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Background: Bone bruises are commonly seen on magnetic resonance imaging (MRI) in acute anterior cruciate ligament (ACL) injuries and can provide insight into the underlying mechanism of injury. There are limited reports that have compared the bone bruise patterns between contact and noncontact mechanisms of ACL injury. Purpose: To examine and compare the number and location of bone bruises in contact and noncontact ACL injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Three hundred twenty patients who underwent ACL reconstruction surgery between 2015 and 2021 were identified. Inclusion criteria were clear documentation of the mechanism of injury and MRI within 30 days of the injury on a 3-T scanner. Patients with concomitant fractures, injuries to the posterolateral corner or posterior cruciate ligament, and/or previous ipsilateral knee injury were excluded. Patients were stratified into 2 cohorts based on a contact or noncontact mechanism. Preoperative MRI scans were retrospectively reviewed by 2 musculoskeletal radiologists for bone bruises. The number and location of the bone bruises were recorded in the coronal and sagittal planes using fat-suppressed T2-weighted images and a standardized mapping technique. Lateral and medial meniscal tears were recorded from the operative notes, while medial collateral ligament (MCL) injuries were graded on MRI. Results: A total of 220 patients were included, with 142 (64.5%) noncontact injuries and 78 (35.5%) contact injuries. There was a significantly higher frequency of men in the contact cohort compared with the noncontact cohort (69.2% vs 54.2%, P = .030), while age and body mass index were comparable between the 2 cohorts. The bivariate analysis demonstrated a significantly higher rate of combined lateral tibiofemoral (lateral femoral condyle [LFC] + lateral tibial plateau [LTP]) bone bruises (82.1% vs 48.6%, P < .001) and a lower rate of combined medial tibiofemoral (medial femoral condyle [MFC] + medial tibial plateau [MTP]) bone bruises (39.7% vs 66.2%, P < .001) in knees with contact injuries. Similarly, noncontact injuries had a significantly higher rate of centrally located MFC bone bruises (80.3% vs 61.5%, P = .003) and posteriorly located MTP bruises (66.2% vs 52.6%, P = .047). When controlling for age and sex, the multivariate logistical regression model demonstrated that knees with contact injuries were more likely to have LTP bone bruises (OR, 4.721 [95% CI, 1.147-19.433], P = .032) and less likely to have combined medial tibiofemoral (MFC + MTP) bone bruises (OR, 0.331 [95% CI, 0.144-0.762], P = .009) compared with those with noncontact injuries. Conclusion: Significantly different bone bruise patterns were observed on MRI based on ACL injury mechanism, with contact and noncontact injuries demonstrating characteristic findings in the lateral tibiofemoral and medial tibiofemoral compartments, respectively.

To evaluate the effect of duration of preoperative hip pain symptoms on outcomes in patients undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS).A systematic review of the literature was conducted with the following keywords: "hip arthroscopy," "outcomes," "femoroacetabular impingement," "duration," "symptoms," "time," "delay," "earlier," and "timing" was performed in PubMed and Cochrane in May 2022. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used for this review. When available, article information including the author, study type, study period, and follow-up, demographics, preoperative duration of symptoms, surgical outcome tools, and secondary surgeries were recorded.Six studies including 3,298 hips were included in this systematic review. Five studies had minimum 2-year follow-up and one study had minimum 5-year follow-up. Femoroacetabular impingement (including subtypes cam and pincer impingement) was a surgical indication in all six studies, and the most common indication for surgery. All six studies reported patient-reported outcome scores (PROs). All studies conducted statistical analyses comparing the duration of symptoms' effect on outcomes and found superior outcomes in patients with shorter duration of symptoms prior to hip arthroscopy. In three studies, mHHS, HOS-ADL, HOS-SS and VAS-Satisfaction ranged from 79.1-82.6, 86.3-88.4, 75-75.5. and 75.3-82.5, respectively in cohorts with2-year duration of symptoms, compared to 72-77.7, 79.6-84, 65.0-66.7, and 69.7-75.3 in2-year cohort. Similarly, in one study the2-year duration group was reported to have a conversion to total hip arthroplasty rate of 0.6% and an overall secondary surgery rate of 0.9%, while the2-year duration group had a conversion to total hip arthroplasty rate of 6.4% and an overall secondary surgery rate of 10.1%.Patients with hip pain symptoms of less than 2 years before arthroscopic treatment of FAIS have better outcomes than those patients who had a longer duration of symptoms. However, significant improvements can still be expected regardless of time between onset of symptoms and surgery.Level IV, systematic review of Level III and Level IV studies.

To compare complication rates and 5-year reoperation rates between open debridement (OD) and arthroscopic debridement (AD) for lateral epicondylitis.The PearlDiver MUExtr database (2010-2019) was reviewed for patients diagnosed with lateral epicondylitis (queried by International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision [ICD-10] codes) undergoing OD or AD of the common extensor tendon without repair (queried by Current Procedural Terminology codes). Patients were stratified into 2 cohorts: those who underwent AD and those who underwent OD. Nonoperative treatment modalities were reported for both groups within 1 year before index procedure. The rates of 90-day postoperative complications were compared, and multivariate logistic regression analysis was used to identify risk factors for complications. The 5-year reoperation rates, using laterality-specific ICD-10 codes, were also compared between the 2 groups.In total, 19,280 patients (OD = 17,139, AD = 2,141) were analyzed in this study. The most common nonoperative treatments for patients who underwent OD or AD were corticosteroid injections (49.5% vs 43.2%), physical therapy (24.8% vs 25.7%), bracing (2.8% vs 3.2%), and platelet-rich plasma injections (1.3% vs 1.0%). There were no significant differences in radial nerve injuries, hematomas, surgical site infections, wound dehiscence, and sepsis events between the 2 procedures (P = .50). The 5-year reoperation rate was not significantly different between the AD (5.0%) and OD (3.9%) cohorts (P = .10).For lateral epicondylitis, both AD and OD of the extensor carpi radialis brevis (without repair) were found to have low rates of 90-day adverse events, with no significant differences between the 2 approaches. Similarly, the 5-year reoperation rate was low and not statistically different for those treated with OD or AD.Level III, cross-sectional study.

