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Successful outpatient anterior cruciate ligament (ACL) reconstruction hinges on effective analgesia. Routinely, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents have several known adverse effects and are associated with a potential for abuse. This study evaluates the efficacy of ketorolac, a nonsteroidal anti-inflammatory drug with analgesic properties, as an adjuvant agent for postoperative pain control after ACL reconstruction.Adult patients undergoing primary ACL reconstruction were prospectively enrolled. Exclusion criteria involved patients with a history of bleeding diathesis, renal dysfunction, chronic analgesia use, or alcohol abuse. Eligible patients were randomized into one of two groups. The control group received a standard-of-care pain protocol involving oxycodone-acetaminophen 5 to 325 on discharge. The ketorolac group additionally received intravenous ketorolac postoperatively and 3 days of oral ketorolac on discharge. Pain levels and total narcotic utilization were recorded three times per day for the first 5 days after surgery. Pain and functional outcomes were obtained at 2 and 6 weeks postoperatively.The final analysis included 48 patients; the mean age of the cohort was 32 ± 11.6 years, and 60.4% of patients were female. No differences were observed in preoperative demographics, comorbidities, and preoperative functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 45.4% fewer narcotic pills than the control group (P0.001). In addition, mean postoperative pain scores were 22.36 points lower for patients in the ketorolac group (P0.001). There was no difference in functional outcome scores at up to 6 weeks postoperatively or adverse events between the two groups with no reported cases of gastrointestinal bleeding.The use of adjunctive intravenous and short-term oral ketorolac substantially reduces narcotic utilization and pain levels after ACL reconstruction.NCT04246554.

Background and objective Primary patellar dislocations can concomitantly involve osteochondral injuries for which prompt recognition is paramount for joint preservation. These injuries can be missed on radiographs, necessitating MRI examinations. In this study, we aimed to identify patient parameters that correlate with occult osteochondral injuries. Methods Patients were retrospectively identified between 2015 and 2020 through a chart review. The inclusion criteria were as follows: patients diagnosed with a primary patellar dislocation with three radiographic views and an MRI of the injured knee. Demographic and radiographic data were evaluated. Results A total of 61 patients met the inclusion criteria. There were no statistically significant demographic differences between patients with osteochondral injuries and those without (p0.05). Seven knees (88%) with an osteochondral lesion and 20 (38%) without had an effusion (p=0.02). There was no association in terms of ligamentous laxity (p=0.49), Caton-Deschamps index (CDI) (p=0.68), sulcus angle (SA) (p=0.68), congruence angle (CA) (p=0.56), and lateral patellofemoral angle (LPFA) (p=0.25) between patients with and without an occult osteochondral injury. Conclusion Among the parameter examined, the presence of an effusion was the only one that correlated with the presence of occult osteochondral injury in our cohort.

Background: Few studies have compared clinical outcomes between the traditional Latarjet procedure for anterior shoulder instability and the congruent arc modification to the Latarjet procedure. Purpose: To systematically evaluate the literature for the incidence of recurrent instability, clinical outcomes, radiographic findings, and complications for the traditional Latarjet procedure and the congruent arc modification and to compare results of each search. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies published between January 1990 and October 2020 that described clinical outcomes of the traditional Latarjet and the congruent arc modification with a follow-up range of 2 to 10 years. The difference in surgical technique was analyzed using a chi-square test for categorical variables, while continuous variables were evaluated using a Student t test. Results: In total, 26 studies met the inclusion criteria: 20 studies describing the traditional Latarjet procedure in 1412 shoulders, and 6 studies describing the congruent arc modification in 289 shoulders. No difference between procedures was found regarding patient age at surgery, follow-up time, Rowe or postoperative visual analog scores, early or late complications, return-to-sport timing, or incidence of improper graft placement or graft fracture. A significantly greater proportion of male patients underwent glenoid augmentation using the congruent arc modification versus traditional Latarjet ( P < .001). When comparing outcomes, the traditional Latarjet procedure demonstrated a lower incidence of fibrous union or nonunion ( P = .047) and broken, loose, or improperly placed screws ( P < .001), and the congruent arc modification demonstrated improved outcomes with regard to overall return to sport ( P < .001), return to sport at the same level ( P < .001), incidence of subluxation ( P = .003) or positive apprehension ( P = .002), and revision surgery for recurrent instability ( P = .027). Conclusion: Outcomes after the congruent arc modification proved at least equivalent to the traditional Latarjet procedure in terms of recurrent instability and return to sport, although early and late complications were equivalent. The congruent arc procedure may be an acceptable alternative to traditional Latarjet for the treatment of anterior shoulder instability with glenoid bone loss; however, long-term outcomes of this procedure are needed.

