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A large prospective cohort was used (1) to evaluate the overall ability of magnetic resonance imaging (MRI) to detect Outerbridge grade III and IV cartilage defects found during surgery and (2) to identify the specific MRI findings most associated with these cartilage defects so that the practicing hip arthroscopist can better predict cartilage injury before surgery.All patients undergoing hip arthroscopy between February 2015 and May 2017 at 1 institution were enrolled in a prospective cohort. Intra-articular findings were documented at the time of surgery. MRI reports were retrospectively reviewed for radiologist-reported articular cartilage, osseous, or synovial abnormalities. Sensitivity and specificity of MRI findings were calculated; multivariate logistic regression analysis determined which findings were associated with high-grade chondral damage at the time of arthroscopy and used to create an online risk calculator, https://orthop.washington.edu/hiprisk/.Of 598 patients who underwent hip arthroscopy, 550 had MRI reports available for review (92%). Grade III and IV cartilage injuries were reported on arthroscopy in 70 patients (13%) of average age 33 ± 13 years. On univariate analyses, individual MRI findings were not sensitive in detection of articular cartilage injury (mean 22%; range, 1.4%-46%), but positive findings were highly specific (mean 90%,; range, 76%-99%). Multivariate analysis revealed that older age (odds ratio [OR] 1.09 [1.06-1.11], P.001) and osseous findings such as subchondral cyst or edema (OR 4.77 [2.51-9.05], P.001) were most predictive of grade III and IV defects (P.001).MRI was a specific but not sensitive tool in diagnosing articular cartilage injury. Surgeons should be aware that osseous findings such as cysts or edema are highly predictive of full-thickness cartilage loss in FAI.Level III, development of diagnostic criteria (consecutive patients with consistently applied reference standard, no blinding).

The purpose of this study was to evaluate short-term outcomes including medical complications, overnight admission, and 30-day readmission with regard to patient age at the time of shoulder instability surgery.Patients undergoing surgery for glenohumeral instability were collected from the National Surgical Quality Improvement Program between the years of 2005 and 2016. These patients were separated into cohorts of younger than 25 years, 25-34 years, and older than 34 years. Medical complications, hospital admission, and 30-day readmission were compared using multivariate analysis.Of the 5449 patients included, there were 2035 (37.0%) patients younger than 25 years, 1815 (33.0%) between 25 and 34 years, and 1649 (30.0%) 35 and older. Overall, 81.7% of patients underwent an arthroscopic Bankart repair, 12.6% of patients underwent an open Bankart repair, and 5.7% of patients underwent a Latarjet-Bristow procedure. The risk of 30-day readmission increased with age, ranging from 0.24% for25 years old to 0.92% for 35 years and older (P = .040). Operative duration greater than 60 minutes (odds ratio [OR] 1.76; P = .001), duration greater than 90 minutes (OR 3.58; P.001), and American Society of Anesthesiologists class III and IV (OR 1.80; P = .001) were associated with increased risk of overnight hospital stay. Compared with arthroscopic Bankart repair, the Latarjet-Bristow procedure was associated with increased total complications (OR 3.30; P = .021), overnight hospital stay (OR 4.64; P.001), and 30-day readmission (OR 3.39; P = .013).This study demonstrates that even in the relatively young and healthy shoulder instability patient cohort, patients older than 25 years are almost 4 times more likely to experience a complication. Additionally, Latarjet-Bristow procedures are 3-4 times more likely to experience a complication or readmission than other shoulder instability procedures.

Musculoskeletal (MSK) disease comprises over 20% of all visits to healthcare providers each year, yet a disproportionately small percentage of medical school education focuses on MSK disease. Even among students applying into orthopaedic surgery, less than 50% demonstrate prerequisite anatomic knowledge before beginning their residency. Medical school curriculum reform is needed, given that only 15% have a required MSK curriculum. Inadequate education ultimately leads to poor patient care and forces clinicians to learn MSK medicine later in practice. Although this inadequacy in medical school MSK education has been recognized for decades, little has changed to address this critical deficiency. A successful curriculum development requires defining critical MSK topics, evaluative methods to assess knowledge acquisition, and ultimately assessment of applying that knowledge to the care of patients. Newer strategies for MSK education include "near-peer" learning from senior classmates and residents, clinical immersion within MSK care teams, peer interest groups, and standardize learning platforms and assessment tools. Technologies such as virtual reality simulation, adaptive video learning, and other technologies will inform the development of affordable, succinct, evidence-informed curriculums that can enhance medical student MSK education with universal implementation. As clinical practice evolves to optimize patient care, so should the education of physicians who deliver that care.

Background:Patellar tendinopathy is an overuse injury of the patellar tendon frequently affecting athletes involved in jumping sports. The tendinopathy may progress to partial patellar tendon tears (PPTTs). Current classifications of patellar tendinopathy are based on symptoms and do not provide satisfactory evidence-based treatment guidelines.Purpose:To define the relationship between PPTT characteristics and treatment guidelines, as well as to develop a magnetic resonance imaging (MRI)–based classification system for partial patellar tendon injuries.Study Design:Cohort study (prognosis); Level of evidence, 2.Methods:MRI characteristics and clinical treatment outcomes were retrospectively reviewed for 85 patients with patellar tendinopathy, as well as 86 physically active control participants who underwent MRI of the knee for other conditions. A total of 56 patients had a PPTT and underwent further evaluation for tear size and location. The relationship between tear characteristics and clinical outcome was defined with use of statistical comparisons and univariate and logistic regression models.Results:Of the 85 patients, 56 had partial-thickness patellar tendon tears. Of these tears, 91% involved the posterior and posteromedial regions of the proximal tendon. On axial MRI views, patients with a partial tear had a mean tendon thickness of 10 mm, as compared with 6.2 mm for those without ( P < .001). Eleven patients underwent surgery for their partial-thickness tear. All of these patients had a tear >50% of tendon thickness (median thickness of tear, 10.3 mm) on axial views. Logistic regression showed that tendon thickness >8.8 mm correlated with the presence of a partial tear, while tendon thickness >11.45 mm and tear thickness >55.7% predicted surgical management.Conclusion:Partial-thickness tears are located posterior or posteromedially in the proximal patellar tendon. The most sensitive predictor for detecting the presence of a partial tear was patellar tendon thickness, in which thickness >8.8 mm was strongly correlated with a tear of the tendon. Tracking thickness changes on axial MRI may predict the effectiveness of nonoperative therapy: athletes with patellar tendon thickness >11.5 mm and/or >50% tear thickness on axial MRI were less likely to improve with nonoperative treatment. A novel proposed classification system for partial tears, the Popkin-Golman classification, can be used to guide treatment decisions for these patients.

Introduction Patient-reported outcome (PRO) instruments typically are delivered via paper or computer; we validated administration of hip-specific instruments over a mobile phone software communication platform outside a clinical encounter. Methods Consecutive patients (n = 69) presenting to a hip preservation clinic completed the Hip Disability and Osteoarthritis Outcome Score Short Form physical function and pain subscales (HOOS-PS and HOOS-PAIN) using standard collection techniques. The subsequent day, patients completed these instruments via a text messaging software program. Text reminders were sent to encourage completion of unanswered questions. Correlation between in-office and mobile phone delivery of PROs was assessed. Results The intraclass correlation coefficient between in-clinic and mobile phone delivery of HOOS-PS and HOOS-PAIN was 0.72 (95% confidence interval, 0.58 to 0.81) and 0.80 (95% confidence interval, 0.69 to 0.87), respectively. Completion rate of 93% (64 of the 69) was observed using mobile phone and software messaging. Nine patients completed their PRO after being sent a text message reminder. Fifty-one percent of patients completed all PRO questions within 5 minutes; 26% took between 5 and 10 minutes, and 16% took 10 to 30 minutes for completion. Discussion HOOS-PS and HOOS-PAIN PRO instruments administered via text messaging with automated reminders demonstrate good to excellent reproducibility, no minimal detectable change between communication methods, and a high completion rate in adolescents and young adults with hip pain. Mobile phone delivery via automated software may be a valid method for administration of other PROs, allowing for communication with patients anytime and anywhere. Level of evidence Level IV, case series.

