknown, but these findings may serve as a benchmark for other labral preservation techniques and support future correlations with clinical outcomes.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Harvest and Application of Bone Marrow Aspirate Concentrate to Address Acetabular Chondral Damage During Hip Arthroscopy

Background

During hip arthroscopy, managing concomitant cartilage damage and chondrolabral junction breakdown remains an ongoing challenge for orthopaedic surgeons, as previous studies have associated such lesions with inferior postoperative outcomes1-7. Although higher-level studies are needed to fully elucidate the benefits, recent literature has provided supporting preliminary evidence for the utilization of bone marrow aspirate concentrate (BMAC) in patients with moderate cartilage damage and full-thickness chondral flaps undergoing acetabular labral repair7,8. Thus, as the incorporation of orthobiologics continues to advance, there is a clinical demand for an efficient and reliable BMAC-harvesting technique that utilizes an anatomical location with a substantial concentration of connective tissue progenitor (CTP) cells, while avoiding donor-site morbidity and minimizing additional operative time. Thus, we present a safe and technically feasible approach for harvesting bone marrow aspirate from the body of the ilium, followed by centrifugation and application during hip arthroscopy.

Description

After induction of anesthesia and appropriate patient positioning, a quadrilateral arrangement of arthroscopic portals is established to perform puncture capsulotomy9. Upon arthroscopic visualization of cartilage/chondrolabral junction injury, 52 mL of whole venous blood is promptly obtained from an intravenous access site and combined with 8 mL of anticoagulant citrate dextrose solution A (ACD-A). The mixture is centrifuged to yield approximately 2 to 3 mL of platelet-rich plasma (PRP) and 17 to 18 mL of platelet-poor plasma (PPP). Then, approaching along the coronal plane and aiming toward the anterior-superior iliac spine under fluoroscopic guidance, a heparin-rinsed Jamshidi bone marrow biopsy needle is driven through the lateral cortex of the ilium just proximal to the sourcil. Under a relative negative-pressure vacuum, bone marrow is aspirated into 3 separate heparin-rinsed 50 mL syringes, each containing 5 mL of ACD-A. Slow and steady negative pressure should be used to pull back on the syringe plunger to aspirate a total volume of 40 mL into each syringe. To avoid pelvic cavity compromise and minimize the risk of mobilizing marrow-space contents, care should be taken to ensure that no forward force or positive pressure is applied during the aspiration process. A total combined bone marrow aspirate/ACD-A mixture of approximately 120 mL is consistently harvested and subsequently centrifuged to yield roughly 4 to 6 mL of BMAC. The final mixture containing BMAC, PRP, and PPP is combined with thrombin to generate a megaclot, which is then applied to the central compartment of the hip.

Alternatives

Currently, strategies to address acetabular cartilage lesions may include microfracture, autologous chondrocyte implantation, matrix-induced autologous chondrocyte implantation, autologous matrix-induced chondrogenesis, osteochondral allografts, and orthobiologics10. Orthobiologics have shown mixed yet promising results for addressing musculoskeletal injuries and may include bone-marrow-derived mesenchymal stromal cells, adipose tissue derivatives, and PRP7,8,11,12. Specifically, bone marrow aspirate can be harvested from numerous locations, such as the iliac crest, the proximal aspect of the humerus, the vertebral body, and the distal aspect of the femur. Moreover, alternative approaches have utilized multiple-site and/or needle-redirection techniques to optimize cellular yield16,17, while also appreciating the potentially variable cellular characteristics of aspirated and/or processed samples18. However, previous literature has demonstrated that the body of the ilium contains a CTP cell concentration that is similar to or greater than other harvest locations when utilizing this outlined single-site and unidirectional aspirating technique13,14.

Rationale

This versatile and updated technique is a safe and reproducible method for BMAC harvesting, processing, and application that avoids donor-site morbidity, obtains a substantial concentration of CTP cells, minimizes additional operative time, and limits the hip arthroscopy and aspiration to a single procedure15. Specifically, this technique details an evidence-supported approach to addressing chondral injury in patients undergoing acetabular labral repairs7,8.