To evaluate minimum 5-year outcomes and survivorship after primary hip arthroscopy in athletes.A systematic review of current literature was performed with the following key words: "hip arthroscopy," "long-term," "outcomes," "ten-year," "survivorship," "10-year," "5-year," "five-year," "midterm," "athlete," "sport," and "femoroacetabular impingement" in PubMed, Cochrane Trials, and Scopus in April 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Study and demographic variables such as title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcome scores, and rates of secondary surgeries and conversion to total hip arthroplasty. Radiographic, intraoperative surgical treatment, and clinical benefit was documented as well.Ten studies that captured data on 691 hips were included in this study. Eight studies reported mean and standard deviation for the modified Harris Hip Score. Significant improvements were reported in all studies with postoperative scores ranging from 83.3 to 94.4 (standardized mean difference [SMD] 1.65; 95% confidence interval [CI] 1.39-1.91, P.00001). Eight studies reported significant improvement in Hip Outcome Score - Sports Specific Scale with postoperative scores ranging from 59.2 to 94.6 (SMD 1.66; 95% CI 1.33-1.98, P.00001). Seven studies reported significant improvement in Nonarthritic Hip Score with postoperative scores ranging from 79.6 to 95.3 (SMD 1.41; 95% CI 1.16-1.65, P.00001). Seven studies also reported significant improvement in VAS with postoperative scores ranging from 0.7 to 3.1 (SMD -1.57; 95% CI -1.88, -1.26, P.00001). Nine of 10 studies reported achieving at least 1 psychometric threshold at a rate of least 75%. Rates of secondary arthroscopy and conversion to total hip arthroplasty varied from 0% to 15.2% and 0% to 33.3%.Athletes who underwent primary hip arthroscopy demonstrated favorable outcomes and high rates of clinical benefit at 5-year follow-up. In addition, they demonstrated high rates of survivorship and achieving psychometric thresholds.Level IV, systematic review of Level III and IV studies.

Background: Previous studies have suggested that surgical repair of the posterolateral corner (PLC) may be inferior to reconstruction. Hypothesis: We hypothesized that acute repair (Study Design: Case series; Level of evidence, 4. Methods: A total of 28 patients with multiligament knee injuries who underwent acute repair between January 2007 and June 2018 of a PLC avulsion injury with no evidence of midsubstance tearing were included. All PLC avulsion injuries were treated using a transosseous Krackow suture pull-through technique without graft augmentation. Outcome metrics included lateral joint-space widening with varus stress, patient-reported clinical varus instability, patient-reported outcome measures (PROMs), and any subsequent revision or salvage procedure. Results: The mean time from injury to repair was 8.1 ± 5 days. At a mean follow-up of 2 years (range, 3-90 months), clinical varus stress examination at 30° demonstrated a significant reduction in lateral compartment opening, from 9 ± 3 mm preoperatively to 0 ± 3 mm ( P < .0001). The failure rate was calculated to be 10.7% (3/28), which was significantly lower than the failure rate from a 2016 systematic review (38%, 17/45; P = .015). Of the 28 patients, 21 (75%) had PROM scores. Patients who underwent staged bi-cruciate reconstructions (n = 5) had significantly higher subjective International Knee Documentation Committee (IKDC) (87.2 vs 65.5; P = .014) and Lysholm (90.5 vs 75.2; P = .029) scores compared to patients with untreated bi-cruciate injuries (n = 9). Patients with peroneal nerve injury (n = 4) had significantly lower IKDC (58.2 vs 80.8; P = .0045) and Tegner (3.2 vs 5.4; P = .047) scores than those without peroneal nerve injury (n = 17). The mean IKDC and Lysholm scores at final follow-up were 73.4 ± 24.0 and 80.8 ± 23.1 at 7.1 years (range, 2.3-10.6 years) of follow-up. Conclusion: Repair of acute grade 3 combined PLC avulsion injuries using a transosseous Krackow suture pull-through technique demonstrated a failure rate of 10.7%. Patients who underwent a staged cruciate reconstruction(s) had higher subjective outcome scores than those who had cruciate injuries left untreated. Peroneal nerve injury was associated with lower outcome scores.

Background: Autologous chondrocyte implantation (ACI) can be used to treat focal, full-thickness chondral defects of the knee. However, there is limited large-sample evidence available regarding the incidence, timing, and risk factors for revision surgery after ACI. Purpose: To assess the 5-year incidence, timing, and risk factors for revision surgery after ACI in a large national cohort. Study Design: Case series; Level of evidence, 4. Methods: The 2010-2020 PearlDiver database was queried for patients aged 20 to 59 years who underwent primary ACI of the knee without previous chondral procedures or knee arthroplasty. Revision surgery was defined as subsequent revision ACI, osteochondral allograft transplantation, osteochondral autograft transfer, unicompartmental knee arthroplasty, or total knee arthroplasty within 5 years. Kaplan-Meier analysis was used to assess both incidence and timing of revision surgery. Risk factors evaluated for revision surgery included patient age, sex, body mass index (BMI), Elixhauser Comorbidity Index (ECI) score, and previous or concomitant bony realignment procedures. Results: In total, 533 patients underwent primary ACI and met inclusion criteria. The 5-year incidence of revision surgery was 10.3%, with 63% of revisions occurring in the first 2 years after surgery. Risk factors associated with revision surgery included female sex (odds ratio, 2.58; 95% CI, 1.22-5.45; P = .013) and BMI ≥35 (odds ratio, 2.24; 95% CI, 1.01-4.94; P = .047). There was no relationship between age, ECI score, or previous or concomitant bony realignment procedures and revision surgery at 5 years ( P > .05). Conclusion: In an analysis of 533 patients who underwent ACI, 10.3% required a subsequent articular cartilage procedure or conversion to knee arthroplasty in the first 5 postoperative years. Revision surgery was greatest in the first 2 postoperative years. Female sex and severe obesity (BMI, ≥35) were associated with increased risk of revision surgery, while age, ECI score, and previous or concomitant bony realignment procedures were not. These findings suggest that treatment of chondral defects of the knee with ACI is associated with durable outcomes at the 5-year follow-up.