Context: There is currently no evidence-based consensus on how to treat a full-thickness, symptomatic articular cartilage injury of the patella, although numerous treatment options are available. Objective: To systematically evaluate the functional outcomes after operative treatment of patellar cartilage lesions. Our secondary purpose was to evaluate radiographic outcomes after treatment. Data Sources: PubMed, Cochrane, and Embase Study Selection: Studies published between January 1, 1990 and December 31, 2018 that included patient-reported functional outcomes for patients after operative treatment of patellar chondral defects at a minimum 2-year follow-up were included. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: MINORS (Methodological Index for Non-Randomized Studies) score, level of evidence, sample size, demographic data, follow-up data, intervention, functional outcome scores, and magnetic resonance imaging (MRI) data were collected. Results: The review identified 10 studies and 293 patients receiving cartilage restoration procedures for patellar chondral defects with extractable clinical and radiographic results and data on complications and reoperations. All treatments (autologous chondrocyte implantation [ACI], matrix-induced ACI [MACI], autologous osteochondral transplantation [AOT]) utilized in the management of patellar chondral lesions, with the exception of isolated particulated juvenile articular cartilage, demonstrated statistically significant improvements in functional outcome scores compared with preoperative measurements at a minimum of 2-year follow-up. Postoperative MRIs were obtained in 6 studies and found that regardless of treatment, moderate-to-complete infill of patellar cartilage lesions was seen in the majority of patients. While failure rates were low for the various treatment modalities, rates of reoperation were substantial, with up to 40% to 60% reoperation rate seen after ACI. Conclusion: Patients treated with ACI, MACI, and AOT all demonstrated statistically significant improvements in functional outcome scores with radiographic evidence of healing at minimum of 2-year follow-up. Evidence is insufficient to recommend one particular treatment over another.

Background: As the main translational and rotatory stabilizer of the knee, the anterior cruciate ligament (ACL) plays a critical role in knee biomechanics. Anterior cruciate ligament ruptures generally require surgical attention for not only restoration of knee stability but also prevention of meniscal and chondral injuries. There are countless options for both the surgeon and the patient when contemplating graft choice and surgical technique for ACL reconstruction. However, the literature assessing the outcomes following various autografts has varied with some studies citing no significant difference in clinical and patient-reported outcomes, while others showing notable advantage when using bone–patellar tendon–bone (BPTB) autograft. In addition, there have been challenges associated with femoral tunnel placement using an anteromedial portal technique. Indications: In this study, we present a young female patient with a history of remote mid-substance ACL tear now presenting with worsening knee instability and a bucket-handle medial meniscus tear as a sequela of the incompetent ACL. After extensive discussion regarding the treatment options, patient had decided to proceed with surgical intervention with a BPTB autograft using the anteromedial portal technique for femoral tunnel placement and compression technique with bio-absorbable interference screw fixation. Results: Bone–patellar tendon–bone autograft has been noted to have lower risk of revision when compared with other graft options. Discussion: In this surgical technique study, we underline the importance of peritenon handling. We highlight the use of a 70-degree arthroscope to improve posterolateral wall visualization during femoral tunnel placement as well as for inspection of the reamed tibial tunnel. We also provide technique commentary and solutions for management of the medial femoral condyle (MFC) articular surface and femoral tunnel placement using an anteromedial portal technique. Last, we review graft-related outcomes, postoperative management, and rehabilitation protocol.