Arthroscopic procedures to treat hip pathologies such as femoroacetabular impingement (FAI) syndrome are now established in mainstream orthopaedic practice. Surgical techniques, rehabilitation protocols and outcomes are widely published. However, consensus on standards of practice remains to be determined. The International Hip Preservation Society (ISHA) has undertaken a research study to identify current areas of consensus across the global hip preservation community. The study focussed on consensus statements on the operative steps in the arthroscopic treatment of FAI syndrome. The study methodology was an online Delphi consensus method to collect aggregate opinions from hip preservation surgeons worldwide. Phase 1 of the planned three-phase study is presented here—focusing on consensus statements on the operative steps in the arthroscopic treatment of FAI syndrome. Ninety-nine statements achieved >80% consensus from a panel of 165 surgeons from six continents. This study is the first to evaluate global consensus on the arthroscopic treatment of FAI syndrome, as well as highlighting areas of contention and avenues for future research.

Hip injuries in the overhead athlete have attracted little attention in the past; however, hip and groin injuries make up 5.5% of all professional baseball injuries and continue to increase in prevalence. Hip and groin injuries are exacerbated by the repetitive extremes of motion required for throwing, serving, and spiking a ball as well as the rapid acceleration and deceleration involved in overhead athletics. The diagnosis and management of these injuries in overhead athletes can be challenging, and often involves multiple pain sources. These athletes commonly experience adductor strains and athletic pubalgia/core muscle injuries which often occur concurrently with underlying bony pathology such as femoroacetabular impingement, which leads to limitations in hip range-of-motion. Hip and groin injuries in the overhead athlete can be debilitating and recurring; therefore, accurate and prompt diagnosis and management of these injuries are critical.

The purpose of this study is to evaluate the trends in labral repair in American Board of Orthopaedic Surgery Part II candidates performing hip arthroscopy.Candidates who performed arthroscopic hip surgery between 2011 and 2015 during their American Board of Orthopaedic Surgery Part II board collection period were identified using Current Procedural Terminology codes (29860, 29861, 29862, 29863, 29914, 29915, 29916). The proportion of hip arthroscopy cases including labral repair (Current Procedural Terminology code 29916) were calculated for each year and analyzed by fellowship training experience. Trends in labral repair utilization were calculated using univariate and regression analyses, with significance set at P.05.During the study period, 1,606 hip labral repair cases were performed, with a 35% increase in utilization between 2011 and 2015. Overall, labral repair was performed in 64.8% (1,606/2,480) of hip arthroscopy cases, with a significant increase between 2011 and 2015 (47.4% vs 79.2%; P.001). Of the hip arthroscopy cases including labral repair, 80.4% (1,291/1,606) were performed by candidates with sports medicine fellowship training. The proportion of hip arthroscopy cases including labral repair was highest for surgeons with sports medicine fellowship training compared with those without sports medicine fellowship training (66.1% vs 59.8%; P = .007). Candidates with sports medicine training performing at least 1 labral repair each year increased from 68% to 89% over the study period (P = .0007). The average number of labral repairs per candidate increased significantly over the duration of the study period (P = .0072).Labral repair utilization during hip arthroscopy procedures nearly doubled from 2011 to 2015 for American Board of Orthopaedic Surgery Part II candidates, reflecting a significant change in practice. Current data suggest that nearly 80% of hip arthroscopy procedures include labral repair. These trends may reflect the current practice patterns at academic institutions with sports medicine fellowships.

Purpose To examine the effect of arthroscopic simulator training on technical performance in a human model. Methods A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches of PubMed, Embase, and Cochrane Library were conducted using combinations of the terms virtual, digital, computer, reality, simulation, arthroscopy, training, learning, and education. Studies were considered for inclusion if they tested the effect of arthroscopic simulator training in a randomized controlled fashion, performed testing in a cadaver or live patient, and used explicit outcome measures of technical skill. Data from studies were extracted and study characteristics and outcomes were reviewed. The primary outcome measure was the number of studies in which the simulation trained group had significantly improved performance results relative to the control group in ≥50% of all measured outcomes. Risk of bias was assessed with Cochrane’s Collaboration Tool. Results Twelve studies, including 340 total study participants, were included for review. Eight studies showed improved performance of the simulation trained group relative to the control group in ≥50% of assessed outcomes. Six of ten studies reporting completion time, three of six studies reporting task checklist completion, 3 of 7 studies reporting global rating scales, and 1 of 4 studies reporting Arthroscopic Surgical Skill Evaluation Tool scores showed improved performance of the simulation group relative to the control group for the respective outcome measures. Conclusions The literature is limited due to heterogeneity, both in type and merit, of the outcome measures that have been used to assess the transfer validity of arthroscopic simulator training to clinical performance. Despite the limitations of the literature, this review demonstrates that arthroscopic simulator training has potential to improve clinical performance. Level of Evidence II, systematic review of Level II studies.

The understanding of femoroacetabular impingement (FAI) has increased over the past 10 years, with advancements in diagnosis and surgical techniques. Controversy remains regarding the ideal regimen of conservative care. Additionally, there is wide variety in postoperative clinical practice after hip arthroscopy. This review is a synthesis of resources on rehabilitation as a stand-alone treatment for FAI as well rehabilitation following surgery. Best evidence regarding conservative care is presented followed by postoperative debates on weight-bearing, range of motion, and physical therapy. In most cases, such as use of bracing and continuous passive motion, there are limited experimental studies to rely on. Higher quality evidence is required to support today's rehabilitation practices which are based mostly on theory and individual experience.

Purpose To investigate the current readability of online information pertaining to hip arthroscopy. Methods The terms "hip arthroscopy" and "hip scope" were entered into the advanced search functions of Google, Yahoo!, and Bing on March 25, 2017, and results from the first 3 pages were analyzed. Results were required to be unique, accessible websites with information about hip arthroscopy conveyed primarily via analyzable text. Two reviewers applied inclusion criteria to the initial 97 results, discussing to reach consensus in cases of disagreement. Overall, 60 unique results were reviewed with 48 meeting inclusion criteria. Websites were categorized as physician-sponsored, academic, commercial, governmental and nonprofit organization (NPO), or unspecified. Readability was measured via 6 different indices: the Flesch-Kincaid grade level (FKGL), Flesch Reading Ease (FRE), Gunning Fog Score, SMOG Index, Coleman-Liau Index (CLI), and Automated Readability Index (ARI) along with an average grade level and readability classification score. Results Forty-eight unique websites were assessed for readability, with physician-sponsored webpages composing the majority (47.92%) followed by academic sources (35.42%). The webpages' average grade level, incorporating information from all 6 metrics, was 12.79 ± 1.98. Conclusions The current readability of online information pertaining to hip arthroscopy is at an inappropriately high reading level compared with the sixth-grade level recommended by the American Medical Association and National Institutes of Health, thus introducing significant barriers to understanding for many patients. Online materials should be edited to reduce word and sentence length and complexity, use simpler terms, and minimize use of passive voice to facilitate patient knowledge acquisition and understanding of online information about hip arthroscopy. Clinical Relevance This study shows that the current readability of online information on hip arthroscopy exceeds the suggested sixth-grade reading level. It also emphasizes the need for simplifying written materials and offers specific suggestions on doing so to increase accessibility of information for patients.