Expected Outcomes

Patients with moderate cartilage damage treated with BMAC at the time of labral repair experienced significantly greater improvements in functional outcomes at 12 and 24 months postoperatively compared with similar patients without BMAC augmentation7. Furthermore, patients with full-thickness chondral flaps treated with BMAC at the time of arthroscopic labral repair demonstrated significantly greater improvements in functional outcomes at 12 months compared with microfracture. Moreover, 77.6% of the BMAC cohort reached the minimal clinically important difference threshold for the International Hip Outcome Tool-33 (iHOT-33) compared with 50.0% in the microfracture group8.

Important Tips

Utilize the previously established Dienst arthroscopic portal for the bone marrow aspiration in order to avoid secondary donor site morbidity.Under fluoroscopic guidance, approach the ilium along the coronal plane, aiming toward the anterior superior iliac spine.With a heparin-rinsed Jamshidi bone marrow biopsy needle, penetrate the lateral cortex of the ilium just proximal to the sourcil in order to consistently harvest a total combined bone marrow aspirate/ACD-A volume of approximately 120 mL.Simultaneously perform the bone marrow aspirate and whole venous blood centrifugation during the hip arthroscopy procedure in order to minimize additional operative time.Bone marrow aspiration should be performed without applied traction in order to minimize the risk of neurovascular complications associated with extended traction time.

Acronyms and Abbreviations

ACD-A = anticoagulant citrate dextrose solution AADSCs = adipose-derived stem cellsASIS = anterior superior iliac spineBMAC = bone marrow aspirate concentrateCI = confidence intervalCTP = connective tissue progenitorDVT = deep vein thrombosisHOS-ADL = Hip Outcome Score, Activities of Daily LivingiHOT-33 = International Hip Outcome Tool-33MCID = minimal clinically important differenceMRA = magnetic resonance arthrogramMSCs = mesenchymal stromal cellsPPP = platelet-poor plasmaPRP = platelet-rich plasmaRBCs = red blood cellsSD = standard deviationT1 = longitudinal relaxation timeT2 = transverse relaxation timeWBCs = white blood cells.

Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes

Background

The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament.

Purpose

To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique.

Study Design

Case series; Level of evidence, 4.

Methods

The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs.

Results

A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively.

Conclusion

Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.

Return to Full Function in Patient with Nonoperative Management of a Comminuted, Displaced Clavicle Fracture: A Case Report

Case

Clavicle fractures are common skeletal injuries that account for 2%-10% of adult fractures. Surgical indications include presence of an open fracture, severe angulation, comminution, displacement, skin tenting with a threat of skin perforation, neurovascular compromise, symptomatic nonunion, or fracture shortening >1.5-2cm. In this case, the patient had a comminuted, displaced fracture - thus meeting criteria for operative treatment. However, the patient opted for nonoperative management.

Conclusion

After 3 months, the patient regained full strength and range-of-motion. This case highlights the current heterogenous mixture of studies in the literature surrounding the best management for midshaft clavicle fractures. The patient was informed that data concerning the case would be submitted for publication and provided consent.

Adhesive Capsulitis of the Hip: A Case Presentation and Review

There remains a paucity of literature addressing adhesive capsulitis of the hip (ACH), making the diagnosis and treatment a continued challenge for healthcare providers. ACH encompasses restricted hip range-of-motion and pain that progresses through analogous Stages (1-4) to adhesive capsulitis of the shoulder. We report a case presentation of a middle-aged man that illustrates the significance of certain patient factors and provide a review of current literature to aid in the diagnostic evaluation and treatment for addressing ACH. Initial conservative treatment of ACH includes the appropriate management of associated comorbidities, oral and/or injectable pharmacologics, and physical therapy. While frequently resolving with time, refractory cases of ACH may require more aggressive approaches including pressure dilation, manipulation under anesthesia, synovectomy, capsular release and, for select patients, total hip arthroplasty. Given the limited available literature addressing ACH, healthcare providers may be forced to rely on a small number of published case reports and outdated review articles to guide their diagnostic evaluation and treatment approaches. Thus, this case presentation and review provides an updated approach to better diagnose and manage patients with ACH.