BACKGROUND Arthroscopic rotator cuff repair (RCR) is associated with substantial postoperative pain. Oral narcotic agents are the preferred analgesic postoperatively. However, these agents are associated with several side effects and a potential for abuse. This study evaluates the efficacy of ketorolac as an adjunctive agent for postoperative pain control after arthroscopic RCR. METHODS Adult patients undergoing arthroscopic RCR were prospectively enrolled and randomized to one of two groups. The control received our institution's standard-of-care pain protocol, including oxycodone-acetaminophen 5 to 325 mg on discharge. The ketorolac group received the standard-of-care protocol, intravenous ketorolac at the completion of the procedure, and oral ketorolac on discharge. Pain and functional outcome scores and narcotic utilization were recorded three times per day for the first 5 days after surgery. Repeat magnetic resonance imaging was done at least 6 months postoperatively. RESULTS In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7 ± 10.6 years, and 66.7% of patients were male. No differences were observed in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 10.6 fewer narcotic pills, a consumption reduction of 54.6% (19.42 versus 8.82, P < 0.001). No difference was observed in functional outcome scores at up to 6 weeks postoperatively between the two groups. No difference was observed in adverse events between the two groups with no reported cases of gastritis or gastrointestinal bleeding. Twenty-two of 39 patients underwent repeat magnetic resonance imaging at a mean of 7.9 months postoperatively, of which 5 (22%) demonstrated a retear of their rotator cuff. No significant difference was observed between the ketorolac and control groups in the rate of retear (P = 1.00). DISCUSSION Adjunctive ketorolac substantially reduces narcotic utilization after arthroscopic RCR.

Background: Major League Baseball (MLB) adopted a rule change in 2016 to reduce the number of collisions that occur when a player slides into a base. The effect of rule 6.01(j) has not been quantified, and it remains unknown if this rule change has led to improved player safety. Hypothesis: Rule 6.01(j) would be associated with a reduction in the number of collision-related injuries at second base. Study Design: Cohort study; Level of evidence, 3. Methods: Using data from the MLB Health and Injury Tracking System, we quantified the number of collision-related injuries for defensive (ie, fielding) players in the infield at the major and minor league levels between the 2010 and 2019 seasons. We compared the median number of collision-related injuries for defensive players in the infield from before (2010-2015) to after (2016-2019) the implementation of rule 6.01(j) and also calculated the difference in location of the median from the seasons before versus after the rule change. An additional 3 analyses were performed to support or contradict a conclusion that any observed reduction in injuries at the start of the 2016 season was likely caused by the adoption of rule 6.01(j). Results: The median number of collision-related injuries for defensive players at second base decreased from 58.5 to 37.5 injuries per season after the rule change, which was a 36% decrease (difference in location, 19.5 [95% CI, 5.0 to 31.0]; P = .019). In contrast, the median number of collision-related injuries at first base decreased by only 14.1%, from 49.5 before to 42.5 after the rule change (difference in location, –9.0 [95% CI, –4.0 to 18.0]; P = .16), and the median number of collision-related injuries per season at third base was unchanged at 15 per season. Conclusion: This rule change was associated with a decrease in the number of collision-related injuries, with the largest effect observed at second base, as expected.

Background Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. Methods In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents’ prescribing practices, and methods of patient counseling regarding opioid use and disposal. Results A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient’s symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. Discussion To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

PURPOSE OF REVIEW: The purpose of this review is to discuss relevant anatomy and pathoanatomy in the knee following anterior cruciate ligament reconstruction, risk factors for contralateral ACL tear, and mechanisms of contralateral injuries in the pediatric population. RECENT FINDINGS: Contralateral ACL rupture rates following ACL reconstruction (ACLR) range from 4% to 42%. Pediatric patients show increased risk compared with adults, likely due to inherent anatomical differences along with biomechanical and neuromuscular changes that occur in both the operative and contralateral knees following index ACLR. Pediatric athletes who return to sport more quickly have been found to be at increased risk for contralateral tears, as have athletes who participate in cutting and pivoting sports. Contralateral tears tend to occur via non-contact mechanisms. SUMMARY: Pediatric patients are at increased risk of contralateral ACL injury following index ACL reconstruction compared with adults. Further study is warranted to determine appropriate biologic, functional, and rehabilitative parameters gauged toward preventing contralateral ACL tear while minimizing time lost from sport.