Background: The use of arthroscopic treatment for intra-articular hip pathology has demonstrated improved patient-reported outcomes (PROs) with a lower rate of complications, reoperation, and patient morbidity as compared with traditional methods. Although the use of this minimally invasive approach has increased in prevalence, no evidence-based return-to-play (RTP) criteria have been developed to ensure an athlete’s preparedness for sporting activities. Purpose: To determine if there exists sufficient evidence in the literature to support an RTP protocol and functional assessment after hip arthroscopy, as well as to assess the mean rate and duration of RTP. Study Design: Systematic review and meta-analysis. Methods: The search terms “hip arthroscopy,” “return to play,” and 10 related terms were searched in PubMed, Cochrane Library, Scopus, and Web of Science, yielding 263 articles. After screening, 22 articles were included. RTP timeline, rehabilitation protocols, and conditional criteria measures were assessed with previously established criteria. Pooled estimates were calculated for RTP rate and duration, and weighted mean scores were determined for PROs. Results: A total of 1296 patients with 1442 total hips were identified. Although 54.5% (12 of 22) of studies did not provide a guideline for RTP duration after hip arthroscopy, 36.4% (8 of 22) recommended a duration of 4 months, while 9.1% (2 of 22) recommended 3 months. The most frequently described postoperative rehabilitation protocols were weightbearing guidelines (15 studies) and passive motion exercises (9 studies). Only 2 studies satisfied the criteria for a sufficient RTP protocol, and 3 provided a specific replicable test for RTP. The mean RTP duration was 7.4 months (95% CI, 6.1-8.8 months), and the return rate was 84.6% (95% CI, 80.4%-88.8%; P = .008) at a mean ± SD follow-up of 25.8 ± 2.4 months. Mean modified Harris Hip Score (mHHS) improved from 63.1 to 84.1 postoperatively (+33.3%), while Non-arthritic Hip Score improved from 61.7 to 86.8 (+40.7%). A lower preoperative mHHS was significantly associated with a higher postoperative improvement ( r = −0.95, P = .0003). Conclusion: Significant variability exists in RTP protocols among institutions owing to a lack of standardization. Despite a high overall rate of RTP and improvement in PROs after hip arthroscopy, the majority of rehabilitation protocols are not evidence based and rely on expert opinion. No validated functional test currently exists to assess RTP.

The number of times an article has been cited is thought to correspond with its level of academic influence. Within the orthopaedic literature, several citation analyses have been performed, including a recent investigation on the most commonly cited articles on femoroacetabular impingement (FAI); however, no study has determined the most cited investigations on extracapsular hip pathologies, including osteitis pubis, athletic pubalgia, and muscle strains. Such pathologies constitute a significant proportion of lower extremity injuries among athletes. The purpose of this study was to determine the 50 most cited investigations on extra-articular hip injuries by performing a systematic query of the Institute for Scientific Information (ISI) Web of Science (Thomson Reuters, Philadelphia, PA). The following characteristics were determined for each article: number of citations, citation density, journal and publication year, country of origin, language, article type, article subtype, and level of evidence. The number of citations ranged from 46 to 202 (mean 84.4), and the citation densities ranged from 1.7 to 28.4 citations per year (mean: 7.9). Sixty-eight percent of the selected articles involved hamstring strains. The majority of articles were published in the American Journal of Sports Medicine (58%), followed by the Journal of Orthopaedic and Sports Physical Therapy (12%). Most articles were published during the 2000s, originated from the United States, and 100% were written in English. Eighty percent were clinical studies; the majority of which had Level IV evidence. This collection of academic investigations on athletic extra-articular hip injuries can aid in the establishment of a reading curriculum for trainees participating in orthopaedic training programs.

The process of matching into an orthopaedic surgery residency program can be daunting for medical students. Rumors, innuendo, urban myths, and electronic misinformation can accentuate the angst experienced by students both domestically and internationally. This article dispels myths and presents an up-to-date, evidence-based (where possible), and experience-laden road map to assist medical students interested in pursuing a career in orthopaedic surgery. Our framework takes into account the program selection, test scores, letters of recommendation, visiting rotations, interviews, and communication. We hope that this survival guide will serve as a reference point assisting medical students in achieving successful matches into orthopaedic surgery residency programs.

Background: A medial ulnar collateral ligament (UCL) injury of the elbow is an increasingly common injury in professional baseball pitchers. Predictors of success and failure are not well defined for the nonoperative management of these injuries. Purpose: To evaluate the efficacy of objective measures to predict failure of the nonoperative management of UCL injuries. Study Design: Case-control study; Level of evidence, 3. Methods: Thirty-two professional pitchers (82%) met inclusion criteria and underwent an initial trial of nonoperative treatment for UCL tears based on clinical and radiological findings. Age, preseason physical examination results, magnetic resonance imaging (MRI) characteristics, and performance metrics were analyzed for these pitchers. Successful nonoperative management was defined as a return to the same level of play or higher for >1 year. Failure was defined as recurrent pain or weakness requiring a surgical intervention after a minimum of 3 months’ rest when attempting a return to a throwing rehabilitation program. Results: Thirty-two pitchers (mean age, 22.3 years) who underwent initial nonoperative treatment of UCL injuries were evaluated. Thirty-four percent (11/32) failed and required subsequent ligament reconstruction. Sixty-six percent (21/32) successfully returned to the same level of play for 1 year without a surgical intervention. There was no significant difference seen in physical examination findings or performance metrics between these patients. When comparing MRI findings between the groups, 82% (9/11) ( P < .001) who failed nonoperative management had distal tears, and 81% (17/21) who did not fail had proximal tears ( P < .001). When adjusting for age, location, and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 12.40 times greater ( P = .020) with a distal tear. No other variable alone or in combination reached significance. When combining the parameters of a high-grade tear and distal location, 88% (7/8) failed nonoperative management. Conclusion: In professional pitchers, distal UCL tears showed significantly higher odds of failure with nonoperative management compared with proximal tears. Thus, tear location should be considered when deciding between operative and nonoperative management.

Historically, athletic hip injuries have garnered little attention; however, these injuries account for approximately 6% of all sports injuries and their prevalence is increasing. At times, the diagnosis and management of hip injuries can be challenging and elusive for the team physician. Hip injuries are seen in high-level athletes who participate in cutting and pivoting sports that require rapid acceleration and deceleration. Described previously as the "sports hip triad," these injuries consist of adductor strains, osteitis pubis, athletic pubalgia, or core muscle injury, often with underlying range-of-motion limitations secondary to femoroacetabular impingement. These disorders can happen in isolation but frequently occur in combination. To add to the diagnostic challenge, numerous intra-articular disorders and extra-articular soft-tissue restraints about the hip can serve as pain generators, in addition to referred pain from the lumbar spine, bowel, bladder, and reproductive organs. Athletic hip conditions can be debilitating and often require a timely diagnosis to provide appropriate intervention.

Background: The acetabular labrum is critical to maintenance of hip stability and has been found to play a key role in preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function. Purpose: To provide a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue. Study Design: Systematic review and meta-analysis. Methods: PubMed and Scopus online databases were searched with the key terms “hip,”“labrum,”“reconstruction,” and “graft” in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% CIs. Results: Eight studies with 537 hips were included. Mean age was 37.4 years (95% CI, 34.5-40.4 years), and mean follow-up time was 29 months (95% CI, 26-33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to total hip arthroplasty and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% total hip arthroplasty conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the modified Harris Hip Score improved by a mean 29.0 points after labral reconstruction ( P < .0001). Conclusion: Arthroscopic hip labral reconstruction results in clinically significant improvements in patient-reported outcomes. Our analysis indicates that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.