Supraspinatus pathology on MRI is associated with degree of weakness on dynamic clinical strength testing

OBJECTIVE

To analyze shoulder strength and function in patients presenting with possible supraspinatus pathology and to ascertain if these clinical findings are associated with severity of supraspinatus pathology on MRI.

MATERIALS AND METHODS

In total, 171 patients with presumptive rotator cuff pathology and with preserved strength on standard rotator cuff examination were prospectively recruited. Patients were subjected to bilateral shoulder strength testing employing dynamometry; this included isometric strength testing at 90° of abduction, followed by eccentric assessment of isotonic strength from full abduction through the full range of motion until the arm rested at the patient's side. We calculated absolute strength and symptomatic-to-asymptomatic arm (S/A) strength ratios. On subsequent shoulder MRI, supraspinatus pathology was designated into one of seven categories. The association between strength measurements and MRI findings was analyzed.

RESULTS

Increasing lesion severity on MRI was associated with both decreasing absolute strength (no tear [59.9 N] to full-thickness tear [44.2 N]; P = 0.036) and decreasing S/A strength ratios during isotonic testing (no tear [91.9%] to full-thickness tear [65.3%]; P = 0.022). In contrast, there were no significant relationships between imaging severity and absolute strength or S/A strength ratios on isometric testing.

CONCLUSION

Severity of supraspinatus pathology on MRI was associated with dynamic clinical function. These results validate the clinical correlation between MRI designations of supraspinatus pathology and function and suggest the need for future work to investigate utility of dynamic (versus isometric) rotator cuff physical examination maneuvers.

Racial disparities in arthroscopic rotator cuff repair: an analysis of utilization and perioperative outcomes

Background

There remains a paucity of literature addressing racial disparities in utilization and perioperative metrics in arthroscopic rotator cuff repair procedures.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was used to evaluate patients undergoing arthroscopic rotator cuff repair from 2010 to 2019. Baseline demographics, utilization trends, and perioperative measures, including adverse events, operative time, length of hospital stay, days from operation to discharge, and readmission, were analyzed.

Results

Of 42,443 included patients, 38,090 (89.7%) were White, and 4353 (10.3%) were Black or African American. Black or African American patients had a significantly higher percentage of diabetes mellitus (23.6% vs. 15.6%), smoking (16.9% vs. 14.8%), congestive heart failure (0.3% vs. 0.1%), and hypertension (59.2% vs. 45.9%). In addition, logistic regression showed that Black or African American patients had increased odds of longer operative time (adjusted rate ratio 1.07, 95% confidence interval 1.05-1.08) and time from operation to discharge (adjusted rate ratio 1.19, 95% confidence interval 1.04-1.37). Disparities in relative utilization decreased as the proportion of Black or African American patients undergoing arthroscopic rotator cuff repair increased (7.4% in 2010 vs. 10.4% in 2019) compared with White patients (P _trend < .0001).

Conclusion

Racial disparities exist regarding baseline comorbidities and perioperative metrics in arthroscopic rotator cuff repair. Further investigation is needed to fully understand and address the causes of these inequalities to provide equitable care.

Sex Differences in Utilization and Perioperative Outcomes of Arthroscopic Rotator Cuff Repair

Background

As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex.

Results

Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable.

Conclusion

Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

Arthroscopic Acetabular Labral Repair Versus Labral Debridement: Long-term Survivorship and Functional Outcomes

Background:

Arthroscopic treatment for labral tears includes debridement and repair. Long-term studies have failed to demonstrate a difference between these treatments in terms of conversion to total hip arthroplasty (THA).

Purpose:

To investigate 2 different labral treatments, debridement and repair, using an adjusted analysis to evaluate long-term conversion to THA.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This was a retrospective cohort study of patients who underwent hip arthroscopy by a single surgeon between April 2007 and October 2014. Postoperative follow-up information included conversion to THA, patient satisfaction, and patient-reported outcome measures (modified Harris Hip Score; Hip Outcome Score, Activities of Daily Living and Sports Specific subscales; International Hip Outcome Tool; Nonarthritic Hip Score; and Lower Extremity Functional Scale).