The purpose of this study is to evaluate midterm outcomes, long-term outcomes, and survivorship in the borderline dysplastic population after primary hip arthroscopy.A systematic review of current literature was performed with the following keywords: "hip, "arthroscopy," "borderline dysplasia," "borderline hip dysplasia," "developmental dysplasia," "ten-year," "survivorship," "10-year," "5-year," "five year," "mid-term," "long-term," ,"outcomes," "arthroscopic," and "femoroacetabular impingement" in PubMed, Cochrane, and Scopus in March 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The following information were recorded: title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcomes (PROs), characteristics of patients converting to total hip arthroplasty (THA), and rates of secondary surgeries and conversion to THA were recorded. Survivorship was defined as not converting to THA. Kappa values for the title/abstract and full-text screening were calculated. Forest plots were created for PROs that were included in 3 or more studies.Six articles comprising of 413 hips were included in the study. Three studies were level III evidence, and three studies were level IV evidence. Average follow-up ranged from 5.7 to 12.2 years. One study defined BHD as lateral center-edge angle (LCEA) 18-25˚ and 5 defined it as LCEA 20-25˚. All studies included PROs and reported significant improvement after surgery in at least one PRO. Three studies reported clinical benefit and across the studies at least 70% of patients achieved MCID in at least one PRO. Rates of undergoing revision hip arthroscopy and THA ranged from 2.1% - 7% and 0% - 24%, respectively. Tönnis Grade 2, Tönnis Angle15, and Outerbridge Grade IV cartilage damage were identified as predictors of conversion to THA.Patients with BHD undergoing primary hip arthroscopy demonstrated significant improvement in PROs at mid-term and long-term follow-up. Survivorship at mid-term follow-up was 98.2% (328/334 hips) and 76.3% (29/38 hips) at long-term follow-up.

Background: Despite several studies’ reports on outcomes of concomitant hip arthroscopy and periacetabular osteotomy (PAO), there is a paucity of aggregate data in the literature. Purpose: To evaluate outcomes and survivorship after concomitant hip arthroscopy and PAO. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Cochrane, and Scopus databases were searched in April 2022 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following keywords were used: (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (periacetabular osteotomy or rotational osteotomy) AND (outcomes OR follow-up). Of 270 articles initially identified, 10 studies were ultimately included. The following information was recorded for each study if available: publication information; study design; study period; patient characteristics; follow-up time; indications for hip arthroscopy; patient-reported outcomes (PROs); rates of secondary hip preservation surgeries; and rates of conversion to total hip arthroplasty (THA). Survivorship was defined as nonconversion to THA. Results: The study periods for the 10 included articles ranged from 2001 to 2018. Three studies were level 3 evidence, and 7 studies were level 4 evidence. This review included 553 hips with a mean follow-up of 1 to 12.8 years. All 10 studies listed dysplasia as an indication for surgery. Of 9 studies that reported PRO scores, 7 reported significant improvement after surgery. Studies with a 5-year follow-up reported conversion to THA rates of 0% to 3% and overall secondary surgery rates of 0% to 10%. Conclusion: Patients who underwent concomitant hip arthroscopy and PAO reported favorable outcomes, with 7 of the 9 studies that provided PRO scores indicating significant preoperative to postoperative improvement.

Background Traditional shoulder physical examination (PE) tests have suboptimal sensitivity for detection of supraspinatus full-thickness tears (FTTs). Therefore, clinicians may continue to suspect FTTs in some patients with negative rotator cuff PE tests and turn to magnetic resonance imaging (MRI) for definitive diagnosis. Consequently, there is a need for a secondary screening test that can accurately rule out FTTs in these patients to better inform clinicians which patients should undergo MRI. The purpose of this study was to assess the ability of two new dynamic PE tests to detect supraspinatus pathology in patients for whom traditional static PE tests failed to detect pathology. Methods We prospectively enrolled 171 patients with suspected rotator cuff pathology with negative findings on traditional rotator cuff PE, who underwent two new dynamic PE tests: first, measurement of angle at which the patient first reports pain on unopposed active abduction and, second, the dynamic isotonic manipulation examination (DIME). Patients then underwent shoulder magnetic resonance arthrogram (MRA). Data from the new PE maneuvers were compared to outcomes collected from MRA reports. Results Pain during DIME testing had a sensitivity of 96.3% and 92.6% and negative predictive value (NPV) of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 N had a sensitivity of 100% and 96.3% and NPV of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and positive predictive value of 100% for supraspinatus pathology of any kind (i.e. tendinopathy, “fraying”, or tearing). Conclusion DIME is highly sensitive for supraspinatus FTTs in patients with negative traditional rotator cuff PE tests for whom there is still high clinical suspicion of FTTs. Thus, this test is an excellent secondary screening tool for supraspinatus FTTs in patients for whom clinicians suspect rotator cuff pathology despite negative traditional static PE tests. Given its high sensitivity, a negative DIME test rules out supraspinatus FTT well in these patients, and can therefore better inform clinicians which patients should undergo MRI. In addition, the angle at which patients first report pain on unopposed active shoulder abduction is highly specific for supraspinatus pathology. Study Design Level II; Diagnosis Study