Background: Multiple studies have shown that patients are susceptible to posttraumatic osteoarthritis (PTOA) after an anterior cruciate ligament (ACL) injury, even with ACL reconstruction (ACLR). Prospective studies using multivariable analysis to identify risk factors for PTOA are lacking. Purpose/Hypothesis: This study aimed to identify baseline predictors of radiographic PTOA after ACLR at an early time point. We hypothesized that meniscal injuries and cartilage lesions would be associated with worse radiographic PTOA using the Osteoarthritis Research Society International (OARSI) atlas criteria. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 421 patients who underwent ACLR returned on-site for standardized posteroanterior semiflexed knee radiography at a minimum of 2 years after surgery. The mean age was 19.8 years, with 51.3% female patients. At baseline, data on demographics, graft type, meniscal status/treatment, and cartilage status were collected. OARSI atlas criteria were used to grade all knee radiographs. Multivariable ordinal regression models identified baseline predictors of radiographic OARSI grades at follow-up. Results: Older age (odds ratio [OR], 1.06) and higher body mass index (OR, 1.05) were statistically significantly associated with a higher OARSI grade in the medial compartment. Patients who underwent meniscal repair and partial meniscectomy had statistically significantly higher OARSI grades in the medial compartment (meniscal repair OR, 1.92; meniscectomy OR, 2.11) and in the lateral compartment (meniscal repair OR, 1.96; meniscectomy OR, 2.97). Graft type, cartilage lesions, sex, and Marx activity rating scale score had no significant association with the OARSI grade. Conclusion: Older patients with a higher body mass index who have an ACL tear with a concurrent meniscal tear requiring partial meniscectomy or meniscal repair should be advised of their increased risk of developing radiographic PTOA. Alternatively, patients with an ACL tear with an articular cartilage lesion can be reassured that they are not at an increased risk of developing early radiographic knee PTOA at 2 to 3 years after ACLR.

INTRODUCTION The purpose of this study is to compare the utility and validity of the OrthoMiDaS (Orthopaedic Minimal Data Set) Episode of Care (OME) database with the current benchmark for recording procedural details, the operative note (OpNote), with regard to disease severity and risk factors for hip arthroscopy cases. METHODS A convenience sample of the first 100 hip arthroscopy cases for labral tears done at our institution between February and August 2015 were selected for this study. Surgeons recorded procedural details within OME after each case. An individual blinded to the OME data performed a chart review of the OpNote and/or implant log and recorded the information in a separate REDCap database. RESULTS OME demonstrated higher completion rates than the OpNote for important procedural details such as previous left and right hip surgery (P < 0.001), anchor type (P = 0.008), and labrum tear clockface variables (P < 0.001 for both). In addition, OME exhibited "near-perfect" agreement with the OpNote for several important procedural details such as surgical limb (Kappa = 1.000), suture configuration (Kappa = 0.982), repair type (Kappa = 0.947), tear clockface: from (Kappa = 0.949), and tear clockface: to (Kappa = 0.885). On average, surgeons took 117 seconds to complete data entry within OME. CONCLUSION The findings of this study validate the ability of OME to accurately and consistently capture important procedural details pertaining to arthroscopic hip surgery. Through the use of OME, high-quality standardized information can be captured and used to advance the field of hip arthroscopy by determining the clinically useful predictors of patient-reported outcome measures.

Background: Hip arthroscopy for femoroacetabular impingement (FAI) syndrome continues to gain popularity and indications for its use are expanding. Though low complication rates have previously been reported, there are iatrogenic complications specific to the use of the perineal post, such as pudendal nerve injuries, and possible pressure skin necrosis that warrant concern in the healthy young patient. The risk of these complications are increased during simultaneous bilateral hip arthroscopy. Indications: We describe a new technique, which will prevent such problems by using a postless pink pad technique in order to achieve adequate hip distraction. Technique Description: Arthroscopic investigation begins with proper, safe patient positioning in order to gain access to the hip joint with sufficient joint distraction. In the postless technique, a dense foam pad is utilized in lieu of a perineal post. The static friction between the pad, bed, and the patient counters the manual gross traction necessary to distract the hip joint while preventing the patient from sliding down or off of the operating table. The postless technique avoids pressure to the perineum and also allows for greater range of motion during dynamic intraoperative examination and femoroplasty. After hip distraction, standard portal placement allows for access to the central compartment in order to assess intraarticular pathology. Once identified on diagnostic arthroscopy, appropriate techniques are utilized to correct acetabular-sided pincer lesions, labral tears, and femoral-sided cam deformities. Results: When discussing this technique with patients, it is important to highlight that it diminishes the possibility of iatrogenic pressure injury to the pudendal nerve and skin of the perineum. The risk of these injuries typically occurs when the pudenal nerve is compressed against the post during traction and abduction. As such, postless technique prevents any compression and pressure to these regions. Discussion/Conclusion: Hip arthroscopy is a minimally invasive, low morbidity technique for treating a variety of chondral, ligamentous, and bony conditions of the hip. However, studies suggest that pudenal nerve injury is seen in up to 4.3% of patients following hip arthroscopy. Given avoidance of iatrogenic post complications, we describe a postless technique for achieving hip distraction during hip arthroscopy.

Anterior cruciate ligament (ACL) injuries are common and affect a young, active patient population. Despite much research, ACL reconstruction graft choice remains a topic of debate. Based on the best available evidence, autograft seems to be superior to allograft for ACL reconstruction in young, active patients. Future high-level studies are required in order to better define the role of allograft in ACL reconstruction. As graft choice is often influenced by surgeon preference, it is important that surgeons understand the current literature as well as the goals of their patients.

Purpose To provide a comprehensive review of outcomes associated with local anesthetic (LA) or LA and corticosteroid (CS) diagnostic hip injections, and how well response predicts subsequent operative success. Methods A systematic review from database (PubMed, Medline, Scopus, Embase) inception to January 2015 for English-language articles reporting primary patient outcomes data was performed, excluding studies with >50% underlying osteoarthritis. Studies were assessed by 2 reviewers who collected pertinent data. Results Seven studies were included, reporting on a total 337 patients undergoing diagnostic hip injection. The mean age was 34.4 years, with 5 studies reporting 94 (35.2%) males and 173 (64.8%) females. One study examined the rate of pain relief with LA (92.5%); 2 CS studies reported relief on a scale from 0% to 100% (no to complete relief), ranging from 61% to 82.3%; and 3 studies used 10-point pain scales, with a CS study noting a pain score of 1.0, an LA study with a score of 3.03, and 1 study using either CS or LA scores of 3 to 5.6. Duration of pain relief was 9.8 (CS) and 2.35 days (LA). By pathology, greatest relief was achieved in acetabular chondral injury (93.3%) and least in cam impingement (81.6%), with clinical and imaging findings being unreliable predictors of relief. One study showed nonresponse to be a strong predictor of negative surgical outcome for femoroacetabular impingement. Conclusions Diagnostic hip injections provide substantial pain relief for patients with various hip pathologies, with limited data to suggest greatest relief for those with chondral injury. Clinical and imaging findings are unreliable predictors of injection response, and nonresponse to injection is a strong negative predictor of surgical outcome. Future research should focus on elucidating differences by underlying pathology and predicting future operative success. Level of Evidence Level IV, systematic review.