BACKGROUND In patients on warfarin anticoagulation therapy, elective shoulder arthroplasty surgeons must carefully balance bleeding and embolic risks. Currently, an international normalized ratio (INR) threshold of 1.5 is supported in the setting of elective surgery. However, no previous study has investigated the optimal preoperative INR target specifically in shoulder arthroplasty. The purpose of this study was to evaluate the association of preoperative INR with rates of transfusion, complication, and readmission/revision surgery in shoulder arthroplasty. METHODS Patients who underwent elective shoulder arthroplasty were identified in a national database. The primary outcome of interest was the risk for all-cause complication at 30 days postoperatively. Major and minor complication, revision surgery, and readmission rates were also investigated. RESULTS From 2006 to 2016, 1,014 procedures were identified who had undergone elective shoulder arthroplasty with a perioperative INR lab result within 24 hours of surgery. In our cohort, 550 patients (54.2%) were women, with an average age of 71.0 ± 9.8 years. After controlling for confounders, patients with a preoperative INR > 1.5 were 18.9 times as likely to have a major complication as those with a preoperative INR ≤ 1.0 (P = 0.003). Patients with an INR of 1.25 < INR ≤ 1.5 did not have a statistically significant risk of minor or major complication in comparison with those with an INR ≤ 1.0 (P = 0.23, P = 0.67). DISCUSSION Although recent hip and knee arthroplasty literature has found that an INR < 1.25 may be an optimal preoperative INR goal, our results did not find an increased risk for bleeding and complication with an INR ≤ 1.5 for shoulder arthroplasty. These results support current guidelines recommending a preoperative INR ≤ 1.5 for shoulder arthroplasty.

» Injuries to the posterior root of the lateral meniscus occur frequently in acute knee injuries with concomitant tearing of the anterior cruciate ligament (ACL). » The meniscofemoral ligaments (MFLs), consisting of the anterior MFL (ligament of Humphrey) and the posterior MFL (ligament of Wrisberg), as well as the osseous attachment of the meniscal root, stabilize the lateral meniscus, enabling appropriate load transmission and maintenance of contact forces within the lateral compartment of the knee during loading and range of motion. » In the setting of an ACL injury to the knee with osseous root injury of the posterior root of the lateral meniscus, the MFLs (when present) may stabilize the lateral meniscus against meniscal extrusion, thereby maintaining appropriate contact mechanics within the knee, decreasing the risk of subsequent chondral and meniscal injury and the development of premature osteoarthritis. » Additional study on the indications for posterior meniscal root repair during ACL reconstruction is warranted since the ideal management of lateral root injury in the MFL-intact knee remains unknown.

To evaluate whether a narrow posterior joint space (2 mm) correlated with posterior joint cartilage degeneration in the hip preservation patient population.A retrospective chart review of 155 consecutive hip arthroscopy cases by a single surgeon (SKA) from March 2012 to February 2013 was performed. Patients were included in the study if they had an adequate perioperative false profile radiograph and clear intraoperative arthroscopic images of the posterior hip joint. The narrowest posterior joint space (NPJS) width and the directly posterior, posterosuperior, superior, and anterosuperior joint space widths were measured on the false profile radiograph. Femoral and acetabular cartilage of the posterior hip joint were graded according to the International Cartilage Repair Society (ICRS) classification system using arthroscopic images obtained at the time of surgery. The cartilage grades of patients with2 mm NPJS were compared with cartilage grades of patients with ≥2 mm NPJS.There was no difference in cartilage grading between patients with2 mm NPJS (19 patients) and those with ≥2 mm NPJS (81 patients) (P = .905). The mean age of patients with NPJS ≥2 mm and2 mm was 34.0 (median 31.2; interquartile range [IQR] 23.7, 42.9) and 38.7 (median 43.0; IQR 26.1, 50.9) respectively, and was not statistically different (P = .183). No correlation between cartilage grade and NPJS measurement was found (P = .374).In this predominantly cam-type femoroacetabular impingement patient cohort, our findings indicate there is no correlation between a2 mm posterior hip joint narrowing seen on false profile radiographs and posterior hip cartilage degeneration confirmed with arthroscopy. Although posterior arthritis can be visualized on a false profile radiograph, a posterior joint space measurement2 mm should not be interpreted as isolated posterior joint wear and should not be considered a hip arthroscopy contraindication.Level IV, case series.