Purpose To evaluate the short-term outcomes of endoscopic repair of full-thickness gluteus medius and minimus tendon tears with a minimum of 2-year follow-up and add to the paucity of literature on abductor tendon tears. Methods All patients who underwent endoscopic abductor tendon repair between December 2013 and August 2017 were prospectively evaluated. The inclusion criteria for this study were primary full-thickness gluteal tendon tears and at least 2-years of follow-up. Clinical outcome data consisted of visual analog scale (VAS) pain score, hip abduction strength, Trendelenburg sign, complications, and patient-reported outcome measures (PROMs): modified Harris Hip Score, Hip Outcome Score, Non-arthritic Hip Scale, International Hip Outcome Tool-33, and Lower Extremity Functional Scale. Results A total of 15 hips, all full-thickness tears, met inclusion criteria with an average follow-up of 31.2 months, with no patients being excluded. On physical examination, there was a significant improvement in VAS pain score from 5.36 to 2.43 (P = .0243), hip abduction strength with 8 (53.3%) hips improving by at least 1 point (P = .02056), and resolution of Trendelenburg sign in all 15 hips at 2-years (P = .0019). The mean difference for all 6 PROMs was statistically significant, even after Bonferroni adjustment, with the majority of patient improvement exceeding the minimal clinically important difference (MCID) thresholds: modified Harris Hip Score: 86.67%, Hip Outcome Score—ADL: 86.67%, Hip Outcome Score—SSS: 66.67%, Non-arthritic Hip Scale: 93.33%, and International Hip Outcome Tool-33: 80%. Greater Goutallier grade was associated with a greater VAS pain score. There were no complications, including no retears. Conclusions In this study of 15 hips with full-thickness gluteal tendon tears managed endoscopically, we found excellent outcomes that exceeded the MCID thresholds in the majority of patients at an average of 31.2 months follow-up, while offering the potential advantages of less tissue violation, ambulatory day surgery, and fewer complications compared with open repair. Level of Evidence Level 4, Case Series.

Three-dimensional (3D) printed guides are finding increasing applications in the field of orthopaedic surgery and more recently spine surgery. This retrospective cohort study compares benefits and costs of 3D printed guides in surgical treatment of adolescent idiopathic scoliosis (AIS) compared to freehand techniques.Intraoperative screw placement was conducted either with 3D printed guides (3D cohort) or traditional freehand technique (freehand cohort) for AIS patients undergoing spinal fusion at a single institution. Patient and perioperative data include: screw placement time, length of surgery, blood loss, hospital stay, spinal curvature correction, total implant costs and training level of surgical assist. Multivariate analysis assessed for confounding and effect modification. P-values0.05 were considered significant.There were 29 patients included in analyses, 18 in the 3D and 11 in the freehand (FH) cohort, for a total of 263 3D and 307 freehand screws. Between cohorts, there were no significant differences in patient age (P=0.93), gender (P=0.15), height (P=0.18) or weight (P=0.40). The 3D cohort (mean $26,215, SD =$6,374) had significantly higher implant costs than FH (mean $18,660, SD =$5,587, P=0.003) with significantly reduced intraoperative blood loss (mean 559 mL, SD =273 FH;At significant cost, 3D printed guides reduce intraoperative blood loss compared to freehand pedicle screw placement and reduce screw placement time for surgical residents.

Total hip arthroplasty (THA) may be complicated by dislocation. The incidence of and risk factors for dislocation are incompletely understood. This study aimed to determine the incidence and predictors of hip dislocation within 2 years of primary THA.The 2010 to 2020 PearlDiver MHip database was used to identify patients undergoing primary THA for osteoarthritis with a minimum of 2 years of postoperative data. Dislocation was identified by associated codes. Age, sex, body mass index, Elixhauser Comorbidity Index, fixation method, and bearing surface were compared for patients with dislocation versus control subjects by multivariate regression. Timing and cumulative incidence of dislocation were assessed.Among 155,185 primary THAs, dislocation occurred within 2 years in 3,630 (2.3%). By multivariate analysis, dislocation was associated with younger age (65 years), female sex, body mass index20, higher Elixhauser Comorbidity Index, cemented prosthesis, and use of metal-on-poly or metal-on-metal implants ( P0.05 for each). Among patients who experienced at least one dislocation, 52% of first-time dislocations occurred in the first 3 months; 57% had more than one and 11% experienced5 postoperative dislocation events. Revision surgery was done within 2 years of index THA for 45.6% of those experiencing dislocation versus 1.8% of those who did not ( P0.001).This study found that 2.3% of a large cohort of primary THA patients experienced dislocation within 2 years, identified risk factors for dislocation, and demonstrated that most patients experiencing dislocation had recurrent episodes of instability and were more likely to require revision surgery.

Background: While medial meniscocapsular tears (ramp lesions) are commonly associated with isolated anterior cruciate ligament injuries, there are limited descriptions of these meniscal injuries in multiligament knee injuries (MLKIs). Purpose: To (1) retrospectively evaluate preoperative magnetic resonance imaging (MRI) scans for the presence of ramp lesions in patients surgically treated for acute grade 3 combined posterolateral corner (PLC) knee injuries and (2) determine if a preoperative posteromedial tibial plateau (PMTP) bone bruise is associated with the presence of preoperative ramp lesions on MRI in these same patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Data on consecutive patients at a level 1 trauma center with MLKIs between 2001 and 2021 were retrospectively reviewed. Only patients with acute grade 3 combined PLC injuries who received an MRI scan within 30 days of injury were assessed. Two musculoskeletal radiologists retrospectively reviewed each patient’s preoperative MRI for evidence of ramp lesions and bone bruises. Intraclass correlation coefficients (ICCs) were used to calculate reliability among the reviewers. Multivariate analysis was used to evaluate the relationship between PMTP bruising and the presence of a ramp lesion on MRI. Results: A total of 68 patients (79.4% male; mean age, 33.8 ± 13.7 years) with an acute grade 3 combined PLC injury were included in the study. On MRI, the ICCs for detection of ramp lesions and PMTP bone bruising were 0.921 and 0.938, respectively. Medial meniscal ramp lesions were diagnosed in 18 of 68 (26.5%) patients. Eleven of 18 (61.1%) patients with ramp lesions also showed evidence of PMTP bruising, while 13 of 50 (26.0%) patients without ramp lesions had PMTP bruising ( P = .008). When controlling for age and sex, PTMP bruising was significantly associated with the presence of a ramp lesion in combined PLC injuries (odds ratio, 4.62; P = .012). Conclusion: Preoperative medial meniscal ramp lesions were diagnosed on MRI in 26.5% of patients with acute grade 3 combined PLC injuries. PMTP bone bruising was significantly associated with the presence of a ramp lesion on MRI. These findings reinforce the need to assess for potential ramp lesions at the time of multiligament reconstruction.