Background: A preexisting rotator cuff tear may affect the draft status and career performance of National Football League (NFL) players. Hypothesis: Preexisting rotator cuff tears decrease a player’s draft status, performance, and longevity in the NFL. Study Design: Retrospective cohort study. Level of Evidence: Level 3. Methods: Medical reports of prospective NFL players during the NFL Scouting Combine from 2003 to 2011 were evaluated to identify players with a previous rotator cuff tear. Athletes were matched to control draftees without documented shoulder pathology by age, position, year drafted, and round drafted. Career statistics and performance scores were calculated. Results: Between 2003 and 2011, 2965 consecutive athletes were evaluated. Forty-nine athletes had preexisting rotator cuff tears: 22 athletes underwent surgical intervention for their tear and 27 were treated nonoperatively. Those with a rotator cuff tear were significantly less likely to be drafted than those without a previous injury (55.1% vs 77.5%, P = 0.002). The 27 drafted athletes with preexisting rotator cuff tears started significantly fewer games (23.7 vs 43.0, P = 0.02) and played significantly fewer years (4.3 vs 5.7, P = 0.04) and significantly fewer games (47.1 vs 68.4, P = 0.04) than matched control athletes without rotator cuff tears. Conclusion: Athletes with a preexisting rotator cuff tear were less likely to be drafted and had decreased career longevity.

Background:The early recognition and management of patients with hip lesions, such as femoroacetabular impingement (FAI) and early hip osteoarthritis (OA), may preempt significant hip morbidity. The identification of reliable biomarkers may help guide decision making in an efficient and cost-effective manner.Purpose:To determine the biomarkers that have been associated with FAI as well as identify serum, synovial, and urinary analytes that have shown clinical utility in the prediction or identification of hip OA.Study Design:Systematic review and meta-analysis.Methods:The terms “hip arthroscopy,” “femoroacetabular impingement,” “labral tear,” “osteoarthritis,” and “biomarker” were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, yielding 276 articles. After screening, 7 articles were included. Pooled estimates were calculated utilizing a fixed-effects inverse-variance model weighted for individual study size.Results:A total of 1747 patients with a mean age of 37.5 ± 4.5 years (76.4% female) were identified. Forty-three unique biomarkers were assessed. Although general proinflammatory cytokines IL-1 and TNF-α exhibited inconsistent trends in arthritic hips, IL-6 demonstrated a consistent increase (+84.8% [95% CI, 81.9%-87.6%]; P < .05). A significant difference was found in levels of the fibronectin-aggrecan complex (FAC) in patients with OA compared with controls (0.08 ± 0.40 vs 1.15 ± 0.35 μg/mL, respectively; P < .001). It was the only specific analyte to show a significant difference between those with and without OA. In the setting of FAI, cartilage oligomeric matrix protein (COMP) was significantly increased in athletes after adjusting for concurrent knee and hip OA. A statistically significant difference was present in FAI-positive hips (9.0 ± 0.1 [95% CI, 8.8-9.3]) compared with controls (8.4 ± 0.1 [95% CI, 8.2-8.4]) ( P < .05). Other biomarkers, such as CXCL3, which exhibited statistically significant differences compared with controls, did not control for underlying factors such as age and concomitant lesions.Conclusion:COMP and FAC are specific biomarkers with potential utility in the diagnosis and management of FAI and hip OA, given their ability to differentiate between controls and patients with hip lesions. Further research is necessary to identify their ability in determining disease severity, predicting the response to treatment, and establishing an association with the risk of long-term OA.

Background: Ulnar collateral ligament (UCL) reconstruction is a reliable treatment for elite overhand throwers with UCL tears. In recent years, this procedure has become increasingly common among Major League Baseball (MLB) pitchers. Predisposing factors and associated comorbidities, however, have not been fully elucidated. Purpose/Hypothesis: The purpose of this study was to determine whether professional baseball pitchers who underwent UCL reconstruction had an increased incidence of hip or groin injuries 4 years before or after surgery. We hypothesized that MLB pitchers who sustain hip or groin injuries may be more likely to develop UCL tears because of alterations and overcompensation in the kinetic chain during overhand throwing. Study Design: Cohort study; Level of evidence, 3. Methods: A comprehensive list of all 247 MLB players who underwent UCL reconstruction between 2005 and 2017 was created using publicly accessible online data. The application of inclusion criteria yielded a final sample size of 145 athletes. These athletes’ injury histories were identified and cross-referenced with the official MLB disabled list. Matched controls were generated for a comparison of results. Results: Of the 145 MLB pitchers who underwent UCL reconstruction between 2005 and 2017, 40 (27.6%) endured a proximal lower extremity injury within 4 years of their surgery. Specifically, 16 pitchers sustained hip injuries, 13 suffered hamstring injuries, and 14 experienced groin injuries. A significantly lower rate of hip- and groin-related injuries (17.9%) was identified in matched controls during a similar time frame (P = .049). Conclusion: The results of this study demonstrate that MLB pitchers who required UCL reconstruction sustained a higher frequency of proximal lower extremity injuries both before and after surgery compared with matched controls. This finding is significant as the treatment of antecedent hip lesions, as well as an emphasis on hip and core muscle mobility and strengthening, may help reduce injuries to the UCL.

Background:Despite improvements in understanding biomechanics and surgical options for ulnar collateral ligament (UCL) tears, there remains a need for a reliable classification of UCL tears that has the potential to guide clinical decision making.Purpose:To assess the intra- and interobserver reliability of the newly proposed magnetic resonance imaging (MRI)–based classification for UCL tears. Secondary objectives included assessing the effect of additional views, discrimination between distal and nondistal tears, and correlation of imaging reads with intraoperative findings of the UCL.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Nine fellowship-trained specialists from 7 institutions independently completed 4 surveys consisting of 60 elbow MRI scans with UCL tears using a newly proposed 6-stage classification system. The first and third surveys contained 60 coronal images, while the second and fourth contained the same images with coronal and axial views presented in a random order to assess intraobserver variability via the weighted kappa value and the effect of additional imaging views. Weighted kappa values were also calculated for each of the 4 surveys to acquire interobserver reliability. Reliability analysis was repeated through a 2-group classification analysis for distal and nondistal tears. Observer readings were compared with intraoperative UCL findings.Results:For the newly proposed 6-stage MRI-based classification, intra- and interobserver reliability demonstrated near perfect and substantial agreement, respectively. These values increased only when substratified into the 2-group distal and nondistal tear classification ( P < .05). The additional axial view did not statistically improve the agreement within and among readers. When compared with intraoperative findings from 30 elbows, observer readings were accurate for tear grade (partial and complete), proximal location, and distal location but not midsubstance tears.Conclusion:The newly proposed 6-stage MRI-based classification utilizing grade and location of the injury had substantial to near perfect agreement among and within fellowship-trained observers.

Background: The indications for the use of platelet-rich plasma (PRP) are vaguely defined despite the frequency of its use as a treatment for athletes. While select studies have advocated for its efficacy, the majority of orthopaedic research conducted on the topic has been equivocal. Purpose: To define the use of PRP in elite athletes by team physicians from professional sports leagues. Study Design: Cross-sectional study. Methods: A survey assessing treatment timing, usage patterns, indications, and complications was generated by fellowship-trained sports medicine orthopaedic surgeons. The survey was distributed to team physicians from the National Football League, National Basketball Association, Major League Baseball, National Hockey League, Major League Soccer, and the “Power 5” Division I conferences of the National Collegiate Athletic Association. From a compilation of publicly available email addresses and those available from professional team physician associations, 149 team physicians were sent this PRP assessment tool. Results: Of the 149 professional and collegiate team physicians contacted, 59 started the survey and 46 completed it, resulting in a 39.6% participation rate and a 30.9% completion rate. Approximately 93% of physicians stated that they use PRP in their practices, and 72% use ultrasonography for injection guidance. On average, collegiate team physicians and National Football League physicians treated the most players per season with PRP (69.4 and 60.4 players, respectively), while National Hockey League physicians treated the fewest (18.0 players). The majority of respondents reported no complications from PRP injections (70%), with pain being the most common complication reported (26%). There was no consensus on the most important aspect of PRP formulation, with the top 2 responses being platelet concentration (48%) and white blood cell concentration (39%). When grading the importance of indications to use PRP, physicians found athlete desire on average (7.5 ± 2.2 [SD]; out of 10) to be more important than reimbursement (2.2 ± 2.2) ( P < .001). Importantly, physicians stated that they moderately (5.4 ± 2.3) believed in the evidence behind PRP. Physicians listed hamstring injuries as the most common injury treated with PRP. Hamstring injuries were treated with a mean 3.14 PRP injections, as opposed to 2.19 injections for nonhamstring injuries. Conclusion: Professional and collegiate team physicians frequently use PRP despite a lack of consensus regarding the importance of the formulation of the product, the timing of treatment, and the conditions that would most benefit from PRP treatment.