Purpose In this cadaveric study, we aim to define the basic anatomy of the anterior glenoid with attention to the relationships of calcified cartilage, capsulolabral complex, and osseous morphology of the anterior glenoid. Methods Seventeen cadaveric glenoid specimens (14 male, 3 female, mean age 53.9 ± 10) were imaged with micro-computed tomography (CT) and embedded in poly-methyl-methacrylate. Specimens were included for final analysis only if the entire glenoid articular cartilage, labrum, capsule, and biceps insertion were pristine and without evidence of injury, degeneration, or damage during the preparation process. Group 1 members (n = 9) were axially sectioned through 3 to 9 o'clock and 4 to 8 o'clock; group 2 members (n = 8) were radially sectioned through 3, 4, 5, and 9 o'clock. A scanning electron microscope (SEM) analysis quantified the percentage of bone within a 5 × 2.5 mm region at the glenoid rim. Micro-CT, SEM, and light microscopy evaluated the capsulolabral complex and calcified fibrocartilage. Results A 7 ± 2.1 mm region of calcified fibrocartilage at 4 o'clock was identified from the articular face to the medial glenoid neck supporting the overlying capsulolabral footprint and was >3× thicker at the articular attachment (316 ± 153 μm) versus the glenoid neck (92 ± 66 μm). At 3 to 9 o'clock and 4 to 8 o'clock 79.2% ± 5.4% and 75.2% ± 7.8% of the glenoid osseous width was covered with articular cartilage. The labrum accounted for 13.1% ± 3.4% of the glenoid width at 4 o'clock. SEM analysis demonstrated decreased glenoid bone density at 3, 4, and 5 o'clock (P ≤ .015) and no difference (P = .448) at 9 o'clock versus central subchondral bone. Conclusions The capsulolabral footprint contributes significantly to the glenoid face, inserts directly adjacent to the articular cartilage, and extends medially along the glenoid neck. A layer of calcified fibrocartilage lies immediately beneath the capsulolabral footprint and is 3× thicker at the articular insertion compared with the glenoid neck. Lastly, there is a bone density gradient at the anterior-inferior rim versus the central subchondral bone. Clinical Relevance Arthroscopic Bankart repair has been reported to have a significant failure rate in many settings. It is felt that reproducing anatomy with the repair could help improve outcomes. Based on this study's findings, an arthroscopic Bankart technique that most closely reproduces native anatomy and potentially optimizes soft-tissue healing could be performed. This includes removal of 1 to 2 mm of articular cartilage from the glenoid face with anchor placement at this location to appropriately reposition the capsulolabral complex.

BackgroundSubspine impingement is a recognized source of extraarticular hip impingement. Although CT-based classification systems have been described, to our knowledge, no study has evaluated the morphology of the anteroinferior iliac spine (AIIS) with plain radiographs nor to our knowledge

Background Acromioplasty has been proposed as a means of altering elevated critical shoulder angles (CSAs). We aimed to localize the critical acromion point (CAP) responsible for the acromial contribution of the CSA and determine whether resection of the CAP can alter the CSA to a normal range. Methods The CAP and 3-dimensional (3D) CSAs were determined on 3D computed tomography reconstructions of 88 cadaveric shoulders and compared with corresponding CSAs on digitally reconstructed radiographs. The position of the CAP was fluoroscopically isolated in 20 of these specimens and the resulting fluoroscopic CSA compared with the corresponding 3D CAP and 3D CSA. We investigated the CSA before and after a virtual acromioplasty of 2.5 and 5 mm at the CAP in specimens with a CSA greater than 35°. Results The mean CAP was 21% ± 10% of the acromial anterior-posterior length from the anterolateral corner. There was no difference between the mean 3D CSA and the CSA on digitally reconstructed radiographs (32° vs 32°, P = .096). No difference between the mean fluoroscopic CSA and 3D CSA was found (31° vs 31°, P = .296). A 2.5-mm acromial resection failed to reduce the CSA to 35° or less in 7 of 13 shoulders, whereas a 5-mm resection reduced the CSA to 35° or less in 12 of 13. Conclusion The CAP was localized to the anterolateral acromial edge and was easily identified fluoroscopically. A 5-mm acromial resection was effective in reducing the CSA to 35° or less. These data can guide surgeons in where and how to alter the CSA if future studies demonstrate a clinical benefit to surgically modifying this radiographic parameter.

Background The humeral subluxation index (HSI) is frequently assessed on computed tomography (CT) scans in conditions of the shoulder characterized by humeral displacement. An arbitrarily set HSI cutoff value of 45% for anterior subluxation and 55% for posterior subluxation has been widely accepted. We studied whether mean values and thresholds of humeral subluxation, in relation to the glenoid and scapula, were influenced by different imaging modalities. Methods The HSIs referenced to the scapula (SHSI) and glenoid (GHSI) were compared between conventional CT scans, CT scans reoriented into the corresponding reference plane (ie, scapular plane for the SHSI and glenoid center plane for the GHSI), and 3-dimensional (3D) CT reconstructions of 120 healthy shoulders. The 95% normal range determined the cutoff values of humeral subluxation. Results The SHSI thresholds for conventional, reoriented, and 3D CT scans were 33%-61%, 44%-68%, and 49%-61%, respectively. A different mean SHSI was found for each imaging modality (conventional, 47%; reoriented, 56%; 3D, 55%; P ≤ .014), with the conventional SHSI showing an underestimation in 89% of the cases. GHSI thresholds for conventional, reoriented, and 3D CT scans were 40%-61%, 44%-56%, and 46%-54%, respectively. The mean GHSI did not differ between each imaging modality (conventional, 51%; reoriented, 50%; 3D, 50%; P = .146). Conclusions The SHSI and GHSI are susceptible to different imaging modalities with consequently different cutoff values. The redefined HSI cutoff values guide physicians in the evaluation of humeral subluxation in conditions characterized by humeral displacement, depending on the available image data.