Results:

Of the 204 hips included in the study, 99 (48.5%) underwent labral repair, and 105 (51.5%) underwent debridement. In total, 28 (13.7%) of the 204 patients underwent conversion to THA within 10 years after hip arthroscopy (labral repair: 5 [5.0%] vs labral debridement: 23 [21.9%]). Labral repair was associated with a significantly lower risk of conversion to THA compared with debridement (hazard ratio [HR] = 0.24; 95% CI, 0.07-0.74; P = .014). Additional factors associated with risk of conversion to THA included older age at the time of arthroscopy (HR = 1.06 per year; 95% CI, 1.02-1.11; P = .002) and Tönnis grade (HR = 2.39; CI, 1.14-5.41; P = .026). Abrasion chondroplasty, acetabuloplasty, body mass index, Outerbridge grade, and radiographic femoroacetabular impingement were not found to be significantly associated with risk of THA. No significant difference in patient satisfaction was found between treatment groups, and for patients who did not convert to THA, there was no difference in mean patient-reported outcome scores at final follow-up.

Conclusion:

Patients who underwent labral repair were less likely to convert to THA compared with patients who underwent labral debridement, despite adjustment for differences in baseline patient characteristics and preexisting pathology. Additional factors associated with a lower rate of hip survival were older age and osteoarthritis at the time of hip arthroscopy.

Accelerated versus standard physical therapy in patients with transtendinous rotator cuff repair: a propensity-matched cohort study

BACKGROUND

Partial-thickness rotator cuff tears that remain symptomatic despite conservative management can be repaired operatively through a transtendinous approach. Although transtendinous repairs have been linked to superior long-term biomechanical outcomes compared with other surgical techniques, they are classically associated with early postoperative stiffness and a slower rate of recovery.

PURPOSE

To examine the impact of expediting the physical therapy (PT) regimen after transtendinous repair on postoperative range of motion and complications.

METHODS

The first 61 patients to receive accelerated PT after transtendinous repair were compared with a historical cohort of 61 patients who underwent standard postoperative management. The patients were propensity matched on age, sex, smoking status, and biceps procedure performed at the time of rotator cuff repair. Primary outcome measures included active range of motion (AROM) in forward flexion, abduction, external rotation, and internal rotation at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Secondary outcome measures included development of severe stiffness or symptomatic rotator cuff retear at 1-year follow-up. Patients with full-thickness tears and those undergoing revision surgery or tear-completion and repair were excluded.

RESULTS

The accelerated PT cohort showed significantly increased AROM at 6 weeks and 3 months postoperatively. At 6 weeks, AROM in forward flexion (137.0° vs. 114.9°; P < .001), abduction (126.1° vs. 105.3°; P = .009), and external rotation (51.7° vs. 36.5°; P = .005) were all significantly higher in the accelerated PT cohort. A similar increase was seen at 3 months, with superior forward flexion (147.5° vs. 134.0°; P = .01) and external rotation (57.7° vs. 44.0°; P = .008) in patients who received accelerated PT. Severe postoperative stiffness was significantly less common in the accelerated PT cohort (3.3% vs. 18.0%; P = .02), and there were no symptomatic retears (0.00%) in the accelerated PT cohort as compared with 1 symptomatic retear (1.64%) in the standard PT cohort (P = 1.00).

CONCLUSION

Accelerated PT after transtendinous rotator cuff repair is associated with significant improvement in AROM at 6 weeks and 3 months postoperatively. Further, the early motion may help obviate the development of severe postoperative stiffness without any evidence of higher rotator cuff retear rates.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Comparison; Treatment Study.

Evidence-Based Hamstring Injury Prevention and Risk Factor Management: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Hamstring injuries are common among athletes. Considering the potentially prolonged recovery and high rate of recurrence, effective methods of prevention and risk factor management are of great interest to athletes, trainers, coaches, and therapists, with substantial competitive and financial implications.