To determine pre- and postoperative opioid utilization while identifying risk factors for prolonged postoperative opioid use following hip arthroscopy.All patients undergoing hip arthroscopy between 2007 and the second quarter of 2016 were identified within the Humana Inc. administrative claims database. Chronic preoperative opioid utilization was defined as filling of any opioid prescription 1 to 3 months before surgery, whereas acute preoperative opioid utilization was defined as filling any opioid prescription within 1 month of surgery. Rates of pre- and postoperative opioid utilization were calculated, and patient demographic characteristics and medical conditions associated with pre- and postoperative opioid utilization were identified.Of the 1,208 patients undergoing hip arthroscopy, chronic and acute preoperative opioid utilization was observed in 24.9% and 17.3% of patients, respectively. Chronic preoperative opioid utilization was more frequently observed in obese (P.001) patients, those ≥50 years of age (P = .002), and those with preexisting anxiety and/or depression (P.001). In multivariate analysis, chronic preoperative opioid utilization was the strongest predictor of opioid prescription filling at 3, 6, 9, and 12 months postoperatively (odds ratio at 3 months, 18.60, 95% confidence interval, 12.41 to 28.55), whereas preexisting anxiety and/or depression and obesity were additionally identified as predictors of prolonged postoperative opioid utilization.Chronic preoperative opioid utilization before hip arthroscopy is common at 24.9%. The high rate of chronic preoperative opioid utilization is particularly important considering that chronic preoperative opioid utilization is the strongest predictor of continued postoperative opioid prescription filling out to 12 months postoperatively.Level IV, retrospective case series.

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee. Given its extra-articular location, the MCL has great healing capacity such that the mainstay of treatment for most injuries remains conservative management. However, certain injury patterns place patients and athletes at risk of residual valgus laxity, which may require delayed surgical care and prolonged time out from sports. As such, identifying the specific injuries known to place patients at risk for failure with nonoperative management is of paramount importance. Although controversy remains regarding the optimal treatment of grade III MCL injuries, it is generally accepted that MCL ruptures from the distal tibia attachment require operative fixation. This technique article with accompanying video provides a detailed description of a technique for repairing the distal MCL attachment with suture augmentation. There are several advantages associated with an augmented direct repair including early, safe rehabilitation; prevention of valgus instability; and avoiding the comorbidities associated with a larger reconstruction.

Background: Femoroacetabular impingement (FAI) has become a more commonly recognized cause of limited hip range of motion and hip pain among young adults and athletes. Hip arthroscopy is recommended for the surgical treatment of this disorder, unless specific contraindications exist. Despite the increasing rate of published studies in this area, there remains no aggregate data for outcomes after this approach. Purpose: To evaluate risk factors and outcomes after arthroscopic management of FAI, including return to play, revision rate, surgical and nonsurgical complications, change in α-angle, intraoperative bone resection, and patient-reported outcomes. Study Design: Meta-analysis and systematic review. Methods: A review of the current literature was performed with the terms “femoroacetabular impingement,” “hip arthroscopy,” and numerous variations thereof in PubMed, EMBASE, BioMed Central, Cochrane, Science Direct, and Scopus, yielding 1723 abstracts. After screening by eligibility criteria, 31 articles were included. The incidence of bilateral FAI was determined by enrollment data, and pooled estimates were calculated for postoperative patient-reported outcome measures, α-angles, return to sport, postoperative complications, and reoperation risk. Results: A total of 1981 hips among 1911 patients were identified, with a mean ± SD age of 29.9 ± 1.9 years and 29.5 ± 14.0 months of follow-up. The incidence of bilateral FAI in these studies that required operative intervention was 3.6%. The pooled risk of reoperation after hip arthroscopy, including revision surgery or subsequent total hip arthroplasty, was 5.5% (95% CI, 3.6%-7.5%). The risk of clinical complications was 1.7% (95% CI, 0.9%-2.5%). In total, 87.7% of patients demonstrated return to sport after surgery (95% CI, 82.4%-92.9%, P < .001), and all patient-reported outcomes improved postoperatively, with the highest increase observed in the Hip Outcome Score sports scale (41.7 points; 95% CI, 34.1-49.4; P < .001). The α-angle decreased by an average of 23.6° (95% CI, 18.2°-29.0°; P < .001). We identified 11 factors associated with the success of hip arthroscopy in FAI and 16 factors associated with failure or negative outcomes. Conclusion: A high percentage of patients return to sport activities after hip arthroscopy for FAI, with a low rate of complications and reoperation. All patient-reported outcome measures, except for mental health, significantly improved after surgery.

Background: Shoulder disorders are common in football players, with up to 50% of National Football League (NFL) recruits reporting a history of shoulder injuries. Superior labrum anterior-posterior (SLAP) tears are an entity with well-described detrimental effects on return to play in overhead-throwing athletes but with minimal data in contact athletes. Purpose: To identify the incidence, predisposing factors, and effect of SLAP tears in NFL athletes and prospects as well as the treatment patterns of NFL team physicians. Study Design: Descriptive epidemiology study. Methods: This study was a comprehensive analysis of SLAP tears in elite football players using a dual approach: (1) SLAP injuries recorded in the NFL Injury Surveillance System from 2000 to 2014 were evaluated by player position, type of play, days/games lost, and surgical intervention; (2) NFL Scouting Combine athletes from 2003 to 2011 with prior SLAP repair were evaluated for draft success, and drafted athletes were compared with matched controls for career length and performance scores. Results: SLAP tears represented a small portion (3.1%) of shoulder injuries in NFL athletes from 2000 to 2014, occurring most commonly in offensive linemen (28%). Surgically treated SLAP tears (42%) resulted in more days missed than did nonoperatively managed tears (140.2 vs 21.5 days; P < .001) and more games missed (8.4 vs 2.6 games; P = .003). SLAP repairs were also rare in NFL Combine athletes (n = 25 of 2965 athletes), with most having been performed in offensive linemen (32%). As compared with control NFL Combine athletes without SLAP tears, those drafted into the NFL with prior SLAP repair played significantly fewer games (33.7 vs 48.3; P = .049) and had fewer game starts (19.6 vs 35.4; P = .036). Conclusion: In this comprehensive analysis of SLAP tears in elite football players, it is clear that these injuries have the potential to cause significant detriment to an athlete’s career.