Objectives: Arthroscopic rotator cuff repairs are associated with substantial postoperative pain. Traditionally, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents are associated with several side effects and a significant potential for abuse. This study evaluates the efficacy of ketorolac, a non-steroidal anti-inflammatory drug with analgesic properties, as an adjunctive agent for postoperative pain control following arthroscopic rotator cuff repair. Methods: Adult patients undergoing an arthroscopic rotator cuff repair were prospectively enrolled. Patients who met inclusion and exclusion criteria were randomized into one of two groups. The control group received our standard of care pain protocol, including oxycodone-acetaminophen 5-325 on discharge. Patients in the ketorolac group additionally received a dose of IV ketorolac intraoperatively and were prescribed a scheduled dose of oral ketorolac (10mg by mouth every six hours for three days) along with omeprazole (20mg by mouth every day for three days) for acid reflux. Visual Analogue Scale (VAS), functional outcome scores, and total narcotic utilization were recorded three times per day for the first five days after surgery. Statistically significant differences in patient demographics and comorbidities between groups were determined initially with univariate analysis. Linear mixed-effect models were then fitted for each outcome variable to evaluate the main effects of treatment group and follow-up times. Results: In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7±10.6 years and 66.7% of patients were male. There were no differences in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. (Table 1) Patients in the Ketorolac group had lower mean VAS scores and opioid utilization at all time points. (Figure 1, 2) On multivariate analysis that controls for confounding variables, patients in the ketorolac group had a mean 9.67 decrease in VAS scores in comparison to the control group, though these results were not statistically or clinically significant (Coefficient estimate= -9.67, 95% CI -25.13-5.79, p=.2202; MCID 13). (Table 3) Patients in the ketorolac group utilized significantly less narcotics, with a mean of 0.7 fewer pills of oxycodone-acetaminophen per time interval in comparison to the control group (Coefficient estimate=-0.70, 95% CI -1.005 -0.389, pConclusions: In this prospective, randomized, controlled study, the use of adjunctive intravenous and short-term oral ketorolac substantially reduced narcotic utilization following arthroscopic rotator cuff repair.

Hip arthroscopy techniques have continued to evolve for femoroacetabular impingement and other intra-articular pathologies. However, there is still debate about the importance and technique of routine capsular closure. We present an efficient and reliable technique for creating a watertight capsular closure to prevent iatrogenic macro and microinstability. This Technical Note details our stepwise technique using figure of eight sutures to obtain a complete and secure capsular closure.

Background:Distraction of the hip joint is a necessary step during hip arthroscopic surgery. The force of traction needed to distract the hip is not routinely measured, and little is known about which patient factors may influence this force.Purpose:To quantify the force of traction required for adequate distraction of the hip during arthroscopic surgery and explore the relationship between hip joint stiffness and patient-specific demographics, flexibility, and anatomy.Study Design:Case series; Level of evidence, 4.Methods:A total of 101 patients (61 female) undergoing primary hip arthroscopic surgery were prospectively enrolled. A load cell attached to the traction boot continuously measured traction force. Fluoroscopic images were obtained before and after traction to measure joint displacement. The stiffness coefficient was calculated as the force of traction divided by joint displacement. Relationships between the stiffness coefficient and patient demographics and clinical parameters were investigated using a univariable regression model. The regression analysis was repeated separately by patient sex. Variables significant at P < .05 were included in a multivariable regression model.Results:The instantaneous peak force averaged 80 ± 18 kilogram-force (kgf), after which the force required to maintain distraction decreased to 57 ± 13 kgf. In univariable regression analysis, patient sex, alpha angle, hamstring flexibility, and Beighton hypermobility score were each correlated to stiffness. However, patient sex was the only significant variable in the multivariable regression model. Intrasex analysis demonstrated that increased hamstring flexibility correlated with decreased final holding stiffness in male patients and that higher Beighton scores correlated with decreased maximal stiffness in female patients.Conclusion:Male patients undergoing primary arthroscopic surgery have greater stiffness to hip distraction during arthroscopic surgery compared with female patients. In male patients, stiffness increased with decreasing hamstring flexibility. In female patients, increased Beighton scores corresponded to decreased stiffness. The presence of a labral tear was not correlated with stiffness to distraction. These data may be used to identify patients in whom a specific focus on capsular repair and/or plication may be warranted.