Patients with classic hemophilia can develop joint hemarthroses, degenerative changes, and eventually require total hip arthroplasty (THA). Little data exist concerning THA outcomes in this population, and evidence-based guidelines specifically addressing venous thromboembolism (VTE) prophylaxis in this population are lacking.A retrospective study was conducted using the 2010-2020 PearlDiver MHip database. Patients undergoing primary THA were identified, and those with classic hemophilia were matched 1:10 with non-hemophilia patients based on age, gender, and Elixhauser Comorbidity Index. Ninety-day serious adverse events, minor adverse events, and any adverse events were compared with multivariate analysis. Reoperation at 5 years was assessed using Kaplan-Meier analysis.Five hundred eighteen classic hemophilia THA patients were matched 1:10 with 5,193 non-hemophilia patients. On multivariate analysis, those with classic hemophilia had greater odds of aggregated any adverse events (odds ratio [OR] 1.76), serious adverse events (OR 2.30), and minor adverse events (OR 1.52) (P.001 for each). Patients with classic hemophilia had greater odds of bleeding issues (transfusion, OR 1.98; hematoma, OR 4.23; P.001 for both), VTE (deep vein thrombosis, OR 2.67; pulmonary embolism, OR 4.01; P.001 for both), and acute kidney injury (OR 1.63; P = .03). Five-year implant survival was lower in hemophilia patients (91.9%) relative to matched controls (95.3%; P = .009).Hemophilia patients undergoing THA had elevated risks of both 90-day bleeding complications (transfusion and hematoma) and VTE (deep vein thrombosis and pulmonary embolism) relative to matched controls. These findings emphasize the need to balance factor replacement and VTE prophylaxis. Although the 5-year implant survival was lower in hemophilia patients, this represented a difference of 3.4% at 5 years, suggesting that THA remains effective in this cohort.

Many studies track outcomes after procedures, such as posterior lumbar fusion (PLF), for only 30 days because of database limitations. However, adverse events may not have plateaued by this time. Thus, this study used an alternate database to evaluate the timing of adverse events for 90 days after PLF.Adult PLF patients were identified from the 2010 to 2020 Q2 M53Ortho PearlDiver administrative data set. Ninety-day rates of multiple adverse events were determined. The time of diagnosis for each event in the 90-day postoperative period was determined. Data were dichotomized by occurrence in days 0 to 30 and 31 to 90. Median, interquartile range, and middle 80% for the time of diagnosis were determined for each adverse event.Of 51,915 patients undergoing PLF, 7,141 (13.8%) had an adverse event within 90 days of PLF. Of these, 5,174 (72.5%) experienced an event within 30 days and 2,544 (35.6%) after 30 days. For individual adverse outcomes studied, the percent that occurred 31 to 90 days after surgery ranged from 9% to 42%. The time of diagnosis (median; interquartile range; middle 80%) for each adverse event was as follows: transfusion (2 days; 2 to 5 days; 1 to 26 days), acute kidney injury (9; 2 to 29; 1 to 60), hematoma (9; 4 to 20; 3 to 39), cardiac event (11; 3 to 43; 1 to 71), pneumonia (12; 4 to 38; 2 to 68), venous thromboembolism (15; 6 to 33; 3 to 62), sepsis (19; 9 to 39; 4 to 63), surgical site infection (21; 14 to 34; 8 to 48), urinary tract infection (22; 8 to 49; 4 to 72), and wound dehiscence (27; 17 to 39; 9 to 54).This study highlights the importance of looking past the 30-day mark for adverse events after PLF because approximately one-third of adverse events in this study were diagnosed 31 to 90 days after surgery. This can affect research studies, patient counseling about the incidence of specific adverse events, and the development of mechanisms for surveillance at key time points.

Background: Osteochondral allograft transplant (OCA) and osteochondral autograft transfer (OAT) replace damaged cartilage with a plug of bone and overlying articular cartilage; however, limited research is available regarding the survival of these osteoarticular grafting procedures. Hypothesis: We hypothesized that patients who underwent OCA would have a higher rate of subsequent surgery over the course of 5 years compared with patients who underwent OAT. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner administrative database was used to identify patients 10 to 59 years old who had undergone OCA or OAT between 2010 and 2018. All included patients were assessed for subsequent knee surgeries, defined by the occurrence of a subsequent osteochondral procedure (OCA or OAT) or any type of knee arthroplasty for the duration of the time they were included in the data set (maximum of 10 years). Analyses were performed for the total population and those with allograft versus autograft (compared using the Fisher exact test). The 5-year Kaplan-Meier survival curves for operation-free survival were compared using a Mantel-Cox log-rank test. Results: In total, 2598 patients were identified: 1631 patients who underwent OCA (34.5 ± 12.1 years old; 51.6% female) and 967 patients who underwent OAT (32.1 ± 12.9 years old; 51.0% female). Both groups had similarly high rates of subsequent knee surgeries (23.9% vs 21.9%, respectively; P = .249), with no statistical differences in rates of subsequent surgery between groups. Kaplan-Meier survival curves comparing operation-free survival at 5 years indicated no significant difference between the groups (OCA, 88.0% vs OAT, 89.5%; P = .235). Conclusion: Both osteochondral grafting procedures carried a relatively high rate of secondary surgery, which increased with time. The 5-year survival analysis revealed similarly high rates of subsequent surgery.

Background: To assess the accuracy of four wearable heart rate (HR) monitors in patients with established cardiovascular disease enrolled in phase II or III cardiac rehabilitation (CR). Methods: Eighty adult patients enrolled in phase II or III CR were monitored during a CR session that included exercise on a treadmill and/or stationary cycle. Participants underwent HR monitoring with standard ECG limb leads, an electrocardiographic (ECG) chest strap monitor (Polar H7), and two randomly assigned wrist-worn HR monitors (Apple Watch, Fitbit Blaze, Garmin Forerunner 235, TomTom Spark Cardio), one on each wrist. HR was recorded at rest and at 3, 5, and 7 minutes of steady-state exercise on the treadmill and stationary cycle. Results: Across all exercise conditions, the chest strap monitor (Polar H7) had the best agreement with ECG (r c =0.99) followed by the Apple Watch (r c =0.80), Fitbit Blaze (r c =0.78), TomTom Spark (r c =0.76) and Garmin Forerunner (r c =0.52). There was variability in accuracy under different exercise conditions. On the treadmill, only the Fitbit Blaze performed well (r c =0.76), while on the stationary cycle, Apple Watch (r c =0.89) and TomTom Spark (r c =0.85) were most accurate. Conclusions: In cardiac patients, the accuracy of wearable, optically based HR monitors varies, and none of those tested was as accurate as an electrode-containing chest monitor. This observation has implications for in-home CR, as electrode-containing chest monitors should be used when accurate HR measurement is imperative.