Background The first recorded attempt at arthroscopic visualization of the hip can be attributed to Dr. Michael Burman in 1931. Since then, hip arthroscopy has become widely used for the management of femoroacetabular impingement (FAI) because of its clear benefits, including a low complication rate and limited patient morbidity as compared with traditional open approaches. Description Arthroscopic management of FAI begins with arthroscopy of the central compartment, where the intra-articular damage is identified. Standard portal placement provides optimal access for surveying and accessing intra-articular injury. The pathological findings identified preoperatively and confirmed during diagnostic arthroscopy dictate the necessary arthroscopic procedures. Correction of acetabular overcoverage and repair of the labrum to the acetabular rim can correct pincer lesions. Femoral-sided cam lesions require removal of traction and application of hip flexion in order to perform a femoral osteoplasty to recreate a normal anatomic femoral head-neck offset. Finally, capsular management is performed as clinically indicated. Alternatives Appropriate management of FAI typically begins with nonoperative care consisting of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and physical therapy1. Intra-articular corticosteroid injections can also provide relief2. Open procedures involving surgical hip dislocation can be utilized to address pathological conditions not accessible arthroscopically. Additionally, a "mini-open" procedure in which intra-articular disorders are treated arthroscopically and cam lesions are resected via a small anterior exposure can be employed3,4. Rationale Hip arthroscopy offers a minimally invasive technique that can be effective for treating intra-articular hip disorders and is usually favored over open surgical dislocation. Hip arthroscopy has been shown to result in higher functional outcome scores than open procedures, with lower rates of complications5. Hip arthroscopy is playing an increasingly important role as an adjunct diagnostic and therapeutic tool in conjunction with open femoral and/or periacetabular osteotomy for complex hip deformities.

Background: The detection and management of chondral injuries of the hip, especially in a younger patient population, may preempt joint degeneration. Although the outcomes of preservation techniques have been well described for other weightbearing joints, such as the knee, evidence for hip joint preservation after procedures such as microfracture and autologous chondrocyte implantation remains in its infancy. Purpose: To evaluate outcomes of joint preservation procedures in the hip, including the success rate and patient-reported outcomes (PROs). Study Design: Systematic review; Level of evidence, 4. Methods: This review was performed using the terms “hip arthroscopy,” “microfracture,” “autologous chondrocyte implantation,” “fibrin glue,” “osteochondral transfer,” and variations thereof in 5 electronic databases, yielding 325 abstracts. After the application of eligibility criteria, 19 articles were included. Weighted means were calculated for PROs, and pooled estimates were calculated for age, follow-up, chondral lesion size, and success of hip preservation procedures with a random-effects proportion meta-analysis. Results: A total of 1484 patients (1502 hips) were identified across 19 studies (mean age, 38.0 ± 1.3 years; mean follow-up, 31.8 ± 9.6 months). Hip joint preservation techniques demonstrated a high success rate, ranging from 85.6% to 99.7%. The mean pooled chondral lesion size was 2.5 ± 0.3 cm2 (95% CI, 1.9-3.0 cm2). Microfracture was the most frequent technique, utilized by 11 studies, and demonstrated an 89.6% success rate (95% CI, 82.4%-96.7%). The highest pooled success rate was exhibited by autologous membrane-induced chondrogenesis in 3 studies (99.7% [95% CI, 99.0%-100.0%]). All PROs demonstrated a statistically significant increase postoperatively, including the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score–Activities of Daily Living and Hip Outcome Score–Sports-Specific Subscale (all P < .05). The visual analog scale for pain also demonstrated a statistically significant decrease of 37.2% ( P < .05). Conclusion: Hip preservation procedures demonstrate a high success rate, with microfracture representing the most frequently utilized cartilage preservation technique in the peer-reviewed literature. PROs significantly improved after surgery. Further investigation of hip preservation modalities with long-term follow-up is required to create evidence-based clinical recommendations and treatment algorithms.

Background: The optimal postoperative rehabilitation protocol following repair of complete proximal hamstring tendon ruptures is the subject of ongoing investigation, with a need for more standardized regimens and evidence-based modalities. Purpose: To assess the variability across proximal hamstring tendon repair rehabilitation protocols published online by United States (US) orthopaedic teaching programs. Study Design: Cross-sectional study. Methods: Online proximal hamstring physical therapy protocols from US academic orthopaedic programs were reviewed. A web-based search using the search term complete proximal hamstring repair rehabilitation protocol provided an additional 14 protocols. A comprehensive scoring rubric was developed after review of all protocols and was used to assess each protocol for both the presence of various rehabilitation components and the point at which those components were introduced. Results: Of 50 rehabilitation protocols identified, 35 satisfied inclusion criteria and were analyzed. Twenty-five protocols (71%) recommended immediate postoperative bracing: 12 (34%) prescribed knee bracing, 8 (23%) prescribed hip bracing, and 5 (14%) did not specify the type of brace recommended. Fourteen protocols (40%) advised immediate nonweightbearing with crutches, while 16 protocols (46%) permitted immediate toe-touch weightbearing. Advancement to full weightbearing was allowed at a mean of 7.1 weeks (range, 4-12 weeks). Most protocols (80%) recommended gentle knee and hip passive range of motion and active range of motion, starting at a mean 1.4 weeks (range, 0-3 weeks) and 4.0 weeks (range, 0-6 weeks), respectively. However, only 6 protocols (17%) provided specific time points to initiate full hip and knee range of motion: a mean 8.0 weeks (range, 4-12 weeks) and 7.8 weeks (range, 0-12 weeks), respectively. Considerable variability was noted in the inclusion and timing of strengthening, stretching, proprioception, and cardiovascular exercises. Fifteen protocols (43%) required completion of specific return-to-sport criteria before resuming training. Conclusion: Marked variability is found in both the composition and timing of rehabilitation components across the various complete proximal hamstring repair rehabilitation protocols published online. This finding mirrors the variability of proposed rehabilitation protocols in the professional literature and represents an opportunity to improve patient care.

To compare the hip morphology of adolescent male patients and female patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) and determine if gender differences exist.We retrospectively reviewed the records of 177 adolescents, aged 13 to 18 years, who were treated for FAI with hip arthroscopy. We examined and analyzed preoperative magnetic resonance imaging (MRI) scans and plain radiographs, measuring the lateral center-edge angle, Tönnis angle, and alpha angle. The intraclass correlation coefficient between readers was calculated. We created multiple linear regression models incorporating age, gender, and body mass index (BMI) with the radiographic measurements. Intraoperative findings using the Outerbridge grading system, as well as procedure performed, were documented. We compared these findings with our preoperative imaging measurements using the χThe intraclass correlation coefficient showed moderate to strong agreement between the 3 image readers. The BMI- and age-adjusted mean alpha angle was higher in male patients than female patients on both plain radiographs (55.9° vs 45.2°, P.0001) and axial oblique MRI scans (54.1° vs 42.5°, P.0001). An alpha angle greater than 55° was found in 38.9% of male patients compared with only 1% of female patients (P.0001). The lateral center-edge angle and Tönnis angle on MRI scans and plain radiographs displayed no statistically significant differences between genders after we controlled for BMI and age. Male patients were more likely to have chondral damage intraoperatively than female patients (56.3% vs 32.5%, P = .0041).Distinct differences between genders were seen both on preoperative imaging and at the time of hip arthroscopy. We found that male patients with FAI displayed a larger mean alpha angle, and therefore a more severe cam-type deformity, than female patients. Our study also found that male patients were more likely to show evidence of chondral damage than female patients at the time of surgery.Level IV.