Background: Few studies have investigated the influence of patient-specific variables or procedure-specific factors on the overall cost of anterior cruciate ligament reconstruction (ACLR) in an ambulatory surgery setting. Purpose: To determine patient- and procedure-specific factors influencing the overall direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven outcomes (VDO) tool. Study Design: Cohort study (economic and decision analysis); Level of evidence, 3. Methods: All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed. Cost data were derived from the VDO tool. Patient-specific variables included age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) classification, smoking status, preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Testing (PF-CAT) score, and preoperative Single Assessment Numeric Evaluation (SANE) score. Procedure-specific variables included graft type, revision status, associated injuries and procedures, time from injury to ACLR, surgeon, and operating room (OR) time. Multivariate analysis determined patient- and procedure-related predictors of total direct costs. Results: There were 293 autograft reconstructions, 110 allograft reconstructions, and 31 hybrid reconstructions analyzed. Patient-specific factors did not significantly influence the ACLR cost. The mean OR time was shorter for allograft reconstruction ( P < .001). Predictors of an increased direct cost included the use of an allograft or hybrid graft (44.5% and 33.1% increase, respectively; P < .001), increased OR time (0.3% increase per minute; P < .001), surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P < .001 or P = .001, respectively), and concomitant meniscus repair (24.4% increase; P < .001). Within the meniscus repair cohort, all-inside, root, and combined repairs correlated with a 15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared with inside-out repairs ( P < .001). Conclusion: This study failed to identify modifiable patient-specific factors influencing direct costs of ACLR. Allografts and hybrid grafts were associated with an increased total direct cost. Meniscus repair independently predicted an increased direct cost, with all-inside, root, and combined repairs being costlier than inside-out repairs. The time-saving potential of all-inside meniscus repair was not realized in this study, making implant use a significant factor in the overall cost of ACLR with meniscus repair.

Advancements in surgical technique have resulted in the ability to reconstruct lower extremity injuries that would have previously been treated by amputation. Currently, a paucity of data is available specifically addressing limb amputation versus reconstruction for calcaneal fractures with severe soft tissue compromise. Reconstruction leaves the patient with their native limb; however, multiple surgeries, infections, chronic pain, and a poor functional outcome are very real possibilities. We present the case of a complex calcaneal fracture complicated by soft tissue injury and osteomyelitis that highlights the importance of shared decision-making between patient and surgeon when considering reconstruction versus amputation. This case exemplifies the need for open communication concerning the risks and benefits of treatment modalities while simultaneously considering the patient's expectations and desired outcomes.

Traumatic hip instability is a relatively rare phenomenon related primarily to the inherent anatomical stability of the hip joint. As this clinical condition can go unrecognized, it can be a source of significant disability. Hip instability causes pain with possible joint unsteadiness due to extraphysiological hip motion. Although instability can arise from an atraumatic etiology, a traumatic event often causes the presenting injury. Traumatic hip instability can present as a spectrum from subluxation to frank dislocation with associated bony or soft tissue injuries. Recently, hip arthroscopy has gained popularity as both a diagnostic and a therapeutic tool in treating hip pathology, including the injury patterns associated with hip instability.

Case A 47-year-old man with an isolated femoral neck fracture was treated with open reduction and internal fixation with a medial femoral neck buttress plate and a dynamic hip screw. Union was achieved without osteonecrosis of the femoral head. However, hip arthroscopy that was performed for persistent hip pain following the fracture union revealed an intra-articular impingement of the buttress plate and a substantial anterior acetabular chondral injury. Conclusions To our knowledge, this is the first reported complication associated with the application of a medial buttress plate for a femoral neck fracture. This case report may help surgeons who employ this technique to avoid a similar complication.