Background: Open debridement (OD) of the extensor carpi radialis brevis tendon, both with and without repair to the lateral epicondyle, are effective treatments for recalcitrant lateral epicondylitis. However, few comparative studies exist within the literature. Purpose: To (1) compare the 5-year reoperation rates of patients who underwent OD alone versus OD with tendon repair (ODR) and (2) identify the 90-day adverse event rates, total same-day reimbursement amounts, and national usage trends for these 2 procedures from 2010 to 2019. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver MUExtr database was reviewed for patients diagnosed with lateral epicondylitis who underwent OD alone and ODR or reattachment between January 2010 and December 2019. These patients were stratified into 2 cohorts: the OD cohort and ODR cohort. The 5-year reoperation rates were assessed and compared, and the incidence of 90-day postoperative complications and risk factors were identified. The number of ODs and ODRs performed each year and the mean same-day reimbursement amounts (in US$) for both procedures were assessed. Results: Overall, 41,932 lateral epicondylitis patients who underwent debridement were identified, with 17,139 OD patients and 24,793 ODR patients. There were no significant changes in the proportion of OD versus ODR procedures performed during the study period ( P = .18). A significantly higher incidence of hematoma was seen after OD compared with ODR (0.19% vs 0.12%; P = .04), but ODR had a significantly lower 5-year reoperation rate than OD (2.8% vs 3.9%; P = .006), with an absolute risk reduction of 1.1% and a number needed to treat of 91. Finally, ODR ($1683.17 ± $12.15) had a higher mean same-day reimbursement than OD ($1479.05 ± $15.78) ( P = .001). Conclusion: Both OD and ODR had low complication rates. The 5-year reoperation rates were low for both procedures, but they were significantly higher for OD. Over the 10-year study period, there were no significant changes in the relative percentages of OD versus ODR performed. ODR had a significantly higher mean same-day reimbursement.

OBJECTIVES Brachial index is a skeletal ratio that describes the relative length of the distal forelimb. Over the course of hominin evolution, a shift toward smaller brachial indices occurred. First, Pleistocene australopiths yield values between extant chimpanzees and humans, with further evolution in Pliocene Homo to the modern human range. We hypothesized that shorter distal forelimbs benefit walking and running performance, notably elbow and shoulder joint torques, and predicted that the benefit would be greater in running compared to walking. MATERIALS AND METHODS We tested our hypothesis in a modern human sample walking and running while carrying hand weights, which increase the inertia (mass and effective length) of the distal forelimb, simulating a larger brachial index. RESULTS We found longer distal forelimbs and the added mass increased elbow muscle torque by 98% while walking and 70% in running, confirming our hypothesis that shorter distal forelimbs benefit walking and running performance. Shoulder muscle torque similarly increased in both gaits with the addition of hand weights due to elongation of the effective forelimb length. Normalized elbow torque, which accounted for the effect on shoulder torque caused by the experimental manipulation, increased by 16% while walking but 52% while running, indicating that shorter distal forelimbs provide a greater benefit for running by approximately three-fold. DISCUSSION Selection for economical bipedal walking in Australopithecus and endurance running in Homo likely contributed to the shift toward relatively smaller distal forelimbs across hominin evolution, with modern human proportions attained in Pleistocene Homo erectus and retained in later species.

BACKGROUND Risk adjustment has implications across orthopaedics, including informing clinical care, improving payment models, and enabling observational orthopaedic research. Although comorbidity indices (such as the American Society of Anesthesiologists [ASA] classification, Charlson comorbidity index [CCI], and Elixhauser comorbidity index [ECI]) have been examined extensively in the immediate perioperative period, there is a dearth of data on their three-way comparative effectiveness and long-term performance. Moreover, the discriminative ability of the CCI and ECI after orthopaedic surgery has not been validated in the ICD-10 era, despite new diagnosis codes from which they are calculated. QUESTION/PURPOSE Which comorbidity index (ASA, CCI, or ECI) is associated with the greatest accuracy on receiver operating curve (ROC) analysis with respect to the endpoint of death at 90 days and 1 year after hip fracture surgery in the ICD-10 era? METHODS A retrospective study was conducted on all patients undergoing surgical fixation of primary hip fractures at two Level I trauma centers and three community hospitals from October 2016 to May 2019. This time frame allowed for a 1-year baseline period of ICD-10 data to assess comorbidities and at least a 1-year follow-up period to assess mortality. Initially 1516 patients were identified using Common Procedural Terminology and ICD codes, of whom 4% (60 of 1516) were excluded after manual review; namely, those with pathologic fractures (n = 38), periprosthetic fractures (n = 12), and age younger than 18 years (n = 10). Of the patients who were studied, 69% (998 of 1456) were women and the mean ± SD age was 77 ± 14 years; 45% (656 of 1456) were treated with intramedullary nails, 32% (464 of 1456) underwent hemiarthroplasties, 10% (149 of 1456) underwent THAs, 7% (104 of 1456) underwent percutaneous fixations, and 6% (83 of 1456) were treated with plates and screws. The mean ± SD ASA score was 2.8 ± 0.6, CCI was 3.1 ± 3.2, and ECI was 5.2 ± 3.5. Hip fracture fixation was chosen as the operation of interest given the high incidence of this injury, the well-documented effects of comorbidities on complications, and the critical importance of risk stratification and perioperative medical management for these patients. Demographics, comorbidities, surgical details, as well as 90-day and 1-year mortality were collected. Logistic regressions with ROC curves were used to determine the accuracy and comparative effectiveness of the three measures. The 90-day mortality rate was 7.4%, and the 1-year mortality rate was 15.0%. RESULTS The accuracy (area under the curve [AUC]) for 1-year mortality was 0.685 (95% CI 0.656 to 0.714) for the ASA, 0.755 (95% CI 0.722 to 0.788) for the ECI, and 0.769 (95% CI 0.739 to 0.800) for the CCI. The CCI and ECI were more accurate than ASA (p < 0.001 for both), while the CCI and ECI did not differ (p = 0.30). The ECI (AUC 0.756 [95% CI 0.712 to 0.800]) was more accurate for 90-day mortality than the ASA (AUC 0.703 [95% CI 0.663 to 0.744]; p = 0.04), while CCI (AUC 0.742 [95% CI 0.698 to 0.785]) with ASA (p = 0.17) and CCI with ECI (p = 0.46) did not differ at 90 days. CONCLUSION Performance measures and research results may vary depending on what comorbidity index is used. We found that the CCI and ECI were more accurate than the ASA score for 1-year mortality after hip fracture surgery. Moreover, these data validate that the CCI and ECI can perform reliably in the ICD-10 era. If other studies from additional practice settings confirm these findings, as would be expected because of the objective nature of these indices, the CCI or ECI may be a useful preoperative measure for surgeons to assess 1-year mortality for hip fracture patients and should likely be used for institutional orthopaedic research involving outcomes 90 days and beyond. LEVEL OF EVIDENCE Level III, diagnostic study.