Objectives: Injuries to the shoulder are a common cause of missed playing time in professional baseball athletes. These injuries predominately involve the supraspinatus tendon or the glenoid labrum. The purpose of this project is to describe a series of throwing-related injuries to the subscapularis muscle-tendon complex that have been previously unreported amongst baseball players. Additionally, it is the goal to describe a mechanism of injury as well as a treatment program for these athletes. Methods: A retrospective review of shoulder magnetic resonance imaging (MRI) scans of players from 1 Major League Baseball organization over the course of 5 years was performed to identify cases with findings suggestive of a subscapularis injury. The MRIs were graded and the medical records were reviewed to assess clinical findings, treatment plans, and follow-up. In the injured cohort, preinjury baseline measurements of shoulder motion including external rotation at 90° of abduction were compared to measurements from a non-injured baseball athlete cohort to evaluate whether decrease external rotation is a risk factor for this injury. Results: A total of 133 MRI scans of the shoulder were evaluated. Eleven of the 133 MRIs demonstrated signal changes suggesting subscapularis injury. Ten of these 11 patients had clinical findings supporting a diagnosis of throwing-related subscapularis strain. There were 4 grade I, 4 grade II, and 2 grade III injuries. All injuries occurred in the inferior half of the subscapularis at the myotendinous junction. Risk of subscapularis injury increased with lower levels of dominant arm external rotation (odds ratio, 0.89; 95% CI, 0.82-0.94; P < .001). A threshold of dominant arm external rotation of less than 106° demonstrated sensitivity of 0.700 (95% CI, 0.392-0.897) and specificity of 0.951 (95% CI, 0.888-0.982) for subscapularis injury. All players were treated conservatively without surgery; only 1 did not return to play. Of the remaining players, the mean number of days missed because of injury was 27 (range, 11-61 days). Conclusion: Throwing-related subscapularis injuries occur in the inferior half of the muscle at the myotendinous junction. The subscapularis muscle fibers are oriented along a fan shape because of the relatively narrow insertion on the lesser tuberosity of the proximal humerus and a broader origin on the scapula with muscle fiber alignment dependent on arm position. When the thrower's arm is at 90 degrees of abduction and external rotation, the inferior fibers of the subscapularis comes to be aligned in the transverse plane across the glenohumeral joint and are placed on greatest stretch during the late cocking and early acceleration phases of throwing. Our data suggest that there is an increased risk of these injuries with lower levels of dominant arm external rotation as this shorter arc requires greater force production by the subscapularis muscle to achieve the same peak throwing velocity.

Background: Subcoracoid impingement has been implicated as a cause of anterior shoulder pain and subscapularis tendon tears. Purpose/Hypothesis: The purpose of this study was to evaluate the bony anatomy of the coracoid process and the subcoracoid space. We hypothesized that age-related changes that may contribute to subcoracoid impingement occur in the subcoracoid space. Study Design: Descriptive laboratory study. Methods: In total, 418 skeletal shoulder specimens were included in this study. We utilized 214 shoulders from a young cohort (25-35 years of age) and 204 shoulders from an older cohort (>55 years of age) for comparison. We evaluated several morphological characteristics of the coracoid process and the subcoracoid space: coracoid width, coracoid shape, coracoid thickness, and subcoracoid distance. Each coracoid was observed for the presence of spurring or other morphological changes. Results: The mean anteroposterior (AP) thickness of the coracoid tip was 7.9 and 9.4 mm in our young female and male cohorts, respectively, while the mean AP thickness was 8.1 and 9.7 mm in our older female and male cohorts, respectively. The coracoid tip was hooked in 31 of 108 young female shoulders compared with 55 of 102 older female shoulders, and the coracoid tip was hooked in 25 of 106 young male shoulders compared with 45 of 102 older male shoulders. The mean subcoracoid distance in neutral rotation was 14.8 and 12.5 mm in young and older female shoulders, respectively, while the mean subcoracoid distance in internal rotation in these same cohorts was 8.7 and 7.0 mm, respectively. The mean subcoracoid distance in neutral rotation was 14.8 and 13.3 mm in young and older male shoulders, respectively, while the mean subcoracoid distance in internal rotation was 8.6 and 8.1 mm in young and older male shoulders, respectively. Conclusion: The principal findings of our study demonstrate that anatomic changes implicated in subcoracoid impingement may be developmental and worsen with age. The subcoracoid space was narrower in our older cohort of shoulders. Additionally, these older shoulders also had a greater AP width and a more hooked coracoid compared with young shoulders. Clinical Relevance: Narrowing of the subcoracoid space has been shown to be implicated as a cause of anterior shoulder pain and subscapularis tendon tears. This is the first study to show that the morphological changes implicated in subcoracoid impingement become more prevalent with age. This may help to explain the increasing prevalence of subscapularis tendon tears in older patients. Furthermore, subcoracoid decompression may be seen as an option for older patients with anterior shoulder pain and subscapularis tendon tears.

Objectives: Joint pain and function at the time of surgery may influence postoperative rehabilitation, recovery and the final outcome of the patient. Little is known about how patient factors or pathologic findings predict hip pain or function in those presenting with femoroacetabular impingement (FAI). We hypothesized that patient factors including mental health would more strongly correlate with subjective assessments of hip pain and function compared to the extent of the intra- or extra-articular pathology (chondral damage, labral tear, cam or pincer deformities) in patients undergoing surgery for FAI. Methods: A prospective cohort of patients undergoing hip arthroscopy for FAI were enrolled between 2/2015 and 9/2016. Patients d HOOS-Pain, HOOS-Physical Function, VR12-MCS, VR12-PCS and UCLA activity questionnaires at the time of surgery. Surgeons documented intra-articular operative findings for each case by a standardized data collection method utilizing a mobile iPhone application. Multivariable linear regression models were created for continuous scores of HOOS-pain, HOOS-Physical Function and VR12-PCS as dependent variables. Independent variables studied included both patient factors and intra-operative anatomic and pathologic findings [Table 1]. Results: During the study period, 396 patients undergoing arthroscopic surgery for FAI were enrolled. The mean patient age was 34±14 years, mean BMI 26.36±5.01 and 71% were female. The mean baseline scores were 45.94±17.07 for HOOS-Pain, 31.68±10.06 for VR-12 PCS and 40.99±17.75 for HOOS-Physical Function. The mean UCLA activity score was 5.04±2.57. Factors associated with worse HOOS-Pain scores include older age (p=0.01), female sex (pConclusion: Patients with lower mental health scores, lower activity levels and those who smoke have predictably worse subjective hip pain and function when controlling for operative variables. While the presence of a labral tear does predict worse pain, the impact on subjective pain is weaker compared to patient factors such as mental health, smoking or female sex. Future studies evaluating patient outcomes after surgery for FAI should consider correcting for these identified patient factors in order to accurately interpret differences in patient reported outcomes. In order to determine the influence of these factors on the final outcome of the patient, further studies and follow-up are warranted.

Background:Anatomic reinsertion of the distal biceps is critical for restoring flexion and supination strength. Single- and double-incision surgical techniques have been reported, analyzing complications and outcomes measures. Which technique results in superior clinical outcomes and the lowest associated complications remains unclear.Hypothesis:We hypothesized that rerupture rates would be similar between the 2 techniques, while nerve complications would be higher for the single-incision technique and heterotopic ossification would be more frequent with the double-incision technique.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:A systematic review was conducted using the PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SPORTSDiscus, and the Cochrane Central Register of Controlled Trials databases to identify articles reporting distal biceps ruptures up to August 2013. We included English-language articles on adult patients with a minimum of 3 cases reporting single- and double-incision techniques. Frequencies of each complication as a percentage of total cases were calculated. Fisher exact tests were used to test the association between frequencies for each repair method, with P < .05 considered statistically significant. Odds ratios with 95% CIs were also computed.Results:A total of 87 articles met the inclusion criteria. Lateral antebrachial cutaneous nerve neurapraxia was the most common complication in the single-incision group, occurring in 77 of 785 cases (9.8%). Heterotopic ossification was the most common complication in the double-incision group, occurring in 36 of 498 cases (7.2%).Conclusion:The overall frequency of reported complications is higher for single-incision distal biceps repair than for double-incision repair. The frequencies of rerupture and nerve complications are both higher for single-incision repairs while the frequency of heterotopic ossification is higher for double-incision repairs. These findings can help surgeons make better-informed decisions about surgical technique and provide their patients with detailed information about expected outcomes and possible complications.