PURPOSE

To systematically review the literature concerning evidence-based hamstring training and quantitatively assess the effectiveness of training programs in (1) reducing injury incidence and (2) managing injury risk factors.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

A computerized search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus with manual screening of selected reference lists was performed in October 2020. Randomized controlled trials investigating methods of hamstring injury prevention and risk factor management in recreational, semiprofessional, and professional adult athletes were included.

RESULTS

Of 2602 articles identified, 108 were included. Eccentric training reduced the incidence of hamstring injury by 56.8% to 70.0%. Concentric hamstring strength increased with eccentric (mean difference [MD], 14.29 N·m; 95% CI, 8.53-20.05 N·m), concentric, blood flow-restricted, whole-body vibration, heavy back squat, FIFA 11+ (Fédération Internationale de Football Association), and plyometric training methods, whereas eccentric strength benefited from eccentric (MD, 26.94 N·m; 95% CI, 15.59-38.30 N·m), concentric, and plyometric training. Static stretching produced greater flexibility gains (MD, 10.89°; 95% CI, 8.92°-12.86°) than proprioceptive neuromuscular facilitation (MD, 9.73°; 95% CI, 6.53°-12.93°) and dynamic stretching (MD, 6.25°; 95% CI, 2.84°-9.66°), although the effects of static techniques were more transient. Fascicle length increased with eccentric (MD, 0.90 cm; 95% CI, 0.53-1.27 cm) and sprint training and decreased with concentric training. Although the conventional hamstring/quadriceps (H/Q) ratio was unchanged (MD, 0.03; 95% CI, -0.01 to 0.06), the functional H/Q ratio significantly improved with eccentric training (MD, 0.10; 95% CI, 0.03-0.16). In addition, eccentric training reduced limb strength asymmetry, while H/Q ratio and flexibility imbalances were normalized via resistance training and static stretching.

CONCLUSION

Several strategies exist to prevent hamstring injury and address known risk factors. Eccentric strengthening reduces injury incidence and improves hamstring strength, fascicle length, H/Q ratio, and limb asymmetry, while stretching-based interventions can be implemented to improve flexibility. These results provide valuable insights to athletes, trainers, coaches, and therapists seeking to optimize hamstring training and prevent injury.

Acetabular Labral Tear with a Missed Posterior Wall Fracture in an Adolescent Athlete: A Case Report

CASE

We present an adolescent contact-sport athlete presenting with hip pain after a traumatic in-play event. After delayed clinical improvement, a magnetic resonance arthrogram (MRA) revealed a posterior acetabular labral tear and the patient was referred for arthroscopic repair. However, subsequent critical interpretation of the MRA demonstrated a missed concomitant posterior acetabular wall fracture, which was later confirmed with computed tomography.

CONCLUSION

Despite the low incidence of acetabular fractures in adolescents, this case report highlights the importance of maintaining clinical suspicion in young athletes after a traumatic injury, recognizing the association with labral tears, and acknowledging the limitations of certain imaging modalities.

Calf Strain in Athletes

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Calf strain is a common condition. In high-performance athletes, calf strain contributes to a substantial absence from competition.

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Player age and history of a calf strain or other leg injury are the strongest risk factors for calf strain injury and reinjury.

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Although the diagnosis is often clinical, magnetic resonance imaging and ultrasound are valuable to confirm the location of the strain and the grade of injury.

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Nonoperative treatment is effective for most calf strain injuries. Operative management, although rarely indicated, may be appropriate for severe cases with grade-III rupture or complications.

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Further investigation is necessary to elucidate the benefits of blood flow restriction therapy, deep water running, lower-body positive pressure therapy, platelet-rich plasma, and stem cell therapy for calf strain rehabilitation.

Comparison of Perioperative Complications Following Surgical Treatment of Shoulder Instability

Background

Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow.

Methods

This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time.

Results

This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P_trend < .001).

Conclusion

In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.