During running, humans increase leg stiffness on more compliant surfaces through an in-series spring relationship to maintain constant support mechanics. Following this notion, the compliant midsole material of standard footwear may cause individuals to increase leg stiffness while running, especially in footwear with very thick midsoles. Recently, researchers have also proposed that footwear stiffness can affect the stiffness of the foot’s longitudinal arch (LA) via a similar mechanism. To test these ideas, we used 3D motion capture to record 20 participants running on a forceplate-instrumented treadmill while barefoot, and while wearing three types of sandals composed of materials ranging an order of magnitude in Young’s modulus: ethylene vinyl acetate (EVA), and two varieties of polyurethane rubber (R30 and R60). We calculated leg stiffness using standard methods, and measured LA stiffness based on medial midfoot kinematics. While there was an overall significant effect of footwear on leg stiffness (P=0.047), post-hoc tests revealed no significant differences among individual pairs of conditions, and there was no effect of footwear on LA stiffness. However, participants exhibited significantly greater LA compression when barefoot than when running in EVA (P=0.004) or R30 (P=0.036) sandals. These results indicate that standard footwear midsole materials are too stiff to appreciably affect leg stiffness during running, meaning that increasing midsole thickness is unlikely to cause individuals to alter their leg stiffness. However, use of footwear does cause individuals to restrict LA compression when compared to running barefoot, and further research is needed to understand why.

Objectives: Many different magnetic resonance imaging (MRI)-based classifications are used to characterize rotator cuff supraspinatus pathology, ranging from mild tendinopathy to full-thickness tears. While MRIs are chiefly utilized to guide the need for and approach to operative management of supraspinatus pathology, the functional implications, if any, across the entire range of pathologies have not been defined. The purpose of this biomechanical study was to examine shoulder strength and function in patients presenting with presumptive supraspinatus pathology and to determine if these clinical parameters are correlated with radiologic severity. Methods: We prospectively enrolled 171 patients with suspected rotator cuff pathology disease and without apparent strength deficit on traditional rotator cuff physical examination (PE). Exclusion criteria were radiographically apparent glenohumeral OA, previously diagnosed rotator cuff tear of the affected shoulder, previously diagnosed adhesive capsulitis, prior ipsilateral shoulder surgery, injury to the ipsilateral hand or wrist, limited range of motion, and history or radiographic evidence of anterior or posterior shoulder dislocation. For both clinical (e.g. testing isotonic strength in patients with frank weakness yields unreliable strength measurements and provides little useful information) and ethical (e.g. to avoid causing pain to patients already experiencing significant shoulder pain) reasons, this study evaluating dynamic strength testing was strictly limited to patients with negative traditional, static PE tests. All patients underwent two bilateral shoulder strength tests using dynamometry; first, isometric strength was measured at 90 degrees of abduction and, second, isotonic strength was measured eccentrically from full abduction throughout the full range of motion until the arm was at the patient’s side. For both of these tests, the examiner placed the handheld dynamometer (Hoggan microFET® 3; Hoggan Scientific, LLC, Salt Lake City UT, USA) on the patient’s wrist, perpendicular to the arm, to measure the force applied along the arc. Absolute strength and symptomatic-to-asymptomatic arm (S/A) strength ratios were calculated. All patients were included in analyses of absolute strength measurements on strength testing; patients who had a history or clinical evidence of contralateral shoulder pathology were excluded from analyses of S/A strength ratios. Patients then underwent shoulder MRI, classifying supraspinatus findings into one of seven ordinal categories. The primary outcome was the relationship between the radiologic severity of supraspinatus pathology on MRI and the degree of rotator cuff strength deficit upon exam. Results were analyzed for both isotonic and isometric function. Results: The study cohort consisted of 171 patients (102 [59.6%] males, 69 [40.4%] females). The mean patient age (± 95% CI) was 52.0 ± 1.9 years. The mean symptom duration (± 95% CI) was 10.8 ± 2.9 months. MRI revealed: 26 (15.2%) instances of no supraspinatus pathology, 37 (21.6%) instances of tendinopathy, 17 (9.9%) instances of supraspinatus fraying, 39 (22.8%) partial thickness tears (PTTs), 13 (7.6%) high-grade PTTs, 12 (7.0%) focal full thickness tears (FTTs)/full-thickness perforations, and 27 (15.8%) FTTs. Isotonic strength : Increasing imaging severity was significantly associated with decreasing absolute strength during isotonic testing ( P=0.036, Table 1). Specifically, absolute strength measurements declined with increasingly severe imaging findings, from no tear [59.9 N], to tendinopathy [50.9 N], to fraying [48.2 N], to PTT [55.0 N], to high-grade PTT [48.9 N], to focal FTT/full thickness perforation [45.7 N], to FTT [44.2 N]. Similarly, increasing imaging severity was significantly associated with decreasing S/A strength ratios during isotonic testing ( P=0.022, Table 1). Isotonic S/A strength ratios declined with increasingly severe imaging findings, from no tear [91.9%], to tendinopathy [70.8%], to fraying [66.1%], to PTT [76.2%], to high-grade PTT [75.7%], to focal FTT/full thickness perforation [65.2%], to FTT [63.3%]. Isometric strength : In contrast to isotonic testing, increasing imaging severity was not significantly associated with decreased absolute strength measurements on isometric testing ( P=0.12, Table 2). Similar results were seen for isometric S/A ratio, as increasing imaging severity was not significantly associated with S/A strength ratio ( P=0.085, Table 2). Conclusions: Radiologic severity of supraspinatus pathology was correlated with dynamic clinical function across the full range of pathology, revealing the functional importance of these frequently-used classifications. The lower discriminatory ability of isometric measurements and higher strength measurements on isometric assessment may be related to a greater role of compensatory musculature in static testing. These biomechanical results support the need for future work investigating the utility of dynamic rotator cuff physical examination maneuvers.