Objectives: To quantify the force of traction required for adequate distraction of the hip during arthroscopy and explore the relationship between hip joint stiffness and patient-specific demographics, flexibility, and anatomy. Methods: 101 primary arthroscopy patients (61 females) and 23 patients undergoing revision arthroscopy for capsular repair (all female) were prospectively enrolled. A load cell attached to the traction boot continuously measured traction force. Fluoroscopy images were obtained before and after traction to measure joint displacement. The stiffness coefficient was calculated as the force of traction divided by joint displacement. Primary patients were analyzed in a univariable regression model and re-analyzed separately by gender. Variables significant at pResults: For primary arthroscopy, instantaneous peak force averaged 80 ± 18 kgf, after which the force required to maintain distraction decreased to 57 ± 13 kgf. In univariable regression analysis, gender, alpha angle, hamstring flexibility and Beighton hypermobility score were each correlated to stiffness. However, gender was the only significant variable in the multivariable regression model. Intragender analysis demonstrated increased hamstring flexibility correlated with decreased stiffness in males and higher Beighton scores correlated with decreased stiffness in females. Stiffness was significantly less in the revision cases than the primary cases (p=0.006). Conclusion: A substantial force is required to achieve and maintain hip distraction, with males requiring higher forces. Males with increased hamstring flexibility and females with higher Beighton scores are less stiff than their same gender counterparts. Patients indicated for revision capsule repair were less stiff, supporting the importance of the hip capsule on hip stability. These data may be used to identify patients with microinstability and patients where specific focus on capsular repair and/or plication may be warranted.

Background: The majority of rim recession for femoroacetabular impingement (FAI) is performed anteriorly and has traditionally been assessed by the lateral center-edge (CE) angle, which correlates most closely with lateral coverage. The radiographic false-profile view permits measurement of anterior coverage via the anterior CE angle and more closely correlates with anterior coverage. Purpose: To answer the following questions: (1) How does incremental anterior rim recession change lateral and anterior CE angles? and (2) Can these changes be predicted by a formula? Study Design: Descriptive laboratory study. Methods: Twelve cadaveric hips were dissected free of soft tissue to expose the anterior acetabular rim. Incremental resections of 2.5 mm (range, 0-10 mm) were performed from the 12- to 3-o’clock position using a Dremel rotary tool. Anteroposterior hip and false-profile radiographs were obtained at each interval using a fluoroscopic C-arm. The lateral and anterior CE angles were measured by 3 orthopaedic surgeons. Results: The average preresection lateral CE angle was 35.1°, and the mean decrease in lateral CE angle from 0 to 10 mm was 9.9°; the average preresection anterior CE angle was 38.4° and the mean decrease in anterior CE angle from 0 to 10 mm was 18.2°. The anterior CE angle decreased by a factor of 1.9 when compared with the lateral CE angle ( P = 2 × 10−7). The lateral CE angle decreased by approximately 1° (1.0°) per millimeter of rim recessed. The anterior CE angle decreased by approximately 2° (1.8°) per millimeter of rim recessed. Conclusion: The lateral CE angle should not be extrapolated to reflect anterior acetabular coverage. The anterior CE angle is a superior marker and predictably decreases with rim recession at double the rate of the lateral CE angle. Clinical Relevance: The false-profile view is recommended in the perioperative workup for all patients undergoing arthroscopic treatment of pincer impingement.

The purpose of this article is to determine normative values for the length of the acetabular rim and detect differences between gender, age, ethnicity, height and leg length. Six measurements were taken on the acetabular rim of 143 cadaveric skeleton specimens (286 acetabula) using a coordinate-measuring device: circumferential (excluding acetabular notch), anterior inferior iliac spine (AIIS)-anterior, AIIS-posterior, 12–3 o’clock, 12–9 o’clock and 11–5 o’clock. Museum specimen height data and leg length data from a previous study were recorded for 109 of 143 specimens. Intraclass correlation coefficients were calculated. Student t-tests compared mean values. Multiple regression analysis was used to determine the relationship between acetabular rim length and gender, age, ethnicity, height and leg length. The average acetabular rim length in males for circumferential, AIIS-anterior, AIIS-posterior, 12–3, 12–9 and 11–5 o’clock were 15.8, 4.2, 11.7, 4.9, 4.7 and 9.5 cm, respectively; and for females: 13.7, 3.7, 10.0, 4.3, 4.1 and 8.3 cm, respectively. Intraclass correlation coefficients were 0.953, 0.930, 0.958, 0.857, 0.913 and 0.951, respectively, for each measurement. All six measurements were significantly larger for males (P