Scaffolds for Use in Craniofacial Bone Regeneration

Tissue-engineered scaffolds have been identified as appropriate templates for bone regeneration, especially complex geometries seen in craniofacial defects. Here we describe the general fabrication and modification of hydrogels, cryogels, and electrospun scaffolds. These scaffolds offer a variety of templates for facilitating bone growth and regeneration in craniofacial applications.

Treatment of Full-Thickness Acetabular Chondral Flaps During Hip Arthroscopy: Bone Marrow Aspirate Concentrate Versus Microfracture

Background:

The optimal treatment strategy for patients with full-thickness chondral flaps undergoing hip arthroscopy is controversial.

Purpose:

To compare functional outcomes of patients who underwent bone marrow aspirate concentrate (BMAC) application with those of patients who underwent microfracture.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This was a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by 1 surgeon between June 2014 and April 2020. The inclusion criteria for this study were age ≥18 years, preoperative radiographs of the pelvis, arthroscopic acetabular labral repair, exposed subchondral bone with overlying chondral flap seen at the time of hip arthroscopy, microfracture or BMAC to address this lesion, and completed patient-reported outcome measures (PROMs) (International Hip Outcome Tool–33 [iHOT-33], Hip Outcome Score–Activities of Daily Living [HOS-ADL], Hip Outcome Score–Sports Subscale [HOS-Sport], modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) at enrollment and 12-month follow-up. Clinical outcomes were assessed using PROM scores.

Results:

A total of 81 hips with full-thickness chondral flaps were included in this study: 50 treated with BMAC and 31 treated with microfracture. There were no significant differences between groups in age, sex, body mass index, tear size, radiographic osteoarthritis, or radiographic femoroacetabular impingement. In the BMAC cohort, all PROM scores improved significantly from preoperatively to follow-up: 41.7 to 75.6 for iHOT-33, 67.6 to 91.0 for HOS-ADL, 41.5 to 72.3 for HOS-Sport, 59.4 to 87.2 for mHHS, and 6.2 to 2.2 for VAS pain (P < .001 for all). In the microfracture cohort, the score improvements were 48.0 to 65.1 for iHOT-33 (P = .001), 80.5 to 83.3 for HOS-ADL (P = .275), 59.2 to 62.4 for HOS-Sport (P = .568), 70.4 to 78.3 for mHHS (P = .028), and 4.9 to 3.6 for VAS pain (P = .036). Regarding clinically meaningful outcomes, 77.6% of the BMAC group and 50.0% of the microfracture group met the minimal clinically important difference for iHOT-33 at the 12-month follow-up (P = .013).

Conclusion:

Patients with full-thickness chondral flaps at the time of hip arthroscopy experienced greater improvements in functional outcome scores at the 12-month follow-up when treated with BMAC as opposed to microfracture.

Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures

Background

As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care.

Methods

Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time.

Results

A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31).

Conclusion

When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.

A Critical Review and Perspective of Honey in Tissue Engineering and Clinical Wound Healing

Significance: Historically, honey has been regarded as a potent agent in bacterial inhibition and wound healing. An increased prevalence of antibiotic resistant pathogens spurred an initial resurgence in honey's clinical popularity, with it quickly finding a place in wound care and regenerative medicine. However, this renewed usage demanded a need for improved delivery and overall research of its bioactive properties. This review provides an overview of the antibacterial properties and clinical use of honey. Recent Advances: The past and present clinical use of honey is noted, focusing specifically on burns and ulcers, as these are the most common applications of the natural agent. While honey is often used without modification clinically, there are also commercially available products ranging from dressings to gels, which are discussed. Critical Issues: Despite these products growing in popularity, the need for improved delivery and a structure to support wound healing could improve the treatment method. Future Directions: Tissue engineering scaffolds can provide an alternative method of honey delivery with research focusing primarily on electrospun scaffolds, hydrogels, and cryogels. Current studies on these scaffolds are discussed with respect to their advantages and potential for future clinical work. Overall, this review provides a comprehensive overview of the properties of honey, its current use in wound healing, and the potential for future incorporation into tissue-engineered scaffolds to provide an innovative wound healing agent.