Athletes and members of the public increasingly rely on wearable HR monitors to guide physical activity and training. The accuracy of newer, optically based monitors is unconfirmed. We sought to assess the accuracy of five optically based HR monitors during various types of aerobic exercise.Fifty healthy adult volunteers (mean ± SD age = 38 ± 12 yr, 54% female) completed exercise protocols on a treadmill, a stationary bicycle, and an elliptical trainer (±arm movement). Each participant underwent HR monitoring with an electrocardiogaphic chest strap monitor (Polar H7), forearm monitor (Scosche Rhythm+), and two randomly assigned wrist-worn HR monitors (Apple Watch, Fitbit Blaze, Garmin Forerunner 235, and TomTom Spark Cardio), one on each wrist. For each exercise type, HR was recorded at rest, light, moderate, and vigorous intensity. Agreement between HR measurements was assessed using Lin's concordance correlation coefficient (rc).Across all exercise conditions, the chest strap monitor (Polar H7) had the best agreement with ECG (rc = 0.996) followed by the Apple Watch (rc = 0.92), the TomTom Spark (rc = 0.83), and the Garmin Forerunner (rc = 0.81). Scosche Rhythm+ and Fitbit Blaze were less accurate (rc = 0.75 and rc = 0.67, respectively). On treadmill, all devices performed well (rc = 0.88-0.93) except the Fitbit Blaze (rc = 0.76). While bicycling, only the Garmin, Apple Watch, and Scosche Rhythm+ had acceptable agreement (rc0.80). On the elliptical trainer without arm levers, only the Apple Watch was accurate (rc = 0.94). None of the devices was accurate during elliptical trainer use with arm levers (all rc0.80).The accuracy of wearable, optically based HR monitors varies with exercise type and is greatest on the treadmill and lowest on elliptical trainer. Electrode-containing chest monitors should be used when accurate HR measurement is imperative.

Stereotypically, walking and running gaits in humans exhibit different arm swing behavior: during walking, the arm is kept mostly straight, while during running, the arm is bent at the elbow. The mechanism for this behavioral difference has not been explored before. We hypothesized that a mechanical tradeoff exists between the shoulder joint and the elbow joint. Bending the elbow reduces the radius of gyration of the arm and reduces shoulder muscle torque, but at the price of increasing elbow torque. We predicted that the mechanical tradeoff would result in energetics that favored straight arms during walking and bent arms during running. The hypothesis was tested experimentally by having eight subjects walk and run with both straight arms and bent arms while recording arm swing mechanics, and oxygen consumption in a subset of six subjects. The mechanical tradeoff hypothesis was confirmed, with bent arms reducing normalized shoulder muscle torque in both gaits (walking: −33%, running: −32%) and increasing normalized elbow muscle torque in both gaits (walking: +110%, running: +30%). Bent arms increased oxygen consumption by 11% when walking, supporting our prediction that energetics favor straight arms during walking. However, oxygen consumption was equivalent for the straight and bent arm running conditions, and did not support our running prediction. We conclude that straight arms are stereotyped in walking as a result of optimal energetics, while the mechanism leading to bent arms during running remains unknown.

Background: Although minimalist footwear is increasingly popular among runners, claims that minimalist footwear enhances running biomechanics and efficiency are controversial. Hypothesis: Minimalist and barefoot conditions improve running efficiency when compared with traditional running shoes. Study Design: Randomized crossover trial. Level of Evidence: Level 3. Methods: Fifteen experienced runners each completed three 90-second running trials on a treadmill, each trial performed in a different type of footwear: traditional running shoes with a heavily cushioned heel, minimalist running shoes with minimal heel cushioning, and barefoot (socked). High-speed photography was used to determine foot strike, ground contact time, knee angle, and stride cadence with each footwear type. Results: Runners had more rearfoot strikes in traditional shoes (87%) compared with minimalist shoes (67%) and socked (40%) ( P = 0.03). Ground contact time was longest in traditional shoes (265.9 ± 10.9 ms) when compared with minimalist shoes (253.4 ± 11.2 ms) and socked (250.6 ± 16.2 ms) ( P = 0.005). There was no difference between groups with respect to knee angle ( P = 0.37) or stride cadence ( P = 0.20). When comparing running socked to running with minimalist running shoes, there were no differences in measures of running efficiency. Conclusion: When compared with running in traditional, cushioned shoes, both barefoot (socked) running and minimalist running shoes produce greater running efficiency in some experienced runners, with a greater tendency toward a midfoot or forefoot strike and a shorter ground contact time. Minimalist shoes closely approximate socked running in the 4 measurements performed. Clinical Relevance: With regard to running efficiency and biomechanics, in some runners, barefoot (socked) and minimalist footwear are preferable to traditional running shoes.

Background: The accuracy of wrist-worn heart rate (HR) monitors is unconfirmed. We assessed accuracy of 5 wrist-worn HR monitors (Apple Watch, Fitbit Blaze, Garmin Forerunner 235, TomTom Spark Cardio, Scosche Rhythm+) during various types of exercise. Methods: Fifty volunteers completed exercise